The wilting widow’s masquerading illness

Mrs. D’s symptoms had an episodic quality with sudden onset, were repeatedly associated with aphasia, and included some automatic behavior (including dressing and undressing) suggestive of seizures. Symptoms of depression should not be surprising in this context because depression may be the most common comorbid psychiatric condition in elderly persons with epilepsy.¹³ Indeed, Mrs. D’s ultimate diagnosis—NCSE—is characterized by great variability in presentation, ranging from mildly impaired attention and orientation to mood disturbance, speech disturbance, and psychosis. All of these symptoms are seen with seizures.

Further, NCSE can have gradual or sudden onset, varying intensity and duration of symptoms, and fluctuating responsiveness.¹⁴ At least 10% of patients presenting with NCSE have no history of seizures.¹⁵ Precipitating factors include infection and drug toxicity.¹⁴

In reviewing Mrs. D’s case, it is possible that she was in NCSE at her initial presentation, perhaps related to her recent sepsis and subsequent treatment with ciprofloxacin; fluoroquinolones can promote seizures, particularly among elderly patients.¹⁵ By the time Mrs. D was readmitted, her seizures were more dramatic and possibly affected by another fluoroquinolone (levofloxacin) in combination with bupropion.

OUTCOME: Dual treatment

During a one-week neurology hospitalization, Mrs. D continues to receive phenytoin. Long-term EEG monitoring reveals she is no longer in status epilepticus. The patient is prescribed citalopram, 10 mg/d, and olanzapine, 2.5 mg at bedtime, to resolve mild depressive symptoms and hallucinosis. Mrs. D is referred for both neurology and psychiatry outpatient follow-up.

Table 2

Is the patient’s disorder psychiatric or medical/neurologic?

Are the symptoms typical of a psychiatric disorder, including the severity?
Are the onset and course of symptoms usual?
Does the patient have risk factors for psychiatric illness, such as a personal or family history of psychiatric illness?
Are psychiatric symptoms responding poorly to treatment?
Does the patient have a general medical or neurologic condition commonly associated with psychiatric symptoms?
Does the patient exhibit abnormal cognitive functioning, including memory impairment or altered level of consciousness?
Did the psychiatric symptoms emerge after an abrupt change in personality?
Source: Reference 12

Related resources

• Ettinger AB, Kanner AM, eds. Psychiatric issues in epilepsy: a practical guide to diagnosis and treatment. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
  

Drug brand names

• Bupropion • Wellbutrin
  
• Ciprofloxacin • Cipro
  
• Citalopram • Celexa
  
• Levofloxacin • Levaquin
  
• Olanzapine • Zyprexa
  
• Phenytoin • Dilantin
  
• Zolpidem • Ambien
  

Disclosures

Dr. Saragoza reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Maixner receives research/grant support from Neuronetics Inc., and is a speaker for Pfizer Inc., Bristol-Meyers Squibb, Janssen LP, and AstraZeneca.