CPC 6/3/2016

DK – 61 yo F seizures Idiopathic iridocyclitis and uveitis on immunosuppression T2DM, HTN, HLD COPD, OSA Bedbound for one year due to morbid obesity and deconditioning No pertinent family or social history

History The patient was seen at the VA in 2011 for an event of dysarthria lasting for 24+ hours. MRI was unremarkable, so the event was attributed to a non-epileptic spell given her report of stress related to an abusive relationship. No EEG was obtained during that admission.

History In Nov 2014 she was evaluated following a generalized convulsive event and myoclonus. She reported a h/o seizures in childhood treated with phenobarbital for many years. Her last reported GTC seizure was in 1988. In addition to the GTCs, she reported a history of “drop attacks” and “black outs” in the past, but these were too remote for her daughter to provide further description. She had not been on anticonvulsants for 10+ years prior to the breakthrough seizure.

History EEG 11/2011 notable for generalized poly-spike and wave discharges with an after-going slow wave, maximal over the left frontal head region. No clinical changes were noted with the discharges. The background was diffusely slow. She was started on a slow up-titration of Lamictal at that time, however, developed a rash and this medication was discontinued. She represented to the hospital a couple of weeks later with multiple events, and was started on Keppra 500mg/1000mg. She did not have follow up with neurology until this current admission.

MRI Brain 11/5/2014 D8571 (Denise King)

MRI Brain 11/5/2014

MRI Brain 11/5/2014 Hippocampal views. Post-contrast images too motion degraded to be helpful.

History of Present Illness 5 months prior to death: new headache, thought to be from Cellcept, so was switched to Imuran 2 weeks prior to death 4 days prior to death: awoke with slurred speech, progressed to altered level of consciousness, would open eyes to voice, not follow commands At VA, initially afebrile, BP 222/106 and HR 93 had episode of left gaze deviation and lip smacking, followed by multiple episodes of generalized tonic/clonic activity; started on keppra and phenytoin during this time Became hypoxic, hypercarbic, and hypotensive; daughter was called, code status was reversed from DNR/DNI and patient was intubated CT head and CTA obtained, unrevealing Started then vancomycin, bactrim, aztreonam, acyclovir for empiric meningioencephalitis in the setting of penicillin allergy (anaphylaxis)

3 days prior to death Transferred to PUH, where had Tmax 38.5, normotensive, hypoxic completely unresponsive to pain, pupils fixed wbc 23 CSF wbc 337 (248 corrected), rbc 71280, gluc 226, prot 217, HSV and VZV negative, crypto negative EEG: R temporal LPD’s and subclinical R hemispheric seizures Started on versed Abx switched to meropenem, acyclovir

2 days prior to death Continued to have frequent seizures despite maximizing keppra, phenytoin, increasing versed, and loading vimpat Increased vent requirements, never stable enough for CT scan or MRI

1 day prior to death Given worsening clinical status, daughter opted for CMO given previous DNR/DNI order Terminally extubated Family requested brain only autopsy