March 31, 2009

Seizure with hemorrhagic temporal lobe

A 32-year-old previously healthy man is brought to the emergency room after having a seizure. A family member states that recently the patient has been complaining of a headache and has been acting bizarre, which is a change in his personality. Physical examination reveals a temperature of 38.3°C. Blood pressure and heart rate are normal. During examination, the patient has a partial complex seizure. CT scan of the head reveals hemorrhagic necrosis of the temporal lobes [Taken and Modified From Question 387, Physical Diagnosis Pretest® Self-Assessment And Review Fourth Editio, Jo-Ann Reteguiz, M.D., Beverly Cornel-Avendaño, M.D, Mcgraw-Hill Medical Publishing Division Pretest® Series]

1) What further question you would like to ask? (3m)
2)What other investigation that you would like to perform? (2m)
3)What is your provisional diagnosis and justify your answer (3)
4)Give one drug of choice and mode of action (2m)

Answer scheme

1)What further question you would like to ask?
-Any family history of seizure?
-Any alcohol or drug abuse?
-Any history of trauma?
-Did patient sexually active ( HSV infection can cause encephalitis)
-History of mumps (can be exclude as mumps usually attack school-age children), herpes zoster
-Any olfactory or gustatory hallucination? (proceed with frontal and temporal lobe involvement especially in HS Encephalitis)

2)What other investigation that you would like to perform?
-CSF Examination (5-500 lymphocytes, mildly elevated protein, normal glucose)
-EEG examination (generalized slowing with burst of periodic high voltage slow wave complex over the involve temporal lobe)
-Polymerase chain reaction on csf (negative in the first 48 hours)
-CSF HSV- specific antibody (immunofluorescence)

3)What is your differential diagnosis and justify your answer
-Herpes simplex encephalitis
a)Sub acute onset seizure
b)Change in personality
c)Fever, headache, seizure.
d)Hemorrhagic necrosis of temporal lobe)

4)Give one drug of choice and mode of action
-Antiviral drug that inhibit the DNA synthesis.

Reference: (Page 503, Neurology and Neurosurgery illustrated Fourth Edition, Kenneth W. Lindsay & Ian Bone, Churchill Livingstone, 2004]


Narated By ‘Abdullah: The Prophet led us in Zuhr prayer and prayer five Rakat. Somebody asked him whether the prayer had been increased." He (the Prophet) said, "And what is that?" They (the people) replied, "You have prayed five Rakat." Then the Prophet offered two prostrations (of Sahu) after he had finished his prayer with the Taslim.[Shahih Bukhari Volumn 009, Book 091, Hadith Number 355]

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