Abstracts

Rationale: To report a patient with subacute encephalopathy and seizures in alcoholics (SESA) showing lateralized periodic discharges (LPDs, also termed PLEDs) on continuous EEG monitoring (CEEG), which evolved to nonconvulsive status epilepticus (NCSE) despite treatment with multiple antiepileptic drugs (AEDs).Methods: Background: A few cases of SESA have been reported since described by Niermeyer in 1981. SESA is characterized by confusion or lethargy, transient motor deficits, seizures in patients with history of chronic alcoholism. The pathophysiology of SESA remains unclear, but it was proposed that chronic small vessel disease involving epileptogenic brain regions may predispose to development of focal seizures in some of these patients.Results: Case: This is a 75 years old right-handed man, with significant history of chronic alcoholism. The patient was brought to the ER confused and having focal motor seizures involving right face, arm and leg. He also had a right hemiparesis. Head CT and brain MRI showed volume loss and small vessel disease type changes. He became more confused and agitated over the next hours. LP was done. CEEG showed LPDs over the left posterior temporal region. He was then transferred to ICU and was given Acyclovir and Fosphenytoin. The results of extensive blood work were negative. Except for a mild increase in protein (59), comprehensive CSF study was negative, including but not limited to viral, bacterial, and fungi cultures, PCR for herpes simplex, paraneoplastic panel and anti-NMDA receptor antibody. SESA was the most likely diagnosis. Patient developed rash, therefore Fosphenytoin was discontinued and Sodium Valproate was started. CEEG was showing left-sided LPD and recurrent focal electrographic seizures arising from the left temporal region. Lacosamide and then Ketamine were added, but without therapeutic response and subsequent NCSE was diagnosed. Ketamine was then switched to Midazolam to the goal of burst suppression. Over the next days, the patient could be weaned off Midazolam. He remained lethargic but was responsive to few verbal commands. However, his family decided for withdrawal of care.Conclusions: CONCLUSION: SESA is likely an underreported and under diagnosed condition. Our patient presented with focal motor seizures followed by Todd’s paralysis, and encephalopathy. The CEEG showed left posterior temporal LPDs and recurrent focal electrographic seizures. Despite treatment with multiple AEDs and the addition of ketamine, both encephalopathy and seizure severity worsened.