A 30-year-old woman with mental retardation was admitted to our
hospital with fever, cough, and dyspnea. She had received valproic acid
since the age of 20 for generalized seizure disorder. Three weeks
before admission, she presented an episode of viral rhinopharyngitis.
On physical examination, she had bruising with cutaneous ecchymotic
areas on her upper and lower extremities. Crackles were heard over both
lungs. Her consciousness level was normal. Chest radiographs revealed
lower lobe infiltrates. At admission, laboratory data revealed the
following : hematocrit, 15%; hemoglobin, 4.9 g/dL ; WBC count,
3000/μL; and platelet count, 15,000/μL. Arterial blood gas
analysis while breathing oxygen via a face mask (3 L/min) revealed pH
of 7.46; Pao2, 59 mm Hg; and
Paco2, 33 mm Hg. Initial serum
valproate level was 124 μg/mL (therapeutic range, 50 to 100 μg/mL).
Broad-spectrum antibiotics were administered, and transfusions of
packed RBCs and platelets were given, rising her platelet count to
50,000/μL and hemoglobin to 8 g/dL. A bone marrow aspirate was
performed, showing a myelodysplastic syndrome probably related to a
toxic effect of valproate. On day 2, she developed hemoptysis.
Bronchoscopy revealed blood throughout the airways consistent with
alveolar hemorrhage on cytologic examination of the lavage fluid.
Results of bloody lavage fluid, blood, and urine cultures were
negative. On day 3, chest radiographs revealed evolving diffuse
bilateral infiltrates and the patient developed a severe respiratory
failure with cardiac arrest and died.