Abstract Details

Title Levetiracetam Related Encephalopathy with Opsoclonus and Triphasics

Topic Epilepsy

Presentation(s) P01 - (-)

Poster/Presentation
Number 045

Objective

Background Levetiracetam is a widely used antiepileptic medication because of broad spectrum effect and low incidence of adverse effects. Common adverse effects are somnolence, asthenia, headache, dizziness, and behavioral abnormalities. Clearance of levetiracetam is affected by renal function. Correlation between serum concentration and toxicity is not well known.

Design/Methods 12-year-old girl with a Chiari II, repaired myelomeningocele, shunted hydrocephalus, renal tubular acidosis, and well-controlled epilepsy on levetiracetam, was admitted with acute renal failure, metabolic acidosis, respiratory distress, and confusion. With treatment of metabolic abnormalities and respiratory failure she returned to baseline, with continued impaired renal function. Subsequently, within a few hours she became increasingly somnolent, tremulous and encephalopathic. New neurologic findings included continuous, random conjugate jerky eye movements in all directions of gaze(opsoclonus), chin quivering with occasional multifocal twitches of lower face muscles. EEG showed diffuse delta with continuous runs of periodic frontally predominant sharp waves consistent with triphasic waves. Her symptoms did not respond to lorazepam and fosphenytoin. Dose of levetiracetam was adjusted for creatinine clearance. Continuous EEG over several days showed persistent triphasic waves.

Results Plasma level of levetiracetam on the day of declined mental status was later found to be 112 [mu]g/ml (therapeutic range for our lab = 5-60 [mu]g/ml). Other causes of metabolic encephalopathy were excluded. Levetiracetam was discontinued and she was started on valproate. Over the next 4-5 days abnormal eye movements resolved, and she gradually returned to baseline. Follow-up EEG showed resolution of triphasic waves.

Conclusions There are rare reports of toxic encephalopathy due to levetiracetam. Our case has unique manifestations of opsoclonus with triphasic waves on EEG. There should be high index of suspicion in individuals with renal impairment on stable or even adjusted doses of levetiracetam.

Authors/Disclosures
Swapna L. Putta, MD (Brigham and Women'S Hospital, Boston MA) PRESENTER	No disclosure on file
Dinesh Talwar, MD (Center for Neurosciences)	No disclosure on file
Bruce A. Cree, MD, PhD, MAS, FAAN (UCSF, Multiple Sclerosis Center)	The institution of Dr. Cree has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Biogen. The institution of Dr. Cree has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Novartis. The institution of Dr. Cree has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Sanofi. The institution of Dr. Cree has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for TG Therapeutics. The institution of Dr. Cree has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Alexion. Dr. Cree has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Neuron23. Dr. Cree has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Boston Pharma. Dr. Cree has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Hexal/Sandoz. Dr. Cree has received personal compensation in the range of $10,000-$49,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Immunic AG. The institution of Dr. Cree has received research support from Genentech. The institution of Dr. Cree has received research support from Kyverna. Dr. Cree has received publishing royalties from a publication relating to health care.
Jennifer J. Manly, PhD (Columbia University)	The institution of Dr. Manly has received research support from NIH. Dr. Manly has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant with University of Mississippi.
Jennifer J. Manly, PhD (Columbia University)	The institution of Dr. Manly has received research support from NIH. Dr. Manly has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant with University of Mississippi.

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