Midazolam
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Generalised tonic–clonic seizure due to drug withdrawal: case report A 21-year-old woman developed generalised tonic–clonic seizure following withdrawal of midazolam. The woman was hospitalized due to acute change in mental state over previous 24 hours. She had agitation and was singing constantly. She also had altered sleep patterns and disorganised behavior. She had used marijuana for several years. Upon examination, psychotic mania was suspected. Hence, sodium valproate and olanzapine were commenced. Her persistent profound disinhibition was partially alleviated with chlorpromazine. She had received IM midazolam [dosage not stated] during early stages of agitation but later midazolam was stopped. She developed fever secondary to urinary tract infection (UTI) and started receiving unspecified treatment for UTI. Ten days after the admission, she developed generalised tonic-clonic seizure for 2 miuntes and it was considered that the seizure was secondary to withdrawal of midazolam [duration of treatment to reaction onset not stated]. Over the next 2 weeks, she had delirium and agitation. Thereafter, she experienced seizure on day 28 of the admission and developed signs of catatonic stupor. Later, she again developed fever of low grade, increased rigidity and increased level of creatine. These findings were indicative of neuroleptic malignant syndrome. Thereafter, olanzapine was discontinued and electroconvulsive therapy was initiated. Thereafter, she experienced right-sided focal motor seizure along with secondary generalization that required intubation and ventilation. Her EEG showed diffuse cerebral dysfunction. Additionally, levetiracetam, topiramate and phenobarbital [phenobarbitone] were started. Subsequently, she experienced involuntary stereotyped repetitive rolling movements, buccolingual dyskinesia, rapid eye movements and profound agitation. Thereafter, she again experienced generalised tonic-clonic seizures. Infectious or autoimmune encephalitis was suspected and empirical treatment with immune-globulin [immunoglobulin] was initiated on day 53 of the admission that showed modest improvements. However, her condition worsened and methylprednisolone was given that led to improvement in her rigidity, and she became expressive. Meanwhile, she had undergone paraneoplastic antibody testing that showed presence of antibodies to anti-N-methyl-daspartate (NMDA) NR1–NR2 receptors and anti-NMDA-receptor encephalitis was diagnosed. She underwent plasmapheresis; but, she had no significant improvement. Hence, laparotomy and bilateral oophorectomy were performed on day 120 of the admission and immunomodulation was continued with addition of rituximab. Thereafter, she had improvement in her rigidity and buccolingual dyskinesia. Over the next 9 months, her behavior and communication also improved. Neuropsychological investigation 14 months after the admission demonstrated cognitive performance in the high–average range. Parratt KL, et al. Acute psychiatric illness in a young woman: An unusual form of encephalitis. M
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