Adjunctive enteral phenobarbital for adult status epilepticus: a brief report
A 35-year-old, previously healthy male was admitted due to a history of headaches and alteration of consciousness for 4 days. His CSF revealed 6 cells/mm3 of red blood cells and white blood cells. An MRI brain scan was compatible with herpes encephalitis. The patient received 750 mg IV of acyclovir every 8 hours. During hospitalization, he had GTCSE and received endotracheal intubation, 1,200 mg sodium valproate, and 1,000 mg IV phenytoin. The seizures were uncontrolled, and an EEG showed persistent generalized sharp waves followed by slow waves, in both cerebral hemispheres. He was given 900 mg PB by NG tube, and the SE was partially controlled. The seizures were recurrent but successfully treated with reloading of 900 mg of PB, IV phenytoin, and IV propofol. The PB level was 255.55 μg/mL (10–40 μg/mL), the free sodium valproate level was 12.21 μg/mL (50–100 μg/mL), and the free phenytoin level was 0.75 μg/mL (10–20 μg/mL) at day 3 after admission. A follow-up MRI showed evidence of encephalitis at the left limbic system and insular lobe of the left temporal lobe, and diffuse meningitis with evidence of basal arachnoiditis. After 23 days of admission, the patient was still comatose and was referred to a community hospital as per request from his relatives.