The case to be described illustrates apparent drug failure because of noncompliance in the drug delivery system, and the sequelae of this mishap. In connection with investigation of this case further occurrences of noncompliance were found. This incident also brings into focus the importance of plasma drug level determinations for effective application of therapy.
CASE REPORT
A 7-year-old, 26-kg, black girl was admitted with a 16-month history of nonprogressive neurologic disease accompanied by clinical and EEG evidence of petit mal and grand mal epilepsy which responded to diphenylhydantoin (DPH), phenobarbital or ethosuximide (Zarontin) treatment. Generalized convulsions had been infrequent for four months, but, before the present admission, a marked increase in grand mal seizures was noted. On the day of admission (day 1), recurrent generalized seizure activity progressed to status epilepticus within six hours. Intravenous diazepam (Valium [0.18/mg/kg]) controlled the seizures. Primidone (Mysoline), 250 mg tid, and ethosuximide, 500 mg tid were prescribed as maintenance anticonvulsants in an attempt to allay further progression to status epilepticus.
For the next several days her seizures could be controlled only with paraldehyde (0.36 mg/kg intravenously), although administration of other drugs was continued. Assays of drug plasma levels did not become available until day 6. They disclosed that plasma levels of diazepam and demethyldiazepam were high (289 and 50 ng/ml, respectively) one hour after dosing with 0.18 mg/kg. This indicated that diazepam was not effective for continuous control of seizures, but this information was not acted upon immediately. The most striking finding was that primidone was not detected in plasma, although the prescibed dosage was 250 mg tid.
A case of nonconvulsive status epilepticus presenting as dissociative fugue
