Clinical Topics

Case Study: Patient Found Unresponsive


 

References

Nikesh Ardeshna, MD

Dr. Ardeshna is the Medical Director of Epilepsy Services for the Erlanger Health System in Chattanooga, Tennessee.

The patient is a 46-year-old male with a history of HIV and previous intracranial lymphoma treated with chemotherapy and radiation. He was last treated six months ago; at that time he was tumor free. The patient is found unresponsive in his bed one morning by his mother. He is noted to be bleeding from the corner of his mouth. In the ED the patient is obtunded. He briefly opens his eyes to painful stimuli and withdraws his lower extremities to pinprick. He does not follow commands. A CT of the head without contrast is negative. The patient is afebrile.

Initial differential diagnosis include(s):

A. Stroke

B. Tumor

C. Drug overdose

D. Meningitis/encephalitis

E. Seizure

F. All of the above

The correct answer is F—all of the above. Note that the initial head CT can be negative in each of the above cases.

A routine EEG shows almost continuous 2-3 Hz sharp waves over the left frontotemporal region. The patient is loaded with IV levetiracetam and started on a maintenance dose of 1,000 mg IV q12hrs. An MRI of the brain shows a left temporal mass with surrounding vasogenic edema. The patient is started on steroids. Continuous video-EEG is also started. After one day of treatment with the above, the patient is more alert and is able to follow commands intermittently. His exam is significant for a partial expressive and receptive aphasia. The continuous EEG shows five electrographic seizures over 24 hours originating from the left frontotemporal region, each lasting about 20 to 35 seconds. Occasional left frontotemporal sharp waves are seen.

Based on the above information, over the course of the night prior to admission the patient likely experienced a:

A. Seizure

B. Stroke

C. Hemorrhage

D. TIA

The correct answer is A—seizure. Given the way the patient was found bleeding from the corner of his mouth, obtunded (likely postictal), and the findings of a new intracranial lesion, the most likely diagnosis is a seizure secondary to a brain tumor.

Factors that could be contributing to the patient’s partial expressive and receptive aphasia include:

A. Recurrence of tumor

B. Swelling surrounding the tumor

C. Recurrent/intermittent seizures

D. Post-ictal effects of seizures

E. All of the above

The correct answer is E—all of the above. The location of the tumor—left frontotemporal region (near the speech center)—along with its surrounding edema is contributing to the symptoms. In addition, the patient continues to have intermittent seizures from the same region. Moreover, some of the speech difficulties could be postictal symptoms.

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