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Lack of response, and increased convulsive and non-convulsive seizure activity (withdrawal seizure): case report A 19-year-old man experienced lack of response during treatment with midazolam and propofol for non-convulsive status epilepticus with intermittent emergence of convulsive seizures. Subsequently, he developed increased convulsive and non-convulsive seizure activity (withdrawal seizure) following withdrawal of pentobarbital [not all dosages stated]. The man presented to a community hospital for seizure-like activity. After his return from vacation in the Caribbean, he was noted to have nausea and headaches without fever. On the day prior to the presentation, he had suffered several episodes of behavioural arrest followed by weird behaviour and confusional state, indicative of focal impaired awareness seizures. Thereafter, he suffered several generalised tonicclonic seizures. At that time, he was treated with levetiracetam and lorazepam. Thereafter, he was hospitalised to another hospital for higher level of care. After CSF analysis viral meningoencephalitis was suspected, and he was treated with aciclovir. He also received ceftriaxone and vancomycin for coverage against bacterial meningitis. These therapies were discontinued when the culture results came negative. After thorough investigation, he was diagnosed with non-convulsive status epilepticus with intermittent emergence of convulsive seizures. Meanwhile, he was treated with increased dose of levetiracetam and initiation of valproic acid. After the diagnosis, more aggressive treatments were tried. However, the seizures continued. On day 6, he required intubation for airway protection due to worsening mental status in spite of efforts to avoid intubation. For endotracheal tube irritation/ tolerance and seizure management, anaesthesia was started with IV midazolam infusion [initial dose not stated]. But, neither seizure suppression nor burst suppression was achieved with midazolam 10 mg/hour infusion. Therefore, midazolam was switched to IV propofol with burst suppression requiring high doses [maximum dose: 50 µg/kg/hr]. However, seizures continued at lower doses. Therefore, propofol was switched to IV pentobarbital [maximum dose: 5 µg/kg/hr]. Over the following several weeks, multiple anti-epileptics and anaesthetics were tried in an attempt to wean him from barbiturate coma. After extensive work-up a tentative diagnosis of new-onset refractory status epilepticus secondary to anti-GAD 65 antibodies was made. He was treated with plasma exchange, high-dose unspecified steroids and eventually immune-globulin for 5 days. The ketogenic diet was started and maintained throughout hospitalisation. No immediate or delayed response was observed to these treatments within the first 30 days of admission. He received first dose of rituximab on day 22. Brain PET scan showed ongoing multifocal seizures. Convulsive and non-convulsive seizure activity consistently resumed at higher frequencies of 10–20 /hour upon weaning off pentobarbital (withdrawal seizures) [dur