Episode Of Tonic-clonic Seizure Research Articles

#3739 SHUNT PORTOSYSTEMIC COMPLICATED BY HYPERAMMONEMIA AND HEPATIC ENCEPHALOPATHY SUPPORTED BY DAILY DIALYSIS IN A CHRONIC HEMODIALYSIS PATIENT

Abstract Background and Aims Hepatic encephalopathy is a neuropsychiatric syndrome that may develop as a consequence of liver insufficiency. In acute liver failure, hepatic encephalopathy suggests the severity of the disease. In end-stage chronic liver diseases, episodes of hepatic encephalopathy are frequently fully and spontaneously reversible. Clinical manifestations vary from mild neuropsychiatric disorders to coma. The pathogenesis of hepatic encephalopathy is complex and not clearly understood. Ammonia plays a key role. In the healthy individual, ammonia is, during its first hepatic passage, directly degraded into urea, itself excreted by the kidney and the stools, and to a lesser degree in glutamine. Ammonia is also metabolized by the muscle striped. In case of liver failure and/or shunts portosystemic, there is a defect in hepatic clearance ammonia which is then found in excess in systemic circulation. Decreased muscle mass, linked to malnutrition, frequent in the patient cirrhotic and chronic hemodialysis, also helps to decrease metabolism ammonia. Due to the increase in permeability of the blood-brain barrier, the brain is exposed to excessive concentrations ammonia causing functional brain abnormalities and structural, which can partly explain the signs neurology of hepatic encephalopathy. In end stage chronic renal failure, clearance of ammonia via extracorporeal treatment has not been systematically evaluated. Several studies with small samples have demonstrated the effectiveness of hemodialysis, compared to peritoneal dialysis, in terms of ammonium purification in chronic renal failure, on dialysis or not on dialysis. The aim of this study was to evaluate the effectiveness of daily dialysis for the purification of ammoniumin a chronic hemodialysis patient with hepatic encephalopathy. Case Report A 40-year-old man undergoing chronic hemodialysis was referred to gastroenterology department of Mohammed VI University center of Marrakesh for inoperable shunt portosystemic complicated by hyperammonemia causing hepatic encephalopathy consisting of headaches and seizures. His medical history was significant for liver cirrhosis caused by infection with hepatitis B, end stage kidney disease due to membranoproliferative glomerulonephritis, for which the patient is on hemodialysis at the rate of 3 sessions per week. The patient went on to develop portal hypertension and ascites requiring frequent hospital admissions and treatment with diuretics. He was on a low-protein and low-sodium diet. While on oral furosemide 250 mg daily and spironolactone 100 mg daily, his diuresis was adequate. Before referral, this patient had already suffered 4 episodes of tonic clonic seizures. His 1st hemodialysis session in our training was on January 10, 2023, he was given daily hemodialysis sessions with daily blood tests, including immediate pre and post dialysis ammonia. Pre-dialytic ammonia levels varied between 103 and 161 µmol/l, as well as post-dialytic ammonia levels varied between 24 and 37 µmol/l, knowing that the normal value of laboratory ammonia varied between 10 and 51 µmol/l. The evolution was marked by a clear clinical improvement, with a disappearance of the seizures without a significant drop in ammonia after 14 daily hemodialysis sessions. Serum creatinine and urea declined, and sodium increased. Accumulation of ascites slowed and the patient could eat and sleep normally and was again independent with self care. The patient returned home on January 24. Conclusion This study shows the interest of daily hemodialysis sessions as a potential treatment for hyperammonemia in a patient on chronic intermittent hemodialysis, with a portosystemic shunt. The interest lies in the fact that the improvement is mainly clinical than biological (persistent hyperammonemia).

THE COMPLEXITY OF DUAL PATHOLOGY: REGARDING A CASE REPORT OF SEIZURES

IntroductionWernicke’s encephalopathy (WE) is a potentially reversible neuropsychiatric emergency caused by thiamine deficiency, whose classical triad consists of acute onset of confusion, gait ataxia, and oculomotor dysfunction. The diagnosis is missed in 75-80% of cases and approximately 80% of untreated patients develop Korsakoff Syndrome, which is characterized by memory impairment associated with confabulation. Early recognition of nutritional deficiency or any portion of the triad is critical and should prompt treatment, since WE is readily reversible if treated with adequate doses of parenteral thiamine.ObjectivesStarting from a case report of suspected WE, we pretend to discuss the differential diagnosis of seizures in dual pathology.MethodsNon-systematic review of the literature was performed in PubMed database using the keywords “Wernicke’s Encephalopathy”, “Seizures”, “Alcohol” and “Benzodiazepines”. The articles were selected according to their relevance. A patient´s clinical record was reviewed and presented.ResultsWe present a case of a 44-year-old Ukrainian man with suspected background of chronic alcohol abuse and psychiatric history of schizoaffective disorder, who presented with acute onset of confusion, psychomotor agitation, gait ataxia and nystagmus. Anamnesis was hampered by the language barrier and absence of past medical history and patient’s alcoholic habits remained unclear. After suspicion of WE it was introduced thiamine and diazepam, with significant improvement. After discontinuation of diazepam, the patient presented with several episodes of tonic-clonic seizures. He was medicated for seizures with clinical stabilization. At time of discharge the diagnostic discussion prevailed.Seizures are a common presentation of various conditions associated with alcohol use, whose differential diagnosis is difficult, especially in patients with dubious alcohol consumption. Alcohol abuse is a major precipitant of status epilepticus as seizure threshold is raised by alcohol drinking. Seizures may also occur during alcohol withdrawal, for which treatment with benzodiazepines is recommended, however carefully, since both abrupt cessation and high-dose use are critical for the appearance of seizures. Although very rare, WE may also present with seizures, whereby overdiagnosis and overtreatment are preferred to prevent persistent neurocognitive impairments.ConclusionsThis case illustrates the complexity of neuropsychiatric diagnoses in dual pathology. It requires a longitudinal assessment for a better understanding of clinical conditions and establishment of the best therapeutic approach.Disclosure of InterestNone Declared

Diagnosis Challenge of Neurocysticercosis in the Rural Area

Neurocysticercosis (NCC) is caused by infection with the larvae of Taenia solium and is the leading preventable cause of adult‑onset seizure worldwide. The most common route of transmission is by ingestion of T. solium eggs through the fecal–oral route. Common causes of this infection include consuming undercooked food, especially pork, water contaminated with T. solium or uncooked vegetables as well as poor hygiene habits. Epilepsy is the most common clinical manifestation of 70-90% in endemic areas. The case of a 45-years-old woman with history of 4 minutes episode of tonic-clonic seizure 30 minutes before go to the emergency department (ED). There is a history of 2 weeks of progressive headache and fevers with 3 day of acutely worsening headache, nausea and vomiting. Approximately 4-6 weeks earlier, the patient had begun to experience mild headache and fatigue. She was born and lived in East Nusa Tenggara and work as a farmer in Kupang. On physical examination, the patient had Babinski pathology reflexes is positive in left lower extremity. Patient have been head CT-Scan with contrast. Patients were treated with Albendazole, dexamethasone, phenytoin and omeprazole. Keywords: Neurocysticercosis, diagnosis, rural area

TOXIC EPIDERMAL NECROLYSIS INDUCED BY PHENYTOIN: AN UNCOMMONLY USED ANTIEPILEPTIC DRUG IN HIGH-INCOME COUNTRIES

<h3>Introduction</h3> Toxic epidermal necrolysis (TEN) is a rare, severe cutaneous adverse reaction; a form of type IV hypersensitivity, usually drug-induced. Phenytoin, an old antiepileptic, is strongly associated to TEN. Cases are rarely seen now, though, since phenytoin is rarely used in the U.S. We describe a patient with TEN provoked by phenytoin prescribed abroad. <h3>Case Description</h3> A 14-year-old female with past medical history of repaired meningocele and tethered cord complicated by CSF leak and meningitis at the age of 1 year old, had new onset of 2 episodes of tonic-clonic seizures, and was prescribed phenytoin and phenobarbital (the only 2 antiepileptics available in that Pacific Island). Three weeks later, she developed fever and bullous rash that rapidly spread to involve entire body including buccal, genital, and ocular mucosa. Antiepileptics were discontinued due to suspected TEN. Laboratory work-up was negative for autoimmune and multiple infectious etiology. She received meropenem and clindamycin but no immunologic therapy. On transfer to our institution, 2 weeks after, she was afebrile and most of the skin lesions were crusted and dried. Antibiotics were stopped and aggressive wound care, along with ophthalmology care for ocular adhesions, were provided. She was discharged 3 weeks after. <h3>Discussion</h3> TEN is a serious, urgent hypersensitivity condition. It must be promptly recognized, and the potential cause(s) identified and stopped to prevent further damage. The association with phenytoin is well established but rarely seen and poorly recognized by young trainees. This case provided a learning opportunity to all specialist in Allergy and Immunology.

Hormesis Effect of Radon in Rats of the Krushinsky-Molodkina Line

According to this research, the use of radon inhalation in experimental animals, particularly in genetically determined rats with epileptic seizures, altered all parameters of the epileptic seizure development picture, namely the hidden period and the first and second wild jog duration after the audiogenic signal. On the third day, no response to the audiogenic signal was observed at all, and there was not even a single episode of tonic-clonic seizures. All what was mentioned suggests that radon inhalation can be used to treat epilepsy. This study is the first precedent of attempting R-Ho through inhalation for treatment of epileptic seizures in animal models with further translation to clinical study in humans through pilot phase II study. More profound and scientifically systematized approach is needed to determine the uniqueness of Tskhaltubo water springs, investigating the mechanisms of radon effects on the excitatory and inhibitory functioning of CNS, and the use of further clinical studies to establish its effectiveness on humans.&#x0D;

The Trident in the Brain- A Case of Osmotic Demyelination Syndrome Secondary to Alcohol Withdrawal

Osmotic Demyelination Syndrome (ODS) is characterised by demyelination of pons and is also called as central pontine myelinolysis. It has been observed in patients with alcohol dependence, although hyponatraemia remains the most common cause. It should be suspected in chronic alcoholics and especially in those with protracted delirium tremens. Magnetic Resonance Imaging (MRI) is the modality of choice to diagnose this condition with a trident or pig snout appearance of pons being the characteristic finding. This publication discusses the case of a 27-year-old male who reported to the casualty ward in a delirious state following an episode of tonic clonic seizures and was diagnosed with alcohol withdrawal with pontine myelinolysis.

Assessment of Integrated Antioxidant Systems and Hormezis Effect of Radon in Experimental Studies

According to our research, the use of radon inhalation in experimental animals, particularly in genetically determined rats with epileptic seizures, altered all parameters of the epileptic seizure development picture, namely the hidden period, the first and second wild jog duration after the audiogenic signal. On the third day, no response to the audiogenic signal was observed at all, and not even a single episode of tonic-clonic seizures. All mentioned suggest that radon inhalation could be used to treat epilepsy. Presented study is the first precedent of attempt R-Ho through inhalation for treatment of epileptic seizures in animal models with further translation to clinical study in humans through pilot phase II study. More profound and scientifically systematized approach is needed to determine uniqueness of Tskhaltubo water springs, great importance investigation of the mechanisms of radon effects on the excitatory and inhibitory functioning of CNS and further clinical studies to establish its effect on humans.

Benefits of multi-day supplementation with probiotic kefir in Rasmussen encephalitis: the first case report

ABSTRACT Introduction Rasmussen encephalitis (RE) is a rare inflammatory disease, characterized by unilateral hemispheric atrophy, focal intractable seizures, progressive hemiparesis, and neurological deficits. Case report The patient is a young man under pharmacotherapy for epilepsy, exhibiting classical abnormal movements, which are consider typical hallmarks of RE. During clinical care sessions, he presented many episodes of tonic-clonic seizures involving sudden loss of consciousness followed by a post-ictal phase with weakness and interaction difficulty. During the kefir supplementation, the patient presented only short-term absence seizures, quickly returning to activities. Additionally, he presented cognitive and language improvement, being more responsive to commands. The daily diary control of patient’s mother and caregiver at school reported an impressive reduction in number and severity of seizures, becoming less aggressive and more involved in school activities. The serum biochemical markers showed that kefir administration caused a significant decrease of pro-inflammatory and a simultaneous increase of anti-inflammatory cytokine levels. In parallel, after treatment, this probiotic reduced reactive oxygen species levels, increased NO bioavailability, revealing antiapoptotic and antigenotoxic effects. Regarding the microbiological analysis, kefir increased Lactobacillus and Bifidobacterium species. Conclusion To our knowledge, this is the first case reporting remarkable beneficial effects of the probiotic kefir in RE. This case report strongly suggests kefir supplementation as a potential and safe-effective adjuvant therapeutic strategy in the control and treatment of RE.

Rare Presentation of Gitelman Syndrome: A Case Report

Gitelman Syndrome (GS), also known as familial hypokalemia-hypomagnesemia, is a rare genetic disorder. GS presents with a specific defect in kidney function, that leads to hypokalemia, hypomagnesemia, metabolic alkalosis, and hypocalciuria. Here, we present a 30-year-old woman without a medical history. She experienced an episode of tonic-clonic seizure, generalized muscle weakness, and severe hyponatremia as the first presentation of GS. The interesting point of this case was her late-onset presentation and the long period of her disease diagnosis; thus, it highlights the importance of considering this diagnosis.

Abdominal Epilepsy Masked with Hiccups in a Patient with Intracranial Malignant Glioma

Abdominal hiccups are often masked by abdominal epilepsy (AE) in clinical settings. Spontaneous arrhythmic muscular movements sometimes raise the suspicion for abdominal myoclonus as well. AE is an atypical and rare cause of seizure disorder. It is a manifestation of different transient abdominal complaints correlating with abnormal electroencephalogram (EEG) changes and adequate response to anti-epileptic drugs. We present a case of an 80-year-old female who presented with an episode of tonic-clonic seizure that lasted for almost 10 minutes. The patient was confused and had a facial droop. She had another episode of seizure with a perseverative speech followed by left facial drooping and left upper extremity weakness. She continued having fluctuating mental status and left-sided hemiparesis with intermittent abdominal twitching. She was getting more bradykinetic than bradyphrenic. The computed tomography (CT) scan of the head and magnetic resonance imaging (MRI) of the brain showed a parietal lobe mass that was confirmed on biopsy as malignant glioma. The long-term video monitoring EEG report showed the occurrence of persistent right parietal spikes with background slowing. The brain mass was later treated with radiation therapy and surgery.

52. Not every rheumatologic headache is giant cell arteritis: a case of aseptic meningitis on a background of rheumatoid arthritis

IntroductionA 65-year-old Caucasian lady had a background of longstanding seropositive rheumatoid arthritis (RA) for which multiple disease modifying drugs and biologics had been tried, but then stopped due to either inefficacy or intolerance. She presented with possible vasculitis and was initially treated and investigated for giant cell arteritis (GCA).Case descriptionThis patient presented with temporal headache and right-sided visual field loss, with tenderness over a weakly palpable right temporal artery. No jaw claudication or other cranial nerve abnormality and peripheral nervous system examination was normal. She was commenced on prednisolone and the ophthalmologist decided against temporal artery biopsy. She subsequently developed episodes of tonic-clonic seizure and reduced consciousness, which would be unexplained by GCA.ESR 70 and CRP 28. ANCA and ANA negative, rheumatoid factor positive and anti-CCP antibodies >600.Gadolinium-enhanced MRI brain showed subdural effusions in the left frontal/parietal lobes alongside effacement of the gyri, indicating lepatomeningitis. Lumbar puncture showed increased cerebral spinal fluid (CSF) protein of 1.25g/L (0.1-0.4) and mildly reduced glucose of 2.1mmol/L (2.2-3.9). CSF was negative for acid fast bacilli, lyme disease, cryptococcal antigen, PCR for viruses and TB, culture and extensive immunological screening. Tuberculosis T-Spot test was negative whilst PET-CT demonstrated widespread polyarthropathy but no evidence of an underlying malignancy. The patient was referred for meningeal biopsy; however it was considered too high-risk given her medical co-morbidities.As an inpatient, she developed pneumonia and two myocardial infarctions. For the next four months, she was seizure-free on levetiracetam, but still experienced right-sided facial twitching. She was commenced on a reducing regime of prednisolone on the assumption of rheumatoid meningitis and also given 12-month empirical therapy to cover for possibility of TB meningitis, although this was deemed less likely. Initially she responded to prednisolone but upon dose reduction, she noticed worsening incoordination and unsteadiness, with simultaneous joint flare-up, indicating that immunosuppression was beneficial to her neurological status. Azathioprine was introduced as a steroid-sparing agent but she developed abnormal liver function and hence mycophenolate has been used instead. No side effects have been reported; she has remained seizure-free and reports an improvement in her neurological status. DiscussionInitially it was appropriate to treat as GCA given very typical history. However, the presence of other unexplained symptoms and MRI findings led the decision that the diagnosis was not purely vasculitic in origin. MRI brain and CSF findings were consistent with aseptic meningitis, typically where there is meningeal inflammation with negative Gram stain and culture of CSF, often with pleocytosis. Although predominantly caused by enteroviruses; it can occur secondary to malignancy, drugs and autoimmune disease. These causes were considered, however the presence of active rheumatoid arthritis made a diagnosis of rheumatoid meningitis likely. This uncommon complication of seropositive rheumatoid arthritis was described by Bathon et al as having three hallmark neuropathological findings; rheumatoid nodules, pachymeningitis and vasculitis. A diagnostic challenge is the lack of correlation between synovitis and neurological presentation. Presentation ranges from cranial/peripheral nerve dysfunction to seizures and altered mental state. In the CSF we expect to find high protein and reduced glucose with sporadic pleocytosis. Findings from MRI and CSF analysis can be variable. Ultimately rheumatoid meningitis as described in the literature is diagnosed by histopathology at biopsy, but this is not always available in clinical practice, and sometimes empirical treatment has to be given.Key learning pointsRheumatoid meningitis is a rare complication of RA, but can present with stroke-like episodes or seizures, so this diagnosis should always be considered in RA patients presenting in such a way. Despite high mortality and the lack of any evidence-based guidelines, combinations of steroids alongside cyclophosphamide, azathioprine and methotrexate are reported to have improved prognosis in some patients. The lack of any RCT evidence means the condition has to be managed according to expert opinion, which may require close co-operation between specialties such as neurology, infectious diseases and rheumatology to achieve a good outcome.Conflicts of interestThe authors have declared no conflicts of interest.

Differential Diagnosis of Transient Left Ventricular Dysfunction in a Critically Ill Patient

There is evidence illustrating that the etiologies of non-ischemic LV (left ventricular) dysfunction such as Takotsubo cardiomyopathy, neurogenic stunning myocardium and post resuscitation stunning myocardium have a favorable clinical outcome. Good prognosis in non-ischemic LV dysfunction provides us courage to treat the condition expecting good. We describe herein the unique case of a 33-year-old woman who was started on combination chemotherapy of oxaliplatin and 5-flurouracil for colon adenocarcinoma. The patient’s baseline QTc was 460 ms. Twenty-four hours following initiation of chemotherapy, the patient developed 3 discrete episodes of tonicclonic seizures. Electrocardiogram assessment demonstrated a prolonged QTc interval (623 ms) with several episodes of TdP. Two episodes required defibrillation to revert to sinus rhythm. Post resuscitation echocardiogram showed severe global LV dysfunction with ejection fraction of 33%. The patient subsequently required mechanical ventilation due to severe LV dysfunction with pulmonary edema. Possible etiologies for LV dysfunction in the present case include global Takotsubo cardiomyopathy, neurogenic stunning myocardium or post resuscitation stunning myocardium. Repeat echocardiogram 48 h later showed the ejection fraction of 60%. Although myocardial dysfunction associated with Takotsubo cardiomyopathy, neurogenic stunning myocardium and post resuscitation stunning myocardium have been previously described independently, the present case is unique in that, to our knowledge, torsade de pointes presented with transient left ventricular dysfunction following several episodes of seizures and post resuscitation stunning myocardium that were stabilized in one patient following oxaliplatin and 5- fluorouracil infusion has not been reported.

Trastuzumab-Associated Posterior Reversible Encephalopathy Syndrome in a Patient With Metastatic Gastric Cancer

Introduction: Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiographic syndrome of seizures, headache, altered mental status and posterior cerebral white matter edema on neuroimaging. The exact pathophysiology of PRES is unclear. However, blood brain barrier vascular endothelial dysfunction has been proposed. Trastuzumab is rarely reported as a cause of PRES. To our knowledge, this is second reported case of trastuzumab-associated PRES, and the first case in a gastric cancer patient. Case summary: A 51-year-old female with a history of hypertension and stage 4, HER-2 positive, gastric adenocarcinoma with peritoneal, bone and lymph nodes metastasis. She presented with an episode of tonic clonic seizure. She did not have any previous history of seizures. The patient was diagnosed with stage 4 cancer two years ago. She was started on trastuzumab, cisplatin and capecitabine for 3 cycles and continued trastuzumab till her presentation (last cycle was 4 weeks prior to presentation). Her vital signs and labs are shown in table 1. A Brain MRI w/wo contrast (figure 1) showed bilateral, symmetric areas of T2 FLAIR hyperintensity involving the occipital and posterior parietal lobes. There was no evidence of acute stroke, intracranial hemorrhage or intracranial metastasis. This was suggestive of PRES. A multi-disciplinary discussion involved medicine, neurology and oncology teams decided that PRES could be due to the toxic effect of trastuzumab or hypertension. They decided to discharge patient on levetiracetam, continue trastuzumab, strictly control the BP and repeat the MRI in 3 months. During that period, the patient's BP was controlled on multiple encounters with all readings < 140/90. A repeated brain MRI w/wo contrast showed persistent T2 FLAIR hyperintensity in the occipital and posterior parietal lobes suggestive of PRES. Trastuzumab was held for 1 month. The patient was admitted shortly with worsening epigastric pain and concern of disease progression. An EGD (figure 2) showed a large, malignant looking, partially obstructing mass in the gastric body with no active bleeding. She died after 2 days of cardiac arrest. Conclusion: PRES has been reported with some chemotherapeutic protocols. Whether the toxic effect of the chemotherapy alone or history of metastatic cancer is responsible is not fully understood. It is extremely important to rule out other common causes of PRES, especially poorly controlled hypertension.Figure: Brain MRI w/wo contrast. A) T2-TSE, B) T2- FLAIR sequence. Showing a bilateral, symmetric areas of T2 FLAIR hyperintensity involving the posterior parietal and occipital lobes. There was no evidence of acute stroke, intracranial hemorrhage, hydrocephalus, dural venous sinuses thrombosis or intracranial metastatic disease.Figure: EGD showing a large malignant looking, friable, fungating, ulcerated mass in the gastric body.Table: Table. Patient's vital signs and laboratory workup

Bilateral Coracoid Avulsion Fractures with Unilateral Anterior Instability with Glenoid Bone Loss: Use of Avulsed Fragment for Reconstruction of Glenoid.

Introduction:Coracoid fractures are often missed since the fracture is not visualized in a routine anteroposterior view of the shoulder and special views are not ordered. Shoulder dislocation is common but it is rare to have a dislocation with a coracoid fracture. The purpose of this paper is to present the rare occurrence of bilateral coracoid fractures in a patient with unilateral anterior shoulder instability managed using the same fractured coracoid fragment by the latarjet procedure.Case Report:We report a case of 48 -year -old male who presented to us with a history of recurrent dislocations of the left shoulder. He had frequent episodes of tonic–clonic seizures 5 years back. He was diagnosed to be suffering from neurocysticercosis of the brain for which he was successfully treated. He did not have any episode of seizure later, but he continued to have repeated episodes of dislocation on his left side only. On examination of his left shoulder, he had normal range of motion. He was found to be very apprehensive, even in the midrange. This made us to suspect glenoid bone loss and hence both magnetic resonance imaging and three -dimensional computed tomography (CT) scan of the left shoulder were ordered. The CT scan revealed bilateral coracoid fractures along with glenoid bone loss. An open bony procedure including iliac crest bone graft was planned after a diagnostic arthroscopy keeping in mind that the latarjet procedure may not be possible due to the coracoid fracture. During the operation, we found that the coracoid fragment was large enough to perform a latarjet procedure rather than doing an iliac crest bone graft. This itself provided stability of the shoulder on abduction and external rotation by providing a bony block not requiring any further procedure for the Hill -Sachs lesion.Conclusion:Epileptic patients should undergo CT scan evaluation for glenoid bone loss, large Hill -Sachs lesion and to rule out coracoid fractures to plan for bony stabilization procedure and since we have used the same fractured coracoids fragment for latarjet procedure and found to be successful, this add on the knowledge to the orthopedic community.

Hashimoto’s encephalopathy in a child treated with immunoglobulin therapy

This case report presents a 14-month follow-up of a case of Hashimoto's encephalopathy (HE) treated with im- munoglobulins for the first time in an 11-year-old adolescent. The diagnostic criteria were: (a) a drop in school performance and psychological withdrawal for several weeks, (b) an euthyroid state with a past medical history of autoimmune thyroiditis treated with thyroxin, (c) a first episode of tonic-clonic seizure with clinical and electroencephalographic (EEG) findings of encephalopathy, (d) a high serum concentration of antithyroglobulin and antithyroid peroxidase antibodies, (e) negative results of cerebrospinal fluid and blood studies for viral and bacterial infections. Her acute epileptic symptoms resolved with clonazepam. Immunoglobulin therapy (400 mg/kg/day for 5 days every 6 weeks) was given for 14 months. Her cognitive function was greatly improved but a light-to-mild cognitive deficit remained. An EEG performed at her 14-month follow-up showed a correlation with her cognitive improvement. We suggest that immunoglobulin can be used as a first-line therapy in HE to avoid side effects or relapses as has been described with long-term steroid therapy.

G411(P) A rare case of primary antiphospholipid syndrome

Introduction Antiphopholipid syndrome (APS) is a systemic autoimmune condition characterised by venous or arterial thrombosis, hypercoagulability and pregnancy comorbidities in the presence of circulating antibodies directed against phospholipids. Cerebrovascular disease including sinus vein thrombosis and ischaemic stroke are the presenting features in approximately 30% of cases. Primary APS in the paediatic population is very rare with the exact incidence unknown. A significant number of cases of APS will be associated with autoimmune disease, particularly systemic lupus erythematosus. There are no studies on the management of paediatric APS, which makes the management of these children a challenge for the paediatrician Case description A 2 year old girl, with no comorbidities presented to the local hospital with one episode of tonic-clonic seizure. Of note, is that for the previous days she became more lethargic, decreased appetite and decreased speech. She was developing normally and there was no family history of note. She had a full septic screen but this showed no evidence of acute infection. An MRI head showed left transverse sinus thrombosis with bilateral thalamic infarcts and right basal ganglia infarction. In view of these findings she had a full thrombophilia screen. The results showed evidence of APS with positive anti cardiolipin antibodies. There was no laboratory features of a secondary autoimmune disease, so a diagnosis of primary APS was made (ANA, ANCA, R. F., C3, C4, IG A, G, M-, Direct Antiglobulin test, PR3, MPO,-negative). She has been anticoagulated with warfarin but her ongoing management has been difficult. Discussion Evidence for the treatment of APS is based on adult studies and the treatment itself comes with it’s own complications. Warfarin dosage is age and weight dependent, so needs to be carefully monitored to achieve the correct dosing. The 2 year old has experienced symptoms of transient ischaemic attacks with an INR of 1.8 and extensive bruising with an INR >2.7. There is also the psychological and emotional impact involved with the frequent hospital admissions and blood tests. This is all in addition to the impact of the neurodisability, which has resulted from the initial thrombotic insult.

Camphor poisoning: An unusual cause of seizure in children

Camphor is a pleasant-smelling cyclic ketone with propensity to cause neurologic side-effect, especially seizures. We report a case of 1½-year-old child who after inadvertent consumption of camphor, experienced an episode of generalized tonic clonic seizure. This case highlights the importance of enquiring any intake of material (medicinal or otherwise) in every patient presenting with seizure and notifying presence of typical smell, if any.

Index of Suspicion in the Nursery

A 4.1-kg, 10-day-old, term Hispanic male infant presents to the emergency department (ED) with multiple episodes of paroxysmal jerky movements, irritability, and an episode of cyanosis. Parents report decreased responsiveness and oral intake 3 days before presentation. Patient was born at 40.1 weeks to a G2P1001 via cesarian delivery for arrest of dilatation. The Apgar scores were 9 and 9 at 1 and 5 minutes, respectively. Prenatal course and delivery history are unremarkable, including negative maternal serologies and group B Streptococcus (GBS) culture. While in the ED, the patient has 5 episodes of tonic-clonic seizures, with dropping oxygen saturation to 70%, and is intubated for airway protection. Vital signs reveal temperature of 101.5°F, heart rate of 170 beats per minute, respiratory rate of 42 breaths per minute, and blood pressure of 90/60 mm Hg. Physical examination reveals markedly decreased responsiveness with no other positive findings. A full sepsis evaluation is performed including cultures of blood, urine, cerebrospinal fluid (CSF), and computed tomography (CT) of the head. Lorazepam is started for seizures. Empiric broad-spectrum antimicrobial therapy including ampicillin, gentamicin, cefotaxime, and acyclovir is initiated. The infant is admitted for further diagnostic and therapeutic management. ### Diagnosis and Hospital Course Laboratory results revealed white blood cell (WBC) count …

Convulsions in 2 Patients After Bilateral Ultrasound-Guided Transversus Abdominis Plane Blocks for Cesarean Analgesia

Transversus abdominis plane (TAP) block is commonly used for postcesarean section analgesia and compares favorably with other systemic and regional analgesia techniques. No major complications of ultrasound-guided TAP block have previously been reported in this indication. We report 2 cases of systemic local anesthetic toxicity in this context leading to seizures and treated with lipid emulsion. The first event occurred 10 minutes after ultrasound-guided bilateral injections, each consisting of 20 mL of levobupivacaine 3.75 mg/mL. Two episodes of tonic-clonic seizure required resuscitation measures and 200 mL of lipid emulsion. The second case 25 minutes after a 20-mL bilateral injection of ropivacaine 7.5 mg/mL. One generalized tonic-clonic seizure required bag-mask ventilation and 250 mL of lipid emulsion. In both cases, patients were successfully treated and fully recovered. These cases cast a cautionary note for the use of TAP blocks after cesarean delivery. The risk of systemic local anesthetic toxicity after this procedure remains unknown in this population and plasma concentration of local anesthetics should be measured in case of suspected toxicity. To limit this risk, a low concentration of local anesthetic solution should be chosen when a "20 mL bilaterally" regimen is necessary to achieve the required spread for a successful block.

Autoimmune encephalitis associated with Graves’ disease: a case report

Almost all patients who developed autoimmune thyroid disease associated with encephalopathy were diagnosed to have Hashimoto's thyroiditis, but a few patients with Graves' disease who developed encephalopathy have been reported. A 36-year-old female with a 10-year history of Graves' disease had experienced three episodes of tonic-clonic seizure. At admission, the patient's status was confused, and she also developed tactile and visual hallucinations. The cranial MRI confirmed white-matter lesion and showed subcortical high signal lesions on T2-weighted images. In EEG record, diffuse slow activity was noticed in both sides. T3 and TSH were decreased, T4 remained normal and thyroid peroxidase antibody (TPO) was evaluated to be more than 2,000 (T4=8.4, T3=12/9, TSH=0/14, TPO >2,000). The diagnosis of autoimmune thyroid disease is probable in all patients with signs of encephalopathy with unknown origin, while they have a previous history of thyroid disease.