Acute hypersensitivity syndrome caused by valproic Acid: a review of the literature and a case report

Repositioning Drugs for Rare Diseases Based on Biological Features and Computational Approaches

Rare diseases are a group of uncommon diseases in the world population. To date, about 7000 rare diseases have been documented. However, most of them do not have a known treatment. As a result of the relatively low demand for their treatments caused by their scarce prevalence, the pharmaceutical industry has not sufficiently encouraged the research to develop drugs to treat them. This work aims to analyse potential drug-repositioning strategies for this kind of disease. Drug repositioning seeks to find new uses for existing drugs. In this context, it seeks to discover if rare diseases could be treated with medicines previously indicated to heal other diseases. Our approaches tackle the problem by employing computational methods that calculate similarities between rare and non-rare diseases, considering biological features such as genes, proteins, and symptoms. Drug candidates for repositioning will be checked against clinical trials found in the scientific literature. In this study, 13 different rare diseases have been selected for which potential drugs could be repositioned. By verifying these drugs in the scientific literature, successful cases were found for 75% of the rare diseases studied. The genetic associations and phenotypical features of the rare diseases were examined. In addition, the verified drugs were classified according to the anatomical therapeutic chemical (ATC) code to highlight the types with a higher predisposition to be repositioned. These promising results open the door for further research in this field of study.

Non-aromatic Anticonvulsant (Divalproex Sodium)-Induced Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) Syndrome

A wide array of commonly prescribed antiepileptic medications, antibiotics, antivirals, anti-parasitic, and antihyperuricemic can cause Drug Reaction Eosinophilia and Systemic Syndrome (DRESS)- a drug induced hypersensitivity reaction characterized by cutaneous manifestation, fever, eosinophilia, thrombocytopenia and one or more visceral organ involvement. The rare occurrence in clinical settings and wide variety of clinical presentations make DRESS a diagnostically challenging case. A vast majority of DRESS cases are attributed to the most commonly prescribed anticonvulsant medications - phenytoin and carbamazepines. Even though non-aromatic divalproex sodium/valproic acid (VPA) can cause life-threatening fatal hypersensitivity reactions on rare occasions, a handful cases of valproate-induced DRESS have been reported. We hereby report a case of a 57-year-old cognitively impaired person with polypharmacy who presented with worsening diffuse skin rash, fever, dysphagia, eosinophilia, thrombocytopenia, and mixed type of hepatic injury. The patient was eventually diagnosed with DRESS due to divalproex sodium- an anticonvulsant medication. The objective of our report is to identify and recognize the rare yet proper causative agent that induces DRESS and potential mitigation of significant systemic consequences by its subsequent withdrawal.

Valproic Acid: A Promising Therapeutic Agent in Glioma Treatment

Glioma, characterized by infiltrative growth and treatment resistance, is regarded as the most prevalent intracranial malignant tumor. Due to its poor prognosis, accumulating investigation has been performed for improvement of overall survival (OS) and progression-free survival (PFS) in glioma patients. Valproic acid (VPA), one of the most common histone deacetylase inhibitors (HDACIs), has been detected to directly or synergistically exert inhibitory effects on glioma in vitro and in vivo. In this review, we generalize the latest advances of VPA in treating glioma and its underlying mechanisms and clinical implications, providing a clearer profile for clinical application of VPA as a therapeutic agent for glioma.

Allergy to chlorpromazine and valproic acid following carbamazepine hypersensitivity in a patient with an HLA-B*4601 allele

A 73-year-old man, exhibiting psychomotor excitement after traumatic brain injury, developed allergic cutaneous eruptions and hepatic inflammation that did not resolve after the cessation of carbamazepine (CBZ). Fusing maculopapular erythema was observed in the face, neck, presternal region, and bilaterally in the forearms and feet. A drug-induced lymphocyte stimulation test revealed hypersensitivity to chlorpromazine (CPZ) and valproic acid (VPA), as well as to CBZ. The allergic reaction with eosinophilia to CPZ and VPA was suspected to have emerged following CBZ hypersensitivity, since previous treatment with CPZ and VPA prior to the introduction of CBZ had not been associated with adverse reactions earlier in the course of treatment. Recent studies have indicated linkages between severe CBZ hypersensitivity - but not mild CBZ hypersensitivity - and specific leukocyte antigens, HLA-B*1502 and HLA-A*3101, in Asian and European populations. The present case exhibited the HLA-B*4601 allele, which is associated with a high relative risk for the development of CBZ-induced maculopapular eruptions in Japanese and Han Chinese populations. Although cross-hypersensitivity among aromatic compounds, including CBZ and CPZ, is well-established, data regarding CBZ allergy-associated hypersensitivity to VPA are limited. In the present case, a cutaneous allergy to mianserin (a tetracyclic antidepressant) was also observed later in the course of treatment, suggesting additional cross-reactivity exists among aromatic psychotropic drugs. Thus, the association between the HLA-B*4601 allele and allergic reactions to VPA, aromatic psychotropic drugs, and CBZ should be further examined in future studies.

Drug-induced hypersensitivity syndrome caused by valproic acid as a monotherapy for epilepsy: First case report in Asian population

Valproic acid (VPA) is a broad-spectrum antiseizure drug used for a variety of clinical conditions, such as epilepsy and mood disorders. Drug-induced hypersensitivity syndrome (DRESS) accompanied by hyponatremia, thrombocytopenia, hypoalbuminemia and elevated aminotransferase has never been reported as an adverse effect of VPA monotherapy during titration for epilepsy in Asian population. Hereby, we present the case of a 73-year-old Chinese male who suffered from DRESS and other complications two weeks after initiating VPA treatment for epilepsy. Understanding the risk associated with VPA-induced DRESS, and taking effective measures to avoid the severe side effects are necessary.

Drug Reaction With Eosinophilia and Systemic Symptoms Induced by Valproic Acid: A Case Report

Introduction

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare but life-threatening reaction to drugs such as carbamazepine and allopurinol. The condition is characterized by skin rashes, fever, hematological disturbances, lymphadenopathy, and organ failure, most probably hepatic dysfunction. To date, only a few cases of valproate-induced DRESS syndrome have been reported.

Case Presentation

We report on the case of a 60-year-old man who had been treated with valproic acid some time before being referred to Kowsar Hospital, Semnan, Iran in December 2015. He was given valproic acid 1000 mg PO, and after 20 days, he had developed widespread rashes, fever, esophagitis, cervical lymphadenopathy, and tender hepatomegaly. Laboratory results at Kowsar showed a drop in hemoglobin, in addition to lymphocytosis, thrombocytopenia, and elevated serum transaminases. DRESS was diagnosed, and corticosteroid therapy was initiated. Administration of the culprit drug to the patient was also stopped. Intravenous immunoglobulin (IVIG) improved the general condition of the patient.

Conclusions

Only a small number of case reports have described valproic acid-induced DRESS syndrome; therefore, the condition is difficult to prevent. Rechallenge with valproic acid should be avoided in patients with a history of reaction to the drug.

Evaluation of the efficacy of sodium valproate in convulsive status epilepticus following to ıschemic stroke

OBJECTIVE

Convulsive status epilepticus (CSE) is very rarely observed after ischaemic stroke. Sodium valproate (SV) is one of the agents used in the treatment of CSE, but its role still controversial, and its degree of efficacy in treating CSE that develops following stroke is unclear.

METHOD

We evaluated 19 patients who were treated with intravenous (IV) SV (20 mg/kg, 2 mg/kg/h-12h) after diazepam. Patients' modified Rankin scores (mRS), SE types, and changes in biochemical parameters after treatment were assessed.

RESULTS

CSE was successfully treated in 12 (63.15%) patients. Side effects such as hypotension and allergic reactions were observed in two patients. Refractory SE development was observed in 5 (29.4%) patients with high mRS (˃ 3). No significant deterioration in patients' laboratory evaluations, conducted before and after status, was observed.

CONCLUSION

SV may be safe and effective in the treatment of CSE observed after ischaemic stroke, especially in patients with low mRS.

Insights from zebrafish and mouse models on the activity and safety of ar-turmerone as a potential drug candidate for the treatment of epilepsy

In a previous study, we uncovered the anticonvulsant properties of turmeric oil and its sesquiterpenoids (ar-turmerone, α-, β-turmerone and α-atlantone) in both zebrafish and mouse models of chemically-induced seizures using pentylenetetrazole (PTZ). In this follow-up study, we aimed at evaluating the anticonvulsant activity of ar-turmerone further. A more in-depth anticonvulsant evaluation of ar-turmerone was therefore carried out in the i.v. PTZ and 6-Hz mouse models. The potential toxic effects of ar-turmerone were evaluated using the beam walking test to assess mouse motor function and balance. In addition, determination of the concentration-time profile of ar-turmerone was carried out for a more extended evaluation of its bioavailability in the mouse brain. Ar-turmerone displayed anticonvulsant properties in both acute seizure models in mice and modulated the expression patterns of two seizure-related genes (c-fos and brain-derived neurotrophic factor [bdnf]) in zebrafish. Importantly, no effects on motor function and balance were observed in mice after treatment with ar-turmerone even after administering a dose 500-fold higher than the effective dose in the 6-Hz model. In addition, quantification of its concentration in mouse brains revealed rapid absorption after i.p. administration, capacity to cross the BBB and long-term brain residence. Hence, our results provide additional information on the anticonvulsant properties of ar-turmerone and support further evaluation towards elucidating its mechanism of action, bioavailability, toxicity and potential clinical application.

Leukemoid reaction secondary to hypersensitivity syndrome to phenobarbital: a case report

The most important adverse effects of phenobarbital, an anticonvulsant drug, are behavior and cognitive alterations. Hypersensitivity syndrome caused by phenobarbital presenting with a leukemoid reaction is a rare side effect, which is rarely ever reported and needs to be known. We report on a 27-year-old Chinese woman who experienced hypersensitivity syndrome three weeks after the initiation of phenobarbital. The patient developed fever, skin rash, face swelling, lymphadenopathy, myalgia, hepatitis, eosinophilia, atypical lymphocytes and leukocytosis. Along with the pathological progress of the disease, the patient noticed a gradual exacerbation of her symptoms. And the highest leukocyte count was up to 127.2 x 10(9)/L. After discontinuing of phenobarbital and administration of methylprednisolone combined with the intravenous immunoglobulin shock therapy, all initial symptoms improved and the leukocyte count normalized. This case is reported because of its rarity of the leukemoid reaction secondary to hypersensitivity syndrome to phenobarbital.

Levetiracetam-induced drug reaction with eosinophilia and systemic symptoms syndrome

OBJECTIVE

To describe a case of levetiracetam-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.

CASE SUMMARY

A 31-year-old white male with a low-grade astrocytoma presenting with tonic-clonic seizures was treated with levetiracetam 1 g twice daily and dexamethasone (initial dosage 12 mg/day, tapered down to 2 mg/day). On day 45 after levetiracetam initiation, dexamethasone was discontinued and levetiracetam continued. The patient developed fever and dyspnea on day 46 and was admitted to the hospital on day 49. A chest X-ray showed bilateral pulmonary interstitial infiltrates, and laboratory tests showed elevated lactate dehydrogenase (LDH; 288 U/L [reference range <204]), ferritin (223 ng/mL [13-178]), and C-reactive protein (CRP; 3.1 mg/dL [<0.5]). Neurologic fever was suspected and the reinitiation of dexamethasone at 6 mg/day was followed by improvement of all symptoms; the patient was discharged on day 55 with dexamethasone 4 mg/day for 2 more days. On day 59, 2 days after the withdrawal of dexamethasone for the second time, the patient presented with a pruritic erythematous maculopapular rash along with recurrence of fever and dyspnea, and was admitted to the hospital. A chest X-ray showed reappearance of the bilateral pulmonary interstitial infiltrates, and laboratory tests showed impaired liver function (alanine aminotransferase 60 U/L [reference range <56], aspartate aminotransferase 53 U/L [<30], LDH 516 U/L, ferritin 419 ng/mL, and CRP 2.6). A diagnosis of DRESS syndrome was suspected and levetiracetam was discontinued. Upon levetiracetam withdrawal, the patient's symptoms resolved by day 66, and radiological images showed resolution of the interstitial infiltrate by day 68. The patient was discharged on day 68. Low-grade fever persisted until day 71, with no other symptoms. During a 2-month follow-up period, liver function test results returned to normal.

DISCUSSION

DRESS is a hypersensitivity reaction to several drugs, mainly antiepileptic drugs (AEDs), characterized by cutaneous, hematologic, and visceral involvement. Levetiracetam is structurally and pharmacologically unrelated to other AEDs. Previously, only one case of levetiracetam-induced DRESS syndrome had been reported, which required corticosteroids to control symptoms. We describe a case of levetiracetam-induced DRESS syndrome presenting with pneumonitis and hepatitis that resolved with levetiracetam withdrawal. Our patient was classified as a definitive DRESS case according to the RegiSCAR scoring system, which grades DRESS cases. According to the Naranjo probability scale, the adverse drug reaction was considered probable.

CONCLUSIONS

Although levetiracetam is usually well tolerated, clinicians should be aware of the potential for it to cause DRESS syndrome.