Fatality from hepatitis A in a child taking valproate

We report an 8-year-old bog with complex partial seizures due to congenital stroke, treated with valproate for more than 3 years (the last 2 years wer e on monotherapy) with no complications during that period except for trans ient thrombocytopenia. His sister had uncomplicated hepatitis A. One month later, the patient became jaundiced, went into fulminant hepatic failure, a nd quickly became encephalopathic despite discontinuation of valproate, agg ressive supportive therapy, and treatment with carnitine. He then died. He had positive hepatitis A IgM; other causes for acute hepatitis were ruled o ut. Liver pathology revealed distended hepatocytes with cholestasis and mic rovesicular changes. We could find in the literature two other articles on four cases who developed liver failure with hepatitis A while on valproate. All those cases, however, recovered In our patient a usually benign diseas e became deadly, probably because of the concomitant use of a hepatotoxic m edication. Immunizing, with hepatitis A vaccine, all children on valproate therapy who are living in, or traveling to, endemic areas should be conside red and is probably advisable.