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.
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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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