Adjunctive enteral phenobarbital for adult status epilepticus: a brief report
A 76-year-old man with history of diabetes and hypertension was admitted because of pneumonia and received ceftazidime and clindamycin. During admission, the patient developed acute right hemiparesis. An acute cerebellar infarction was found at the right cerebellar hemisphere, along the posterior cerebellar artery. He also developed hospital-acquired pneumonia from Acinetobacter baumannii. The patient was referred to the university hospital with Glasgow Coma Scale (GCS) score of E4VTM6 (E = eye opening; V = verbal response; M = motor response). One week later, he became comatose, had dilated pupils (4 mm, with reaction to light), with eye deviation to left side and horizontal nystagmus. The CT scan of the brain showed right cerebellar infarction with hemorrhagic transformation and also left cerebellar infarction. At day 60 of admission, he had alteration of consciousness related to hypoglycemia (plasma glucose 22 mg/dL). He also had generalized tonic-clonic seizures for 30 minutes and was treated with 50% glucose and four times with 10 mg IV diazepam. The seizures were persistent despite his plasma glucose returning to 128 mg/dL, and he did not respond to 750 mg of IV phenytoin (two doses) or 1,200 mg of IV sodium valproate. An EEG showed persistent generalized spikes, and waves were found in both cerebral hemispheres, compatible with CSE. He was successfully treated with 960 mg PB via NG tube feeding. The IV phenytoin and sodium valproate were discontinued. His maintenance therapy was 180 mg/day of PB enterally. He developed uncontrolled sepsis and a second episode of GTCSE 26 days later and was successfully treated with 960 mg PB via NG tube feeding again. Even though the seizures were controlled, the patient had cardiac arrest and 3 hours later died, from uncontrolled sepsis.