Question: CASE SUMMARY

NAME MASTER VIILOHIT GOEL                AGE/SEX: 8 YEARS /MALE
UHID NO: 0000                         IP NO: DELIP38145
DATE OF ADMISSION : 02.04.14

DIAGNOSIS:
Super Refractory Status Epilepticus

HISTORY:,
The 7yrs old Vilohit had presented on 2nd April 2014 with complaint of high grade fever 3 days (March 29-31), lethargy on whole day 5 and GTCS in night followed by loss of consciousness about 30 minute. No seizure or similar incident history with Vilohit and no major illness or disease in past. Vilohit also had alteration in behavior and agitation. Vilohit admitted in PICU Apollo Hospital Ne XXXXXXX relevant investigation sent. Vilohit had repeated seizures, was started on Inj Acyclovir, inj Fosphenytoin, Inj Mannitol, Inj Levera, Vilohit continued to have status epilepticus -AED's upgraded. CDF done-normal. CSF for bacterial antigen-normal, MRI brain done-normal, EEG showed focal seizures with secondary generalization. Clinical and subclinical seizures persisted for 2 months.
MRI:
03/04/14     Normal
21/04/14     T2/flair Hyperintensity involving the bilateral medial temporal lobs and showing restricted diffusion
     D/D mesial temporal sclerosis
EEG:
Abnormal EEG record demonstrating
07/04/14     Brust-supression pattern s/o an encephalopathy
     LEFT Temprocentral epileptic focus
10/04/14     biPLEDs in status
12/04/14     Generalized status epilepticus
14/04/14     Theta-Alpha pattern s/o an modest encephalopathy
     Infrequent right occipitoParietal epileptiform discharges
15-18/04/14     Brust-supression pattern s/o a severe encephalopathy
     biPLEDs, right more than left
25/04/14     focal seizures with sec. generalization in status
08/05/14     Brust-supression pattern s/o a severe encephalopathy
22/05/14     Delta-Theta Coma pattern s/o a severe encephalopathy
     Bilateral focal electrographic seizures in status

Medicine Given during PICU Stay:
ANTIBIOTICS: Inj Monocef, lnj Acyclovir, Inj Meropnem, lnj Piperacillin-Tazobactum, Inj Magnex, Inj Teicoplanin, lnj Colistin, Inj Amikacin, Inj polymixin-B.

ANTIEPILEPTICS: Inj Phenytocin (5 mg/kg/day), Inj Phenobarbitone (upto 22mg/kg/day i/v/o barbiturate coma), Inj Paraldehyde, Tab topiramate, Tab Frisium, Inj thiopental, lnj propofal(70 mg/kg/day), Tab Lacosamide, Inj propofol (Discontinued in less than 24 hours i/v/o lactic acidosis) Inj acidosis) Inj Ketamine, Tab Lamotrigine, Syp Trioptal, Ketogenic diet, IVIG.

SUPPORTIVE CARE: lnj Pantocid, IV fluids, Inj Dopamine, Inj Adrenaline, Inj Noradrenaline, Levolin nebi=ulization, Inj Magnesium sulphate, Syp potcholar, Syp Calcimax plus, Tab Thiamine, Syp Bevon, Inj Vitamin K, Syp Lactulose, Paked cell tranfusion.

Vilohit had persistent seizures for more than 2 months which subsided gradually; Vilohit was kept on ventilator support and was tracheostomised in the second week of hospital stay. Vilohit had episodes of pneumonia antibiotics were changed accordingly to sensitivity reports. AED's were tapered gradually once the seizure frequency decreased. Vilohit improved gradually;

EGG 7/7/2014:
Delta-theta come pattern, right pseudo PLEDs-epileptogenic, solitary left temporal sharp wave.

Vilohit discharged on July 12 with tracheostomies on, on full NG feeds, off oxygen. Parents have been taught care of tracheostomy, NG feeding danger signs, physiotherapy and supportive care.

Neurological status on Discharge: Spontaneous eye opening+, follow verbal commands, able to express some emotion, tries to Move limbs, no speech, pupils: BERL

He was discharged on:-
Tab. Frisium 10 mg twice a day
Tab. Lamotrigine 10 mg twice a day
Tab. Trioplol 225 mg twice a day
Tab. Phenobarbitone 20/25 mg twice a day
Tab. Lonazep MD 0.5 ml once a day as and when required.
Tab Topamac 50 mg twice a day
Syp. Levera 3.6 ml thrice a day

midazolam nasal spray as and when required.
No major complication at home and showing good sign of improvement. Oral feed has been started. Tracheostomy was disconnected on Aug 23. On Oct 28, Vilohit started with focal seizures and presented in hospital on 5/11/14, again with status epilepticus. He was started on Lamtec DT 25mg (1 tab morning, 1 ½ mg night), Tab. Gardenal 1 tab once a day, Syp. Trioptal 7.5 mg for 12mg, Tab. Frisium 5mg thrice a day.
Vilohit continued to have focal seizures and episodes of desaturation. Vilohit was shifted in PICU on 12/11/14.
MRI 12/11/14
Marked dilatation of bilateral lateral ventricles and 3rd ventricle with relatively preserved 4th ventricle and hyper-dynamic CSF flow void in the region of aqueduct of sylvius , likely representing aqueductal stenosis.

The MRI revealed aquaductal stenosis with enlarged ventricles. VilohitVilohit was ventilated;
A ventricular peritoneal shunt was inserted on 18/11/2014. Vilohit however continued to have seizures.
Vilohit was taken on Inj. Midazolam.. The midazolam was treated upto 16.6 mcg/kg/min. The seizures were however persistent. Vilohit was taken on paraldehyde infusion. Vilohit also started having fever. His CSF and blood C/S were repeated. Vilohit was tracheostomized on 26/11/14, Vilohit underwent video EEG with HMPAO scan, Vilohit had grown Klebsiella on blood C/S which was sensitive to Meropenum_ The HMPO scan revealed increase blood flow in right temporal lobe and video EEG revealed: alternately right > left temporal focus both in convulsive and non-convulsive SE. Vilohit has also been started on ketogenic diet since 15/12/14.
IVIG 2g/kg given on 26/12/14.
MRI 29/12/14
-Dilated lateral and 3rd ventricle with normal sized, 4th and ventricular shunt in situ
-thin subdural collections along bilateral high fronto-parietal. Convexities with diffuse dural. Enhancement in supratentorial compartment.
-As compare to MRI dated 12/11/14, subdural collections are new finding.
Ketamine 300mg started on Dec 31. Vilohit also started on Inovelon 100mg.
EEG XXXXXXX 10, 2015
Delta-theta come pattern, left Frontal Epileptiform activity
Vilohit also received 4 doses of Inj. Rituximab 300 mg weekly. Vilohit improved and decreased in seizures frequency. At present, Vilohit is afebrile and on NG feed. He has occasional focal seizure and twitching of the angle of mouth. Discharged in Feb 10, 2015.

Drugs on Discharge
Tab Glycopyrholate 1 mg NG x 12 hourly
Tab, Topamac 125 mg NG x 12 hourly
Tab Lacosamide 100 mg NG x 12 hourly
Tab. Clonazapam MD .25 mg NG x 8 hourly
syp Levera 300 mg NG x 8 hourly
Tab Gardenal 60 mg NG x 12 hourly
Cap Zonisap 50mg NG x 12 hourly

Meloset or pedicloryl to control sleeping disorder. – 10-15 ml/day

Vilohit still having focal seizure and twitching of the angle of mouth. Doctor added Tab. Frisium 5 mg twice a day


XXXXXXX      Dr. Nameet Jerath     Dr VB XXXXXXX
+0000          +0000          +91 0000

Vilohit is still unconscious and taking no commands. having focal seizure and twitching of the angle of mouth. other no medical complication. movement is there and senses like light, noise, pain he feels but no expressions. can you suggest something for his improvement or consciousness? I have given my contact number along with Neurologist Dr VB XXXXXXX Please do let me know if any thing needed.

Thanks doctor for advise and suggestion. My concern is, we are not able to control his seizure and it's more than one year. Seizure must be stopped to recover. Is there any way or line of treatment,we can start to stop speizure?

Thanks doctor!
as I already have given the current medicines and doses, can you please suggest the best adjustment?