Cefepime- Induced Non-Convulsive Status Epilepticus (NCSE)
A 71-year-old woman with a history of diabetes mellitus and liver cirrhosis associated with hepatitis B viral infection was hospitalized for right lower lobe lobectomy after diagnosis of lung cancer. Although she had successful lobectomy, she underwent several post-operative complication including operation site bleeding, acute renal failure, acute respiratory distress syndrome, and atypical pneumonia. Her renal failure was prerenal type after massive operation site bleeding, and continuous renal replacement therapy (CRRT) were started for renal replacement treatment. Post operation (OP) day 9, she experienced confusion, and disorientation and started on quetiapine with diagnoses of delirium. Post OP day 13, she had antibiotic resistance for atypical pneumonia, which had to switch from imipenem and vancomycin to cefepime. Although her serum creatinine level was much improved from 2.7 mg/dL to 1.87 mg/dL, after 5 days of renal replacement therapy, she was started on cefepime renal dose of 2 g every 12h. Plasma concentration of cefepime was not measured because the analytical technique was not available in our hospital. After 5th day of cefepime use, the patient became stupor and developed one episode of brief generalized myoclonic seizure. The neurologic examination revealed change in mental status, and minimal response to noxious pain stimulation. There was no focal neurological sign, pathologic reflex, and neck stiffness. Temperature, vital signs and the rest of the physical examination were normal. The brain magnetic resonance imaging (MRI) including diffusion and gradient echo images revealed no acute lesions which can explain sudden mental status change. Serum blood cell counts, glucose, ammonia and electrolytes were within the normal range. Renal profile showed blood urea nitrogen (BUN) of 27 mg/dL (normal range: 7–25 mg/dL), creatinine of 1.33 mg/dL, creatinine clearance (Ccr) of 25.35 mL/min/1.73m2. The electroencephalograph (EEG) revealed continuous 2–3 Hz generalized sharp and wave (). NCSE was diagnosed and administered lorazepam 4 mg intravenous injection with continuous EEG monitoring were started. She was than further treated with levetiracetam 500 mg and valproic acid 900 mg intravenously. She stay on maintenance doses of valproic acid (900 mg/day) and phenytoin (300 mg/day), clonazepam (1.5 mg/day). Repeated EEG revealed improved after anti-epileptic treatment (). As we discontinued cefepime, considering as a causative agent for NCSE, clinical symptoms improved 3 days after discontinuation of cefepime. She was than diagnosed with cefepime induced non convulsive status epilepticus. Anti-epileptic treatment was than discontinued uneventfully. No relapse occurred.