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Neuro Bonus: myoclonus

Drs. Min, Burgess, and Keegan jointly present a 70 yo male presenting with acute, whole-body tremors in this unique Medicine-Neuro multidisciplinary noon report!


The patient had 2 days' of tremoring starting in both feet, then involving hands and neck. During this time his thinking was "cloudy". He has a history of very intermittent and self-resolving bilateral upper extremity tremors, as well as chronic numbness/tingling in his distal legs. ROS otherwise normal.


He was rececntly hospitalized for: HF exacerbation and in-hospital LLE cellulitis treated with doxycycline (cephalexin started at f/u appt).


His PMH includes: Type 2 DM w/ neuropathy and nephropathy, CKD4, HFpEF, Afib on Warfarin, HTN, HLD, gout


His medications include:

Bumetanide 5 mg BID, Hydralazine 50 mg TID, Metolazone 5 mg, Metoprolol Succ 100 mg Qday, Warfarin 2 mg PO QPM, Pantoprazole 40 mg Qday, Novolog 70/30 (NPH/Reg) 90U QAM, 35U Noon, 95U QPM, Allopurinol 100 mg Qday, Acetaminophen 325 mg Q6h, prn, Pregabalin 75 mg BID, Ferrous Sulfate, Melatonin, Multivitamins


He drinks 1-2 beers/day and stopped smoking years ago.


Vitals: T. 98.1, P94, R18, BP 134/65, SpO2 92% on RA, Pain 8/10

Physical: general myoclonus, brachial and patellar reflexes all 2/5 with preserved strength and sensation. CN2-12 WNL


Labs: B12 631, EtOH negative.


CToH - no infarct, hemorrhage, mass effect. age-related volume loss. chronic microvascular ishcemia


EEG: “heightened neuronal hyperexcitability occurring in runs” and at risk of developing generalized seizures/myoclonic status epilepticus


His final Diagnosis: Non-convulsive Status Epilepticus.


=====================================================================


What is status epilepticus?

- A seizure that lasts longer than 5 minutes

OR

- Having more than 1 seizure within a 5 minute - period, without returning to a normal level of consciousness between episodes


Who's at risk?

- Poorly controlled with epilepsy

- Drug abusers

- CNS infections

- Young, elderly

- Genetic conditions

- Liver failure patients

- Kidney failure patients


Types of Status: convulsive and nonconvulsive


Convulsive Status Epilepticus: a medical emergency that may lead to permanent brain damage or death


Non-convulsive Status Epilepticus Presentation:

- fluctuations in mentation, agitation, mood changes, irrational behavior, or staring off

- pt can be awake, talking, and interacting with the environment


Myoclonic Epilepsy

-Muscles in the body to contract very rapidly and quickly

-Everyone has had myoclonic seizures (hiccups, hypnogogic jerks)

-Most common type: JME (Juvenile Myoclonic Epilepsy).

- children/adolescents (buzz phrase: early morning jerks).

- It usually affects necks, shoulders and arms.

- Often mistaken for clumsiness. EEG will confirm with 4-6Hz polyspike and wave


Myoclonic Non-convulsive Status Epilepticus

•Frequent epileptiform discharges

•Multiple sustained runs of 4-6Hz polyspike and wave discharges from 3 seconds to 8 seconds. Limited breaks between

•Possible progression from non-convulsive to generalized convulsive status epilepticus vs generalized myoclonic status epilepticus


Cephalosporin Adverse Effects (contributed to diagnosis)

•Derm: uncomplicated maculopapular rash most common, can be as severe as TEN or SJS

•Nephrotoxicity: GN, AIN

•GI: hepatitis, diarrhea, increased C. diff risk

•Heme: immune thrombocytopenia, hemolytic anemia, leukopenia

•Neuro: encephalopathy, myoclonus, seizures

• Due to beta lactam ring components, and lipophylic nature of this drug class

(stays in CNS)

•Monitoring: especially in prolonged therapy, should get a CBC and BMP

All cephalosporins aside from ceftriaxone require dose adjustment in renal failure

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