A Case of Epilepsia Partialis Continua following Measles Encephalitis in an Immunocompromised Adult

INTRODUCTION: Epilepsia Partialis Continua(EPC) is a simple focal motor status epilepticus in which frequent repetitive muscle jerks, usually arrhythmic, continue over duration.(1,2) EPC occurring as a sequalae to Measles Inclusion Body Encephalitis (MIBE) in an adult immunocompromised patient is a rare phenomenon.(2,3) CASE REPORT: 48-year male, k/c/o multiple myeloma status post autologous stem cell transplant in March 2023, presented to the hospital with history of fever in March 2024, was diagnosed as dengue and was symptomatically managed. He presented with fever and rash, a month later, thought to be dengue and was accordingly managed. July 2024, he presented with jerky movements on left sided limbs, but had preserved consciousness. Differentials were Focal seizures vs Myoclonic jerks. EEG done did not find any obvious correlation. He was started on IV Antiepileptics. HE WAS ADMITTED IN THE ICU: Initial EEGs did not find any correlation. MRI Brian revealed right frontal T2 hyperintensity. Video EEG recorded multiple events with definite EEG correlation with above mentioned movements, suggestive of Epilepisa Partialis Continua. There was gradual worsening in sensorium over next 3 days. The semiology worsened to generalized tonic clonic seizures. MRI Brain done showed an increase in areas of T2 hyperintensities in the right frontoparietal lobe and involving the left posterior aspect of insular cortex, suggestive of multifocal encephalitis. Possibility of viral vs autoimmune encephalitis considered. Patient was on IV antibiotics, antivirals and other supportive medications. CSF analysis done revealed 17 cells, mildly elevated protein (53.7mg/dL), normal sugars and negative cultures. Myeloma parameters were normal. Considering the immunocompromised status, with EPC, and recent history of fever with rash, a rare possibility of Measles Encephalitis was considered. Meanwhile, the sensorium worsened and decision was made to secure the airway. IV antibiotics were hiked up according to the culture sensitivity. Measles IgG Rubeola: >300AU/mL(Positive) Measles IgM Rubeola: 0.17(Negative) Measles CSF IgG/Serum IgG Antibody Ratio: Positive (1.73) Following this, multidisciplinary team settled on diagnosis of Epilepsia Partialis Continua as sequalae of Measles Inclusion Body Encephalitis. Although brain biopsy is confirmatory, the patient was not fit for the same. The patient was eventually tracheostomised due to prolonged ventilation and was shifted out of the ICU. The patient continues to remain in a palliative center. DISCUSSIONS: EPC following Measles has been reported in a few case reports. The pathogenesis remains unknown and there is no proven therapy.(4) Sudviya et al reported a breakout of measles encephalitis in Children with hematolymphoid malignancies, and most presented with EPC.(1) They reported challenges in diagnosis and high mortality and morbidity. Our patient was immunocompromised, had history of fever with rash, and presented with EPC, further testing was highly suggestive of MIBE. CONCLUSION: MIBE remains a challenging diagnosis due to the varied symptoms. Prognosis remains poor due to lack of effective treatment. With increasing number of transplantations and easier access to innovative therapy, the number of immunocompromised individuals coming to ICU are bound to increase. Although largely eradicated, measles remains a point of concern in these individuals. The best-known strategy still remains prevention of measles.