Alcohol Withdrawal in Scar Epilepsy: A Rare Diagnostic Intersection

Sir, We present a diagnostically intriguing case of alcohol withdrawal in a patient with underlying scar epilepsy. This rare and clinically significant overlap underscores the importance of multidisciplinary evaluation in seizure presentations. A 64-year-old married male was admitted to the neurology ward with complaints of tremors, decreased sleep, and restlessness for 3 days. According to family members, he had been experiencing recurrent episodes of sudden unresponsiveness followed by focal jerky movements of one side of the body for the past year, with an increase in frequency over the previous month. The patient had been consuming alcohol for over 30 years, with a gradual increase in quantity from 90 mL once or twice a week to 90–180 mL of country liquor daily over the past 3 years. Multiple short-lived abstinence attempts were made, but failed due to intense craving, with each abstinence period marked by withdrawal symptoms, including tremors, insomnia, and restlessness. He had his last drink 5 days before being referred for psychiatric evaluation. Significant past history included a head injury 40 years ago following a physical assault, leading to loss of consciousness. There was no family history of psychiatric illness or epilepsy. The physical examination revealed digital tremors, tachycardia, and elevated blood pressure. On mental status examination, he was oriented but displayed an anxious affect, persistent worrying thoughts, and a craving for alcohol. His motivation was at the precontemplation stage, with an external locus of control. Investigations revealed hypocalcemia (serum calcium: 12.0 mg/dL), while sodium and potassium levels were normal. Magnetic resonance imaging of the brain showed encephalomalacia with gliosis in the right parieto-occipital region, along with chronic ischemic changes and age-related cortical atrophy. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA)–Revised Scale score was 8/60, suggesting mild withdrawal. With a diagnosis of alcohol withdrawal with underlying scar epilepsy, he was managed with lorazepam 2 mg BD, which was tapered over 3 days and initiated on levetiracetam 500 mg BD for seizure control, along with parenteral thiamine and other supportive measures. The patient was out of withdrawal after 3 days with no withdrawal symptoms (CIWA score 0/60). On follow-up after 1 month, the patient was seizure-free and abstinent from alcohol and was taking his medications regularly. Alcohol withdrawal seizures are typically generalized and occur within 6–48 h of cessation in independent individuals.[1] However, focal seizures, especially those with chronicity or lateralizing features, must be evaluated for structural lesions such as posttraumatic scar epilepsy.[2,3] This case exemplifies the diagnostic challenge when withdrawal-related symptoms overlap with structural epilepsy. Misattribution to alcohol withdrawal alone may delay appropriate seizure management and neuroimaging. Early identification of focal seizure semiology in alcohol-dependent patients, particularly those with a history of trauma, is essential. This case highlights the importance of multidisciplinary collaboration in reaching a comprehensive diagnosis. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.