Seizures after Recent Concussion

Abstract

HISTORY: A 14 year old high school football player, being treated for 3 prior concussions, most recently 6 weeks ago, presents to the Emergency Department (ED) after a witnessed seizure at home. He was last seen in the office for follow up of concussion 3 weeks ago, tolerating full days of school and hoping to begin the return to play protocol after his next visit. The most recent total symptom score on the Post-Concussion Symptom Scale was 13. One week prior to presenting to the ED he was sick with a high fever and headache which resolved after a few days. According to his parents, he had a prior apparent seizure a few years ago secondary to fever and dehydration. Upon arrival at the ED, two more tonic-clonic seizures were witnessed. He was then admitted to Pediatric Intensive Care Unit for further monitoring and treatment. PHYSICAL EXAMINATION: In-hospital consultation revealed lethargic but responsive male, oriented to person only. Cranial nerves II-XII grossly intact without deficits; pupils equal, round and reactive to light and accommodation. The remainder of physical exam was normal except for mild tenderness to palpation of the lower thoracic and upper lumbar spines. Multiple erythema migrans were noted the day after admission. DIFFERENTIAL DIAGNOSIS: 1.Late post-traumatic seizure (secondary to concussion) 2.Metabolic encephalopathy 3.Seizure secondary to hypernatremia 4.Seizure disorder 5.Seizure secondary to methamphetamine use 6.Lyme disease TESTS AND RESULTS: WBC: 16.5, teardrop cells, large platelets on differential; Na: 154; Lactic acid: 20.5 UA: positive for blood; SG >1.030; Urine drug screen: positive for methamphetamine Head CT: No acute hemorrhage or extra-axial collections Brain MRI: No abnormal enhancement noted. CSF: ELISA positive for Lyme, IgM Lyme 3 bands positive, IgG Lyme 3 bands positive FINAL/WORKING DIAGNOSIS: Lyme encephalitis TREATMENT AND OUTCOMES: 1.Three weeks of oral doxycycline and IV ceftriaxone via PICC line. 2.Levetiracetam 250mg by mouth three times daily. 3.Follow up: Neurology 3 weeks after discharge from hospital. 4.Follow up: Infectious Disease weekly for 1 month. 5.Follow up: Sports Medicine for further concussion management.