Roseomonas species, a rare Gram-negative microorganism, has seldom been reported to cause peritonitis in end-stage renal disease patients on peritoneal dialysis. Only seven cases of peritonitis by this rare microorganism have been reported worldwide. Treatment options can be challenging if not detected early and can lead to significant morbidity and mortality along with the switching of the dialysis modality to hemodialysis which is highly undesirable. Our patient is a 65-year-old Caucasian female who needed to be changed to emergency hemodialysis due to inability to perform peritoneal dialysis from suspected peritonitis and was subsequently discovered to have peritonitis from Roseomonas mucosa. She recovered with a prolonged antibiotics course and returned to peritoneal dialysis in 3 months following her treatment completion. Prompt diagnosis and prolonged antibiotics are a cornerstone in the management of this rare microorganism to prevent mortality and morbidity from peritonitis.

Valproic acid (VPA), an antiepileptic medication, is known to cause hyperammonemia, which may be asymptomatic or can present with encephalopathy. VPA-induced hyperammonemic encephalopathy (VHE) is a serious but reversible condition, which requires high clinical suspicion for diagnosis. It may occur acutely or after chronic use of VPA. We present the case of a 44-year-old male who was on long-term VPA therapy for a seizure disorder. He presented to the emergency department with the complaint of two episodes of seizures two days before admission. On arrival, the patient was confused and tearful and was unable to recollect the events leading to the seizure. The initial complete metabolic panel, liver function tests, urinalysis, and serum VPA levels were observed to be normal. However, there was a marked elevation in ammonia levels. VPA was suspected to be the inciting agent of hyperammonemic encephalopathy, and, therefore, it was discontinued. The patient was started on oral lactulose and prescribed a different antiseizure medication (i.e., lamotrigine). His ammonia levels decreased gradually, and his condition improved. Thus, it was concluded that the patient had developed VHE. At the time of discharge, he was stable and had no confusion or seizures. This case report evaluates his presentation and discusses the possible pathogenesis of VHE.