Abstract
A 13-year-old girl arrived at a community emergency department following a fall while snowboarding. The patient had been unwell with a low-grade fever a week before this presentation. Six hours after her fall, she experienced four separate generalized tonic-clonic seizures, each lasting less than 3 min. She was treated with lorazepam and phenytoin. A lumbar puncture revealed zero red blood cells, 36 white blood cells with 94% lymphocytes. Cerebrospinal fluid (CSF) glucose and protein levels were normal. At the tertiary care centre, the patient had a fluctuating level of consciousness. Her vital signs were stable and she was afebrile. Her physical examination revealed a drowsy girl with a generally normal examination. Her muscle tone was reduced but symmetrical. There were no focal neurological findings. Acyclovir and ceftriaxone were started empirically. Phenobarbital and phenytoin were given for seizure management. Computed tomography and magnetic resonance imaging of the head were normal. CSF cultures were negative. The patient continued to have seizures despite treatment. Continuous electroencephalogram monitoring showed obvious seizure activity, including many subclinical episodes. Multiple antiepileptic drugs were required to achieve adequate seizure control. Further investigation revealed the cause of this girl’s problem.
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