A Case Of New Onset Seizure Activity In A Collegiate Swimming Athlete

HISTORY: A 21-year-old swimmer presented for evaluation of sore throat. He was diagnosed with strep throat. One week later, his symptoms had resolved and he went on a vacation cruise trip. Shortly after boarding his cruise, he began to exhibit high fevers, hand twitching, hallucinations, and memory loss. These symptoms culminated in a witnessed tonic-clonic seizure episode with urinary incontinence sustained for 10-15 minutes. This prompted intubation for airway protection and admission to a critical care unit. He was stabilized and evaluated as discussed below. He denied numbness, tingling, muscle weakness, or recurrence of any seizure-like activity since returning home. PHYSICAL EXAMINATION: He was alert and oriented to person, place, and time. Gait was steady. Pupils were equal and reactive. His cranial nerve exam II-XII was intact. His motor reflexes were normal. Strength and sensation to light touch in all 4 extremities were intact. No pronator drift. His cerebellar testing was intact. DIFFERENTIAL DIAGNOSIS: 1. Genetic epilepsy 2. Infectious encephalitis/meningitis 3. Malignancy/benign tumor TESTS AND RESULTS: Initial lumbar puncture: Elevated glucose 101 mg/dL, elevated protein 167.9 mg/dL, 55 white blood cells/uL with lymphocytic predominance. Bacterial and fungal CSF cultures were negative. HSV 1/2, cryptococcus, encephalitis panel, and VDRL CSF levels were all negative. Normal urine toxicology, respiratory viral panel, blood cultures, HIV testing, and chest x-ray. CT head, MRI brain/cervical spine had no intracranial or other structural abnormalities. EEG performed x3 demonstrated no focal epileptiform discharges. He was treated initially with empiric antibiotics and antivirals. Eventually these were weaned. He was initiated on levetiracetam for anti-epileptic treatment. FINAL/WORKING DIAGNOSIS: Status epilepticus from viral encephalitis. TREATMENT AND OUTCOMES: The patient was referred to neurology for further discussion of anti-epileptics. It was decided that he would bridge to lamotrigine over 8 weeks due to medication intolerance. Neurology has recommended he remain on anti-epileptics indefinitely. Repeat EEG noted generalized slowing but was otherwise normal. He has been able to return to sport with supervised activity both in and out of the pool.