Multiple drugs

Abstract

Status epilepticus and severe lactic acidosis secondary to drug toxicity due to medication error and lack of efficacy: 2 case reports In the case, two patients (an 80-year-old woman and an 85-year-old man) were described, who developed status epilepticus or severe lactic acidosis secondary to fampridine toxicity which was incorrectly compounded (medication error) instead of aminophenazone in a medication which supposed to be contain quinine, aminophenazone, phenazone and aspirin. The patients also exhibited lack of efficacy to benzodiazepines, levetiracetam, valproic acid, propofol, midazolam, phenobarbital, topiramate or lacosamide [not all routes and dosages stated] [durations of treatments to reactions onsets not stated]. Case 1: The 80-year-old woman was brought to the emergency room (ER) with status epilepticus. She did not have any history of epilepsy or any other neurological disorders. She started receiving unspecified benzodiazepines, levetiracetam 2 × 1000mg and propofol. However, despite treatment, EEG revealed continual generalised epileptic discharges (lack of efficacy). Subsequently, she was administered phenobarbital through which burst-suppression was achieved. Initial work-up showed no underlying cause. She had been taking medication which contained quinine [quinine sulphate] 25mg, aminophenazone [amidopyrine] 162.5 mg, phenazone 187.5 mg and aspirin [acetylsalicylic acid] 150mg for myalgia and muscle cramps. Toxicological analysis revealed a strong positive result for fampridine [4-aminopyridine]. Anamnesis revealed that the pharmacist had incorrectly compounded fampridine [4-aminopyridine] instead of aminophenazone (drug compounding error) in the medication. She was managed in the ICU with continuous EEG monitoring. She responded well to the treatment. She improved neurologically and carried out simple tasks. She was transferred to the geriatric department and all her anti-epileptic drugs were tapered off. She recovered physically, however her cognitive status continued to remain poor. Following a few months of rehabilitation, she was discharged to a nursing home facility. Later, it was reconstructed that she would have taken one tablet of the incorrectly compounded medication. Case2: The 85-year-old man arrived at the ER, he had called his family physician because he was unwell after taking medication at home. He was found unconscious in status epilepticus and admitted to the hospital. He started receiving unspecified benzodiazepines, levetiracetam 2 × 2000 mg and valproic acid 3 × 500mg. He had refractory seizures and severe lactic acidosis, hence, he was sedated and intubated. He also received midazolam 1 mg/h and propofol in a variable concentration with continuous IV drip. However, despite this, his seizures remained refractory on EEG. Only after administration of phenytoin 2 × 100mg and phenobarbital 1 × 100mg, his status epilepticus was interrupted, after 4h. Anamnesis revealed that he had administered medication prescribed to his wife (prescription drug used from another patient). The medication contained quinine [quinine sulphate] 25mg, aminophenazone [amidopyrine] 162.5 mg, phenazone 187.5 mg and aspirin [acetylsalicylic acid] 150mg. Toxicological analysis showed a strong positive result for fampridine. Later, the pharmacist confirmed that he had incorrectly compounded fampridine instead of aminophenazone. Despite treatment with multiple anti-epileptic drugs (levetiracetam, valproic acid, phenytoin, phenobarbital, topiramate and lacosamide), he remained in a non-convulsive status for an entire week. Subsequently, anti-epileptic drugs were tapered off and he was extubated. However, clinically, he remained unresponsive. After 10 weeks without improvement, a palliative treatment was started and eventually, he died. Later, it was reconstructed that he took two tablets of the incorrectly compounded medication.