# Interesting Seizure Case. Guess the Diagnosis



## BobBarker (Oct 26, 2016)

I am going to tell a real life scenario that happened to my father and throughout the whole event, I was there to witness everything.

You are dispatched to a seizure call in at 9:30AM. You arrive to a patient who is a 60yo male who has a history of AKA left leg, diabetes,ESRD, hypertension and hyperlipidima. Family states he complained of a 8/10 headache for the last hour of dialysis the night before, still had the headache after 1000mg of Tylenol but fell asleep around 12am. They tried to wake the patient up at around 9AM, and although he was moving his hands and feet slightly, he was not able to speak or open his eyes. Patient subsequently had a seizure(with no history of any seizure prior) for 30 seconds and was foaming at the mouth, which prompted 911 response.

You arrive and find the patient laying down breathing but unresponsive. Vitals: BP is 217/110, RR is 14, BGL is 200 and SP02 is 99%. EKG looks normal, states RBBB but family says he has had that for years.

Current medications are: Atorvistatin 40mg, Lantus 35units, Humalog sliding scale, Gabapentin 100mg, Aspirin 81mg and Metropolol 50mg ER.

You transport the patient to the closest hospital 5 blocks away, which happens to be the hospital where the AKA was done, so all medical history is easily available. During the short trip, you suction and establish an IV to the right arm.

Hospital Treatment: Stat CT which proves normal(no midline shift, no actue or past stroke). Labs are normal except Potassium is 7.4(normal is 3.5-5.5). Blood pressure medication given and patient transported to Step-Down Unit as no ICU beds are available. Dialysis is emergently done upon arrival to the Step-Down Unit because of the critical Potassium value.

Here is what is interesting: My father(the patient) did not wake up for 2 days, even though he was on no sedation whatsoever. His blood pressure was well controlled after the initial 217/110, he would move his hands and feet a little and even scratch his nose, but he could not hear us or open his eyes. Magically, on the 3rd day he woke up a little confused. Over the next 4 days, he got 100% better and was at his baseline by the 7th day, with no brain damage or evidence of a stroke/TIA after an MRI scan. He was discharged after day 7 with better blood pressure medications and anti-seizure medications to continue until a follow up visit with a neurologist that can clear him to stop it. After 1 week, the neurologist cleared him to stop Dilantin.

Can anyone guess the diagnosis? It's pretty uncommon.

Ask me any follow up questions if it will help you. I have access to all the lab results, imaging results and consultation notes.


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## Summit (Oct 26, 2016)

K 7.4 is bad. It is unthinkably high after dialysis, which says that is from the Sz which must have been extensive overnight... what was his lactate and bicarb?

I'm having trouble with my differential right now...


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## BobBarker (Oct 26, 2016)

Here is the labs right after he was admitted:
Bicarb -  26.2 mmol/L
Lactate - 0.8 mmol/L

Also failed to mention WBC were 7 and no evidence of any infection.


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## VFlutter (Oct 26, 2016)

Complex/atypical Migraine with Non-epileptic seizure?


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## BobBarker (Oct 26, 2016)

Chase said:


> Complex/atypical Migraine with Non-epileptic seizure?


Pretty good guess, but negative. I will wait a couple hours for some more responses and tell everyone the diagnosis tonight. All I will say is even the Hospitalist told us he has not seen very many patients with the ending diagnosis.


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## VentMonkey (Oct 26, 2016)

What was dad's Na+ level? Given his history I am leaning towards a metabolic disorder...


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## Summit (Oct 26, 2016)

I'm still drawing a blank... glad your dad is OK


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## VentMonkey (Oct 26, 2016)

@Billy D, aside from the critically elevated K+, the other lab work seems unremarkable.

Can you post the rest of the metabolic panel, or even a few more basic electrolytes?

If the Na+ was critically low, I would lean towards SIADH.

And ditto what @Summit said in regards to pops.


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## BobBarker (Oct 26, 2016)

The K+ was the only elevated number, electrolyte wise. I can get the exact number soon, but the sodium, bicarb, lactate, aninon gap, WBC were all well within normal range. The only values that were not good was the Potassium. RBC and Hemoglobin were low, but its always been that way with the anemia since he started having Kidney failure. When the Dr. was showing me the lab results hours after they were drawn, I was shocked that close to all of them were normal.
*Hint to help get the diagnosis*: Focus on the hypertension, headache and seizure. Although the potassium was critically high and was corrected soon after with dialysis, it didn't cause the seizure or diagnosis, probably just aggravated it.

Summary: Potassium is high. RBC and Hemoglobin slightly low, but it's been that way for months prior so nothing new, all other lab values within normal range. No infection. Chest X-Ray is fine, CT scan shows no midline shift or infarct. EKG is normal/baseline. Vitals are fine except the extremely high blood pressure which was treated soon. Only 1 seizure with no repeats and no history prior.


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## VentMonkey (Oct 26, 2016)

Billy D said:


> Hint to get the diagnosis: Focus on the hypertension, headache and seizure.


Hypertensive encephalopathy.


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## Summit (Oct 26, 2016)

My first thought was electrolytes. (Worth reviewing this paper and this paper )
But apart from the K everything is fine and I think the K is high because of the Sz (unless Dialysis really screwed up, but hard to just screw up the K)

Then I thought TIA but it isn't because it took 3 days to wakeup, which if it was a stroke should show up on imagery and your imagery is strangely clear for this chronically ill 60 year old.

Then I briefly thought they gave you the wrong chart 

A provoked Sz 2* Htn seems likely... but... not rare... and it self-corrected quickly so more likely the high BP just a typical postical BP? We are looking for rare...

So I went and read UpToDate for a while, and I got nothing...


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## VFlutter (Oct 26, 2016)

The symptoms do not really fit Encephalitis or Aseptic Meningitis


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## Summit (Oct 26, 2016)

OK I have one guess... Dialysis Disequalibrium Syndrome?


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## BobBarker (Oct 26, 2016)

VentMonkey said:


> Hypertensive encephalopathy.


BINGO! Although the hospitalist said it was: Posterior Reversible Encepholopathy Syndrome caused by the extreme blood pressure. I guess the RN 2 days before put that my dad refused his BP medications for 2 days, although he has never done that, cause the BP to go up.  Although the doctor said he had never seen someone not wake up for 2 days, he was very happy to see there was no brain damage and everything was almost normal after 7days. Very interesting presnetation to say the least. 
Thank you to everyone for the well wishes, he is doing great. Finally managed to have his HMO pay for an ambulance to/from dialysis 3days a week until he can drive again. Before that, it was me taking him at 4AM before going into work!


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## VFlutter (Oct 26, 2016)

Summit said:


> OK I have one guess... Dialysis Disequalibrium Syndrome?



Damn Dr. House, I like that one. Except I would assume the CT would have shown cerebral edema.



Billy D said:


> BINGO! Although the hospitalist said it was: Posterior Reversible Encepholopathy Syndrome caused by the extreme blood pressure. I guess the RN 2 days before put that my dad refused his BP medications for 2 days, although he has never done that, cause the BP to go up  Although the doctor said he had never seen someone not wake up for 2 days, he was very happy to see there was no brain damage and everything was almost normal after 7days. Very interesting presnetation.



Ah I couldn't think of the name! I have seen PRES a few times in the ICU. Very interesting diagnosis.


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## Summit (Oct 26, 2016)

Chase said:


> Damn Dr. House, I like that one. Except I would assume the CT would have shown cerebral edema.


I read UpToDate for too long... and he said it was rare 
https://www.uptodate.com/contents/seizures-in-patients-undergoing-hemodialysis.
https://www.uptodate.com/contents/n...ers-in-adolescents-and-adults?source=see_link
https://www.uptodate.com/contents/pathophysiology-of-seizures-and-epilepsy?source=see_link
https://www.uptodate.com/contents/s...al-presentation-and-diagnosis?source=see_link


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## VFlutter (Oct 26, 2016)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3524908/


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## BobBarker (Oct 26, 2016)

Billy D said:


> BINGO! Although the hospitalist said it was: Posterior Reversible Encepholopathy Syndrome caused by the extreme blood pressure. Although the doctor said he had never seen someone not wake up for 2 days, he was very happy to see there was no brain damage and everything was almost normal after 7days. Very interesting presnetation.





Chase said:


> Damn Dr. House, I like that one. Except I would assume the CT would have shown cerebral edema.
> 
> 
> 
> Ah I couldn't think of the name! I have seen PRES a few times in the ICU. Very interesting diagnosis.


Yup, when the Dr. called me at 6AM to tell me that, I was asking wtf it was cause I never heard of it. It was so weird to see my dad laying there scratching his nose and moving his hand and feet but not moving his eyes, able to hear us or talk.


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## FLdoc2011 (Oct 27, 2016)

Have seen a few cases of PRES and I think it may have been under recognized in the past.   Did they happen to do an MRI on him?


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## BobBarker (Oct 27, 2016)

FLdoc2011 said:


> Have seen a few cases of PRES and I think it may have been under recognized in the past.   Did they happen to do an MRI on him?


They did although it was 3 days after his seizure and 18hrs after he woke up. It showed some calcification in some vessels in the brain, but the neurologist who looked at it said it was somewhat normal given the age. I actually might be able to get some images from the CT and MRI and attach it here soon.


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## Tigger (Oct 28, 2016)

Would this be a similar mechanism to eclamptic seizures?


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## VentMonkey (Oct 28, 2016)

Tigger said:


> Would this be a similar mechanism to eclamptic seizures?


This, I would think should present more along the lines of a hypertensive crisis patient, and at first glance lead most providers to believe it is more of the TIA/ CVA variety.

And a random "Snapple fun fact" about eclampsia and eclamptic sz, most women who have this can have them up to a couple of weeks post-partum.

I don't know how many providers are aware of this. I know I was never taught this in p school.


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