Cases That Test Your Skills

A teen with seizures, amnesia, and troubled family dynamics

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Ms. A, age 13, is admitted for acute-onset amnesia. She has been treated for intractable seizures for 5 months. What could be causing her amnesia?



CASE Seizures, amnesia
Ms. A, age 13, who has a history of seizures, presents to the emergency department (ED) with sudden onset of memory loss. Her family reports that she had been spend­ing a normal evening at home with family and friends. After going to the bathroom, Ms. A became acutely confused and extremely upset, had slurred speech, and did not recognize anyone in the room except her mother.

Initial neurologic examination in the ED reports that Ms. A does not remember recent or remote past events. Her family denies any recent stressors.

Vital signs are within normal range. She has mild muscle soreness and gait instability, which is attributed to a presumed postictal phase. Her medication regimen includes: leve­tiracetam, 500 mg, 3 times a day; valproic acid, 1,000 mg/d; and oxcarbazepine, 2,400 mg/d, for seizure management.

Complete blood count and comprehen­sive metabolic panel are within normal limits. Pregnancy test is negative. Urine toxicology report is negative. Serum valproic acid level is 71 μg/mL; oxcarbazepine level, <2 μg/mL; ammonia level, 71 μg/dL (reference range, 15 to 45 μg/dL). Other than the aforementioned deficits, she is neurologically intact. The team thinks that her symptoms are part of a postic­tal phase of an unwitnessed seizure.

Ms. A is admitted to the inpatient medi­cal unit for further work up. Along with the memory loss and seizures, she reports visual hallucinations.

What could be causing Ms. A’s amnesia?

a) a seizure disorder
b) malingering
c) posttraumatic stress disorder
d) traumatic brain injury

HISTORY Repeat ED visits
Ms. A’s mother reports that 3 years ago her daughter was treated for tics with quetiapine and aripiprazole, prescribed by a primary care physician. She received a short course of coun­seling 6 years ago after her sister was sexually abused by her grandfather. Approximately 6 months ago, Ms. A engaged in self-injurious behavior by cutting herself, and she briefly received counseling. There is no history of sui­cide attempts, psychiatric hospitalization, or a psychiatric diagnosis.

Medical and surgical history include viral meningitis at age 6 months. Medical records show a visit to the ED for abdominal pain after a classmate punched her in the abdomen, which resolved with supportive care. She was given a diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections 6 years ago.

Ms. A developed multiple recurrent methicillin-resistant Staphylococcus aureus abscesses a year ago, which lasted for 4 months; it was noted that she was self-inoculating by scratching eczema. She had a possible syncopal episode 5 months ago, but the medical work-up was normal. The pediat­ric neurology service diagnosed and treated seizures 4 months ago.

Levetiracetam was prescribed after a pos­sible syncopal episode followed by a tonic-clonic seizure. Because she was still having seizure-like episodes with a single antiepilep­tic drug (AED), oxcarbazepine, then valproic acid were added. Whether her seizures were generalized or partial was inconclusive. The seizures were followed by a postictal phase lasting 3 minutes to 1 hour. Her last general­ized tonic-clonic seizure was 1 month before admission.

Ms. A had 3 MRI studies of the brain over the past 3 years, which showed consistent and unchanged multifocal punctate white matter lesions. The findings represented gliosis from an old perivascular inflammation, trauma, or ischemic damage. There is no history of trau­matic brain injury.

Her perinatal history is unremarkable, with normal vaginal delivery at 36 weeks (pre-term birth). All developmental milestones were on target.

Ms. A lives at home with her mother, 6-year-old brother, and stepfather. Her par­ents are divorced, but her biological father has been involved in her upbringing. She is in seventh grade, but is home schooled after she withdrew from school because of mul­tiple seizure episodes. Ms. A denied bullying at school although she had been punched by a peer. It was unclear if it was a single incident or bullying continued and she was hesitant to disclose it.

The authors’ observations

We focus on the amnesia because it has an acute onset and it seems this is the first time Ms. A presented with this symptom. There is no need to wait for neurology consultation, even though organic causes of amnesia need to be ruled out. Our plan is to develop rapport with Ms. A, and then administer a mental status examina­tion focusing on memory assessment. We understand that, because Ms. A’s chief concern is amnesia, she might not be able to provide many details. We start the initial interview with the family in the patient’s room to understand family dynamics, and then interview Ms. A alone.

EVALUATION Memory problems

On initial psychiatric interview, Ms. A can rec­ognize some of her family members. She is seen in clean attire, with short hair, lying in the bed with good eye contact and a calm demeanor. She seems to be difficult to engage because of her reserved nature.


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