Unit 3:
Interns:
Dr Kalyan
Dr Archana
Dr Sreeja
Dr Harsha Vardhan
Dr Sahiti
Dr Jeeharika
Dr Raveen - PGY1
Dr Aashitha - PGY2
Dr Aravind - PGY3
Dr Vamshi - PGY3
Dr Hareen - SR
Dr Praveen Naik - Ass Prof
Dr Rakesh Biswas - HOD
UNIT 3
INTRODUCTION-
This is an interesting case of a 21 year old woman with acute recurrent episodes of seizures presenting to us since 4 days with a history of recurrent seizures since she was 15 years of age. MRI brain revealed that granulomatous lesion in right temporal region.
Further evaluation revealed a history of anxiety and depression.
CASE HISTORY-
26 year old woman who is unmarried came with c/o involuntary movements of both upper limb and lower limb since 5 days ,drooling of saliva present
uprolling of eyeballs +
No h/o urinary incontinence,
no h/o tongue bite
Patient earlier recalled events dates back when she was 12 years old presented with GTCS (no documentation)
She was having on and off seizure episodes and did not subside for 2 years, she visited many hospitals in that period and later she was taken to hyderabad and was put on antiepileptics and was seizure free for 2 years and then again developed seizures
She gives a history that she was conscious at the time of seizure episodes and was able to recall the events with no post ictal confusion but sometimes preceeded by aura with involuntary movements of both hands and legs with post ictal confusion lasting for 1-2 min with drooling of saliva
She gives a h/o preceeding fever before seizure episodes
From the age 16-24 she was having on and off seizure episodes and were not subsided
For the last 3 years she started using tab carbamazepine 200 mg TID with on and off seizure episodes
On focussing on recent history she had a seizure episode (? Focal ?GTCS) around 7 30 pm on friday
2 nd episode was on saturday morning 9 am and was seizure free until evening when she developed 5-6 episodes of seizures
From sunday to wednesday morning her mother gave h/o multiple episodes each lasting for 1-2 min with post ictal confusion for 1-2 min with 15-20 min gap between each episode and presented to casuality for further evaluation
Patient denies H/o fall ,head trauma,skipping medications
Her mother denies h/o delay in milestones
She completed her secondary education and was forced to quit studies as she was having recurrent episodes of seizure
She developed 8-10 episodes of ?GTCS episodes from the time of presentation to casuality
O/E patient is conscious, coherent,cooperative
Vitals
Patient is afebrile..
Pulse rate :82 bpm
RR: 16 cpm
BP: 140/90 mm hg
Spo2 :99%
Grbs: 123 mg/dl
S/E
Cvs: S1 S2 heard
Rs: BAE present
Cns: higher mental functions
patient is conscious oriented to time place and person
Speech is normal
No signs of meningeal irritation
Cranial nerves intact
Reflexes
rt lt
Biceps - -
Triceps - -
Supinator - -
Knee - -
Ankle - -
PLANTARS- FLEXOR ✓
Investigations
ECG :
CHEST XRAY:
HEMOGRAM:
CUE:
LFT:
RFT-
MRI-
Day 1:
She was started on Inj levipil 1gm /IV /BD after receiving a bolus dose of 1gm IV in 100ml NS.
DAY 2:
The patient had multiple recurrent episodes of seizures lasting for around 10secs each time
Her vitals were stable
All the reflexes were absent
Plantarflexion on both sides
Her dose of levipil for increased to
Inj levipil 1gm/IV/BD
Along with increase in carbamazepine oral dose to 1200mg
She received around 6mg of lorazepam
She was also started on Inj Dexamethasone 8mg /IV/BD
Neuro consultation was taken.
DAY 3:
The patient continued to have multiple recurrent episodes of seizures lasting for around 10secs each time
Her vitals were stable
All the reflexes were absent
Plantarflexion on both sides
Inj levipil 1gm/IV/BD
Tab carbamazepine oral 1200mg
She received around 6mg of lorazepam
She was also started on Inj Dexamethasone 8mg /IV/BD
Inj sodium valproate 500mg/IV/BD was added after receiving a bolus dose of 2g/IV in 100ml NS.
By evening her Inj sodium valproate was increased to 1gm/IV/BD.
DAY 4:
Patient continued to have recurrent episodes of seizures
She was started on Inj Midazolam
Iml/hour
DAY 5:
S - Patient is complaining pain at the site of iv cannula
Advised to change IV cannula
O - Patient has been tapared off Midazolam infusion at 1am
PR - 70bpm
Bp - 140/80mmhg
Afebrile
Cvs - S1, S2 +
R/S - clear on auscultation
P/A - soft
Non tender
A - Seizures secondary to ? NCC/Tuberculoma
P -
Continue
Inj Levipil 1gm/IV/BD
Inj Sodium Valproate 1gm/IV/BD
Tab Carbamazepine 400mg TID ( total dose of 1200mg)
Tab Diazepam 5mg TID
Inj Lorazepam SOS
Inj Dexamethasone 8mg/IV/BD
DAY 6-
S - Patient has no complaints.
No episodes of seizures since 2 days
O -
PR - 82bpm
Bp - 130/80mmhg
Afebrile
Cvs - S1, S2 +
R/S - clear on auscultation
P/A - soft
Non tender
A - Seizures secondary to ? NCC/Tuberculoma
P -Continue
Inj Levipil 1gm/IV/BD
Inj Sodium Valproate 1gm/IV/BD
Tab Carbamazepine 400mg TID ( total dose of 1200mg)
Tab Diazepam 5mg TID
Inj Lorazepam SOS
Inj Dexamethasone reduced to 8mg in the morning and 4mg at night
day 6 evening:
Her sister came to visit the patient
She tells us that the patient has a history of sexual abuse since 1 year and has been anxious regarding it.
We took the patient for a Psychiatry opinion and Gynobs opinion, meanwhile we sent a UPT for her which turned out to be negative.
Psychiatry department diagnosed her with 'ADJUSTMENT DISORDER' and started her on Tab Nexito which is Escitalopram and Tab Lonazep
Day 7-
her U.S.G abdomen was done
INJ Sodium Valproate was stopped.
DISCUSSION -
It remains unclear if he seizures are pseudoseizures or because of the granuloma in the right temporal region.
Open-label, randomized, prospective, follow-up study
P - 52 patients with new-onset seizures and a single enhancing CT lesion of cysticercus
I - Intravenous methyl prednisolone for 5 days along with antiepileptic drug (n = 25)
C - Antiepileptic drug monotherapy (n = 27) alone
O - After 2 months, lesion disappeared in 60% patients of intravenous methyl prednisolone group and 18.5% patients receiving only antiepileptic drug (p = 0.001). As far as seizure recurrence was concerned, a lower number (16% versus 33%) of intravenous methyl prednisolone treated patient had recurrence
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