P0447 - Acetazolamide-exacerbated acute flaccid paralysis and toxic-metabolic encephalopathy

Introduction:
Acetazolamide is an infrequently prescribed medication in the pediatric setting. Though incredibly rare, serious neurologic side effects can occur after its administration.

Description:
A 3 year old female with congenital glaucoma, chromosomal microdeletion, and mild developmental delay was in her usual state of health until she developed vomiting and diarrhea several days prior to admission with a history of gastroenteritis in several family members at home. Recently, ~30mg/kg/day acetazolamide was added for worsening intra-ocular hypertension around the time the patient began to have gastrointestinal symptoms. She then presented for sudden-onset altered mental status and unresponsiveness at home, with catatonia and areflexia on exam. Initial laboratory findings revealed severe hypoglycemia (< 20 mg/dL), severe metabolic acidosis (serum bicarbonate 11 mmol/L, venous pH 7.1), normokalemia (3.6 mmol/L), and 4+ calcium oxalaturia. A robust infectious and neuroimaging work-up was reassuring. Within six hours of admission to the Pediatric Intensive Care Unit (PICU), the patient began to have purposeful movements. Her severe dyselectrolytemia resolved and within twenty-four hours, she was completely back to her neurologic baseline.

Discussion:
This presentation of severe dyselectrolytemia underscores the rare, yet possible, toxic-metabolic and neurologic derangements that can occur in a potentially compromised host with acetazolamide ingestion. Life-threatening conditions must always be ruled out in patients who present with encephalopathy, but a medication history was crucial in clinching this case’s unifying diagnosis. While there are case reports highlighting the rare central nervous system toxicities associated with acetazolamide ingestion, to our knowledge none exist in the pediatric literature.