Effectiveness of Topiramate in Medically Complicated Patients with Status Epilepticus or Acute Refractory Seizures
A 48-year-old woman with no history of seizures was admitted to the hospital in poor health. The patient was diagnosed with paroxysmal nocturnal hemoglobinuria (PNH) 20 years prior to admission and had been treated as an outpatient with oral steroids. RBC transfusions were performed once a month. The routine blood tests on admission revealed pancytopenia (hemoglobin 4.4 g/dL, hematocrit 13.3%, WBC 730/mm3, and a platelet count of 52,000/mm3) and acute renal failure (BUN 126.5 mg/dL and creatinine 9.23 mg/dL). Continuous renal replacement therapy (CRRT) was performed in the intensive care unit. On the third hospital day, GCSE developed. Treatment was started with a LZP injection followed by DPH infusion. However, the GCSE continued. A loading dose of TPM (800 mg) was administrated via a nasogastric tube. By the next day, the continuous seizures were under control and the patient was responsive to verbal stimulation. However, intermittent brief seizures occurred several times under a maintenance dose of TPM (300 mg bid) during the subsequent two days. After three days of TPM administration the seizures stopped. The follow-up EEG showed no epileptiform discharges. The diffusion-weighted MRI revealed multifocal high signal intensity involving the occipital lobes, the right basal ganglia and the subcortical white matter of the prefrontal gyri on the diffusion and T2-weighted images. The identified lesions showed increased values on the ADC map, suggesting vasogenic edema or a posterior reversible encephalopathy (PRES). The EEG showed multifocal sharp waves and intermittent generalized slow waves. The TPM was maintained at a dose of 200 mg bid, and there was no further seizure activity. However, aspiration pneumonia and sepsis developed, and the patient died on the 15th hospital day.