A 21-year-old Nepalese man was brought to our emergency room (ER) after a witnessed generalized tonic clonic seizure (GTCS), lasting for few minutes and aborted spontaneously. The patient was previously healthy with no history of seizures. There were no recent respiratory symptoms or fever. His vaccination status is unknown.
He was fully alert and afebrile with no meningeal signs or focal neurological deficits upon ER arrival. A second GTCS in ER with longer duration prompted treatment with Lorazepam and Fosphenytoin. The patient became subsequently febrile and confused. He desaturated, became hypotensive, and required intubation and ICU admission. The initial EEG showed diffuse generalized slowing with no epileptiform discharges, but a repeat EEG performed on the second day of admission as the patient failed to regain consciousness revealed recurrent focal seizures of independent bihemispheric origin fulfilling the criteria of nonconvulsive SE (Figure 1).
CT head, brain MRI, and cerebrospinal fluid (CSF) analysis were unrevealing. The CSF showed WBC count of two cells/mL, protein of 0.4 g/L, and glucose of 4.4 mmol/L (compared to 5.5 mmol/L serum glucose). CSF cytology, viral screen including herpes, TB PCR and culture, Gram stain, and fungal and bacterial cultures were all negative. Chest X-ray, followed by chest CT scan showed a left upper lobe consolidation (Figure 2). H1N1 infection was confirmed by PCR on bronchoalveolar lavage material. Otherwise, BUN/Creatinine, liver profile, electrolytes, thyroid function tests, RF, ANA, ANCA, HIV serology, and initial blood cultures were unrevealing. Despite aggressive treatment with successive infusions of Midazolam, Propofol and Thiopental, and multiple high doses antiepileptic medications including different combinations of Levetiracetam, Sodium Valproate, Phenytoin, Phenobarbital, and Topiramate, the electrographic seizures recurred at every attempt to reduce the intravenous sedative drugs. The patient was also treated with Oseltamivir. His hospital course was later complicated with septic shock and associated severe hypotension with multiorgan failure, resulting in cardiopulmonary arrest and death two weeks from his initial presentation.