Presented here is a case of a twenty-six-year-old young male who was brought to the emergency room in a state of unconsciousness following by massive drug intake. He was diagnosed with complex partial seizures with secondary generalization 14 years earlier and was on antiepileptic treatment with 300-mg/day phenytoin sodium and 60-mg/day phenobarbitone. His seizures were never controlled, and he had 5-6 episodes of complex partial seizures/month. Precipitating his emergency room presentation, he deliberately consumed a massive dose of antiepileptic drugs (approx. 25 tablets of phenobarbitone and 45 tablets of phenytoin) on account of a sudden emotional outbreak following a dispute with his relatives.
As stated by his family members, there was a significant change in his behavior in the form of irritability, impulsivity, obstinacy, decreased frustration tolerance, and assertiveness. His academic performance also deteriorated. He had poor communication with family members. Before starting antiepileptic medication, he was performing well in his studies.
On physical examination, the patient was of an average build with a poor general condition. Vital signs revealed the following: a temperature of 99.6  F, a pulse rate of 120 beats/min, a blood pressure of 110/68 mm Hg, a respiratory rate of 32 breaths/min, and an SPO2 of 86%. On systemic examination, the patient was comatose (GCS: E1V2M2) with bilateral crepitation on chest examination. The rest of the physical examination findings was insignificant. The patient had been resuscitated, gastric lavage was done, and blood and urine samples were taken. He was put on a ventilator and given supportive and symptomatic treatment. Relevant blood parameters were also monitored. His serum drug concentrations were measured by immunoassay and were 36 mug/ml for phenytoin and 105.67 mug/ml for phenobarbitone. With meticulous symptomatic management, the drug level came down to 22.40 mug/ml for phenytoin and 52 mug/ml for phenobarbitone on the 9th day.
Gradually, his symptoms resolved, and on the 8th day, there was complete recovery. The patient was subjected to EEG and brain MRI. Brain MRI revealed right mesial temporal sclerosis, and EEG revealed epileptiform discharges arising from the right temporal area. His psychiatric evaluation revealed interictal affective-somatoform (dysphoric) disorder, but no further suicidal ideations/intention were elicited. The patient was put on 600-mg/day oxcarbazepine which was gradually built up to 1200 mg/day, while for the psychiatric symptoms, 10-mg/day olanzapine and 50-mg/day sertraline were started. In the follow-up period of six months, he had three complex partial seizures, but he had a marked improvement in depressive mood, impulsivity, and suicidality.