Postgraduate Medicine ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20 Psychomotor status epilepticus masking as a stroke Jeffrey M. Behrens To cite this article: Jeffrey M. Behrens (1980) Psychomotor status epilepticus masking as a stroke, Postgraduate Medicine, 68:5, 223-226, DOI: 10.1080/00325481.1980.11715605 To link to this article: http://dx.doi.org/10.1080/00325481.1980.11715605 Published online: 07 Jul 2016. Submit your article to this journal View related articles Citing articles: 4 View citing articles Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University] Date: 20 August 2017, At: 09:55 Psychomotor status epilepticus masking as a stroke Downloaded by [Australian Catholic University] at 09:55 20 August 2017 Jeffrey M. Behrem., MD POSTGRADUATE MEDICINE invites submission of brief case reports, espe-ciaUy those related to ambulatory medical care. IUustrations and references should be included onll when essential. CASE REPORT A 79-year-old woman with a fouryear his tory of hypertension was admitted to Nassau County Medical Center, East Meadow, New York, in an unresponsive state. Every few months during the year prior to admission she had had periods of light-headedness and tiredness lasting four to five hours. On the day of admission she aga in felt tired and light-headed. That evening she was noted to have twitching movements of the upper extremities followed by a staring spell. She then became unresponsive to external stimuli and was brought to the emergency room by her family. She had no his tory of seizure disorder or trauma or symptoms of headache, fever, photophobia, nausea, vomiting, stiff neck, aura, or incontinence. There was no family history of seizure. Hypertension had been controlled with a combination of methyldopa, 250 mg, and hydrochlorothiazide, 15 mg (Aidoril-15), three times a day. She also was taking indomethacin (lndocin), 25 mg, three times a day for arthritis. In the emergency room the patient was noted to be confused and incontinent of feces. Vital signs were stable: temperature 35.5 C (96 F), pulse rate 108/min, respiratory rate 24/min, and blood pressure 130/88 mm Hg. Findings on examina tian of the head, ears, eyes, nase, and throat were unremarkable. The neck was supple with normal carotid pulses and no bruits. Auscultation of the lungs revealed bibasilar rhonchi. Heart findings were normal. Neurologie examination showed receptive aphasia but no response to painfui stimuli. The patient randomly moved ali four extremities and did not respond to sensory stimulation. Cranial nerve function was intact except for questionable left facial paisy (VII); no evaluation of the first nerve was done, and the patient was uncooperative in evaluation of the eleventh and twelfth nerves. Deep tendon reflexes were exaggerated (3 +) bilaterally, and the Babinski sign was positive on the left. Laboratory tests revealed a leukocyte count of 16,800/cu mm with a significant left shift and blood glucose level of 222 mg/dl. Hemogram, electrolyte values, and results of multichannel biochemical anal ysis (SMA-12) and urinalysis were within normallimits, including a serum calcium level of 9.2 mg/dl and serum magnesium level of 2.2 mg/dl. A chest x-ray film revealed pulmonary vascular congestion, a skull x-ray film was normal except for a demineralized sella, and an ECG showed sinus tachycardia continued VOL 68/NO 5/NOVEMBER 1980/POSTGRADUATE MEDICINE • STATUS EJIILEPTICUS 223 Downloaded by [Australian Catholic University] at 09:55 20 August 2017 CAS& R&PORT CONTINUED with nonspecific ST-segment and T-wave abnormalities. Spinal tap revealed clear, colorless fluid at 140 mm H 20 pressure, with normal glucose and protein values and no cells. Results of the following tests were negative: cultures of blood and CSF specimens for acid-fast bacillus, VDRL, fungal cultures, cryptococcal antigen test, and cytologie studies. Blood ammonia levet was 79 J.Lg/dl (normal 50 to 100). The presumptive diagnosis was cerebrovascular accident or postictal state. The next day the patient remained confused and disoriented to persan, place, and time but obeyed simple commands. The possibility of viral infection or taxie encephalopathy was considered because of temperature to 38.8 C (1 02 F), persistent! y elevated leukocyte count, and lack of positive findings on chest film, spinal fluid culture, urinalysis, and blood cultures. An EEG revealed left temporal spike and slow waves. The neurologie consultant suggested encephalopathy or abscess or septic infarct as possible diagnoses. The patient was started on therapy with antibiotics. Irregular supraventricular rhythm and congestive heart failure developed, for which digitalis therapy was begun. Computed tomography revealed mild to modera te dilatation of the third and fourth lateral ventricles consistent with cerebral atrophy and a small ( 15-mm) low-density lesion in the left frontal opercular 224 region consistent with an infarct. The possibility of psychomotor status epilepticus was raised. During constant EEG monitoring, 1 gm of phenytoin (Dilantin) was slowly infused, followed by 5 mg of diazepam (Valium). Thereafter, spike and slow wave discharges from the left temporal region occurred less frequently, and maintenance therapy with 300 mg of oral phenytoin dai!) was started. The following day the patient responded normally to questioning, and over subsequent da ys temperature and leukocyte count feil. Four days later, a repeat EEG revealed less spike and wave activity and failure of the remaining seizure activity to be propagated over the surface of the brain. She was discharged on the eleventh day after admission, to be followed up in the neurology clinic. Discussion Psychomotor (temporal lobe) status epilepticus, also known as complex partial seizure, is defined as a series of psychomotor seizures of rapid succession that cause the patient to remain in a constant postictal state with depressed leve! of conscious- JeHrey M. Behrena Dr Behrens was formerly a resident, department of medicine, Nassau County Medical Center, East Meadow, New York. He is now captain, US Army Medical Corps, Walson US Army Hospital, Fort Dix, New Jersey, where he is an internist in charge of the cardiology clinic, department of medicine. ness. 1 The case reported here shows the cryptic manner in which this condition can present. There have been only five welldocumented cases of psychomotor status epilepticus, according to Celesia. 2 Diagnosis is not difficult if the patient has repeated psychomotor seizures; however, if the patient is in a stupor, as was true in this case, an EEG is necessary to confirm the diagnosis. This case had many interesting facets which made diagnosis di fficult; sorne remain unexplained. The patient's hypertension and year of episodic light-headedness and tiredness suggested a history of cerebrovascular disease. On admission, this plus the questionable left facial paisy and the positive Babinski sign were highly suggestive of a cerebrovascular accident. On the other hand, the twitching movements, staring spell, and fecal incontinence suggested seizure followed by a postictal state. The causes of status epilepticus are numerous. In over 50% of patients in one series 3 a lesion accounting for a focus of seizure activity could be found. The lesions included birth trauma, residua of encephalitis, and neoplasms. In the case reported here it is possible the infarct in the left opercular area of the brain acted as a seizure focus in the same way that an infarct in another portion of the brain could elicit generalized (grand mal) seizure activity. It is hard to say when the infarct continued ITATU8 EPLEPT1CUS • VOL 68/NO 5/NOVEMBER 1980/POSTGRAOUATE MEDICINE P+S CAS& RI!PORT CONTINUED PROBLEMS+SOLUTIONS Downloaded by [Australian Catholic University] at 09:55 20 August 2017 May we help you? developed. The acute event may have triggered the seizure activity. and symptoms from the previous year could have represented small transient ischemie attacks or microinfarcts. Possibly, the patient had had a cerebrovascular accident in the temporal region that was not noticed owing to a lack of sensory or motor deficits. Either one of these theories could explain the clinical picture. The left-sided Babinski sign is puzzling. Possibly, it was due to a second infarct on the right side of the brain that was not detected by computed tomography, or it may have been secondary to the seizure itself. Truex and Carpenter4 point out that a positive Babinski sign can be present in an adult who is sleeping or intoxicated or who has just had a seizure and may not be present with lesions of the corticospinal tracts! The leukocytosis, fever, and sudden onset of supraventricular arrhythmia with congestive heart failure remain unexplained. The leukocytosis and fever suggested meningitis, concomitant infection, or tu mor as the cause of seizure. Leukocytosis could be accounted for by the stress caused by status epilepticus. Hyperthermia could be caused by continuous muscle contractions occurring in a motor seizure, but this did not take place in the case reported here. Perhaps the patient had a source of infection unknown tous that was adequately treated with the antibiotics. Possi226 ble mechanisms of the arrhythmia and congestive heart failure are ( 1) stress imposed on an already compromised hypertensive heart or either (2) seizure activity causing arrhythmia or (3) fever causing tachyarrhythmia, resulting in congestive heart failure. Summary and conclusion An elderly patient with no history of seizure disorder or trauma was admitted to a county medical center in an unresponsive state. An initial diagnosis of cerebrovascular accident or postictal state was made. However, further evaluation including constant EEG monitoring revealed psychomotor status epilepticus, which was successfully controlled with anticonvulsants. The patient's dramatic improvement following treatment emphasizes the importance of rapid diagnosis and proper therapy for this most interesting condition. . . . Do you need another opinion? When you want consultation about a problem case- its diagnosis, probable course, possible complications, treatment, or potential sequelaesend us your query. Be as succinct as possible, but be sure ta include ali pertinent details. We cannat publish photographs or tracings, but these may be included with the query if essential ta an understanding of the case. We shall try ta return ali su ch material but cannat assume responsibility for its loss. We will submit your question ta one or more of our consultants -ali outstanding specialistsand promptly forward the reply ta you. Selected problems are published anonymously each month. Address reprint requests ta Jeffrey M. Behrens. MD, Walson US Army Hospital, 1614A Ash St, Fort Dix, N J 08640. References 1. Baker AB, Baker H. Clinical neurology Il. Chap 24. New York: Harper & Row, 1976:19 2. Celesia GG. Modern concepts of status epilcpticus. JAMA 1976;235: 1571-4 3. Beeson PB, McDermott W, eds. Textbook of medicine. 14th cd, sec 16. Philadelphia: WB Saunders, 1975:727 4. True" R, Carpenter M. Human neuroanatomy. 6th ed, chap 13. Baltimore: Williams & Wilkins, 1969:279 STAT\18 EPILEPTICUS Send queries to: Problems+Solutions POSTGRADUATE MEDICINE 4530 W 77th St Minneapolis, MN 55435