An Unusual Case of Altered Mental Status Secondary to Non-Convulsive Epilepsy

Document Type

Conference Proceeding

Publication Date

4-2023

Abstract

Introduction

Altered mental status is a common presenting symptom in the emergency department. ?Accurate diagnosis of the cause requires a comprehensive history, physical examination and diagnostic studies. Epilepsy is not an uncommon cause of acute encephalopathy and may present without convulsions. ?This case illustrates a patient who presented with mental status and behavior changes due to non-convulsive epilepsy.

Case Presentation

73-year-old male with past medical history of coronary artery disease and marijuana use presented to the emergency department with chief complaint of altered mental status?. His son reports one episode of emesis the prior evening. On the morning of admission, he called his son confused; didn’t know his son’s name, and stated he was going to drive to a non-existent location?. His son found him several hours later in a parking lot and brought him to the emergency room?. Of note, three months prior to this episode, patient was hospitalized for similar symptoms which resolved spontaneously, but no etiology was determined.? On physical exam, he was agitated, oriented to person and place but not to time?. He had no focal neurologic deficits. His initial work up showed normal complete blood count and comprehensive metabolic panel. His urine drug screen was positive for cannabis. Computed Tomography (CT) non-contrast head showed chronic ischemic demyelination. MRI brain without gadolinium showed a remote infarct of the right temporal lobe but was negative for any acute process. Continuous 24-hour Video EEG revealed right temporal sharp wave discharges (interictal epileptiform activity), and focal slowing in the right temporal region consistent with underlying focal epilepsy. He was loaded on antiepileptic medication (AEM) with improvement in mental status and he was discharged home 24 hours later. ?At one week follow-up with the neurologist, the patient remained asymptomatic and there was no vomiting, so he was continued on the AEM?.

Discussion

Acute encephalopathy has a broad differential, including toxic-metabolic, infectious, and structural causes. Epilepsy is not uncommon and encompasses a group of disorders including seizures with other signs and symptoms. Temporal lobe seizures (TLS) are the most common type of partial seizures. Some patients may experience preictal events and prodromes that include emesis, headaches, irritability, or anxiety. TLS are most associated with sensory auras such as fear, deja and jamais vus, visceral and auditory hallucinations. Some automatisms have also been reported with TLS such as “leaving behaviors” like running away from the house during a seizure. Our patient presented with non-focal symptoms and did experience vomiting and leaving behavior. He responded well to anti seizure medications. The etiology of his encephalopathy was only diagnosed by performing a video EEG which shows the importance of a broad differential and extensive work up. ?

Comments

American College of Physicians Internal Medicine Meeting, April 27-29, 2023, San Diego, CA

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