F03. Could rash be an ictal phenomenon in temporal lobe epilepsy?

Abstract

Seizures in temporal lobe epilepsy (TLE) can cause cutaneous autonomic symptoms, including flushing, pallor, sweating and piloerection. Rash, however has never been described in the literature. We report a case of 46-year-old woman presented with seizures consisting of episodes of loss of consciousness preceded by auras of excessive heat, cold, nausea and urge to defecate. Her husband observed her to flail and roll her eyes back. She was amnesic for this episode except for preserved recollection of the aura. During seizure she always developed an erythematous pruritic rash that persisted for a day. She photographically documented her rash, showing extensive erythema with raised macules and papules, especially on the buttocks. Observed episodes lasted up to 10 min, but the concomitant rash always persisted for a day. Frequency of episodes was once or twice yearly. She denied palpitations, pain, or dyspnea with episodes. Workup prior to her initial neurology visit included echocardiography, tilt table testing, and Holter monitoring, which were all normal. Magnetic resonance imaging (MRI) of the brain showed increased signal intensity and loss of left hippocampal architecture with an en plaque meningioma over the left temporal convexity. Routine electroencephalogram (EEG) demonstrated intermittent left temporal slowing. Treatment with lamotrigine reduced seizure severity and frequency. With missed days of lamotrigine, breakthrough seizure auras with rash occur. Our case is one of dyscognitive seizures due to left temporal lobe epilepsy (TLE). The diagnosis of TLE was made by seizure semiology (altered behavior, amnesia), EEG (intermittent subtle left temporal slowing) and MRI of the brain (left hippocampal abnormality and left temporal en plaque meningioma). The diagnosis is supported by her good response to antiepileptic drug therapy and reappearance of seizures with occasional medication noncompliance. She has several uncommon symptoms with her seizures, including feelings of heat and cold, nausea and urge to defecate. Her seizures also cause one symptom not previously reported in the medical literature, pruritic erythematous rash.The mechanism and localizing value of rash in seizures is unknown because of its rarity, but our patient has good evidence of left temporal lobe localization for her seizures. Rash is the most unusual feature of her case, but an ictal urge to defecate is also unusual. Ictal urge to defecate has been reported quite rarely and she is only the fourth reported case. Contrary to the present case, evidence in previously reported cases of ictal urge to defecate suggested right temporal lobe localization. TLE is known to cause cutaneous autonomic manifestations including flushing, pallor, sweating and piloerection. These symptoms are thought to localize to the left temporal lobe. The present case shows that long lasting diffuse pruritic erythematous rash could also be an ictal phenomenon in left temporal lobe epilepsy.