A Teen with Seizures, Amnesia, and Troubled Family Dynamics Shephali Sharma, MD, and Julie Alonso-Katzowitz, MD
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Cases That Test Your Skills A teen with seizures, amnesia, and troubled family dynamics Shephali Sharma, MD, and Julie Alonso-Katzowitz, MD Ms. A, age 13, is admitted for acute-onset amnesia. She has been How would you treated for intractable seizures for 5 months. What could be handle this case? Answer the challenge causing her amnesia? questions throughout this article CASE Seizures, amnesia Ms. A is admitted to the inpatient medi- Ms. A, age 13, who has a history of seizures, cal unit for further work up. Along with the presents to the emergency department memory loss and seizures, she reports visual (ED) with sudden onset of memory loss. Her hallucinations. family reports that she had been spend- ing a normal evening at home with family What could be causing Ms. A’s amnesia? and friends. After going to the bathroom, a) a seizure disorder Ms. A became acutely confused and b) malingering extremely upset, had slurred speech, and c) posttraumatic stress disorder did not recognize anyone in the room except d) traumatic brain injury her mother. Initial neurologic examination in the ED reports that Ms. A does not remember recent HISTORY Repeat ED visits or remote past events. Her family denies any Ms. A’s mother reports that 3 years ago her recent stressors. daughter was treated for tics with quetiapine Vital signs are within normal range. She and aripiprazole, prescribed by a primary care has mild muscle soreness and gait instability, physician. She received a short course of coun- which is attributed to a presumed postictal seling 6 years ago after her sister was sexually phase. Her medication regimen includes: leve- abused by her grandfather. Approximately tiracetam, 500 mg, 3 times a day; valproic acid, 6 months ago, Ms. A engaged in self-injurious 1,000 mg/d; and oxcarbazepine, 2,400 mg/d, behavior by cutting herself, and she briefly for seizure management. received counseling. There is no history of sui- Complete blood count and comprehen- cide attempts, psychiatric hospitalization, or a sive metabolic panel are within normal limits. psychiatric diagnosis. Pregnancy test is negative. Urine toxicology Medical and surgical history include viral report is negative. Serum valproic acid level meningitis at age 6 months. Medical records is 71 μg/mL; oxcarbazepine level, <2 μg/mL; Dr. Sharma is a Fellow Physician, and Dr. Alonso-Katzowitz is ammonia level, 71 μg/dL (reference range, 15 Attending Physician, Department of Child and Adolescent to 45 μg/dL). Other than the aforementioned Psychiatry, University of Texas Southwestern, Austin, Texas. deficits, she is neurologically intact. The team Disclosures thinks that her symptoms are part of a postic- The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of Current Psychiatry tal phase of an unwitnessed seizure. competing products. Vol. 14, No. 3 43 Cases That Test Your Skills show a visit to the ED for abdominal pain after The authors’ observations a classmate punched her in the abdomen, We focus on the amnesia because it has which resolved with supportive care. She was an acute onset and it seems this is the first given a diagnosis of pediatric autoimmune time Ms. A presented with this symptom. neuropsychiatric disorders associated with There is no need to wait for neurology streptococcal infections 6 years ago. consultation, even though organic causes Ms. A developed multiple recurrent of amnesia need to be ruled out. Our plan methicillin-resistant Staphylococcus aureus is to develop rapport with Ms. A, and abscesses a year ago, which lasted for then administer a mental status examina- 4 months; it was noted that she was self- tion focusing on memory assessment. We inoculating by scratching eczema. She had a understand that, because Ms. A’s chief possible syncopal episode 5 months ago, but concern is amnesia, she might not be able Clinical Point the medical work-up was normal. The pediat- to provide many details. We start the initial ric neurology service diagnosed and treated interview with the family in the patient’s Our plan is to seizures 4 months ago. room to understand family dynamics, and develop rapport Levetiracetam was prescribed after a pos- then interview Ms. A alone. with Ms. A, and then sible syncopal episode followed by a tonic- administer a mental clonic seizure. Because she was still having EVALUATION status examination seizure-like episodes with a single antiepilep- Memory problems tic drug (AED), oxcarbazepine, then valproic On initial psychiatric interview, Ms. A can rec- focusing on memory acid were added. Whether her seizures were ognize some of her family members. She is assessment generalized or partial was inconclusive. The seen in clean attire, with short hair, lying in seizures were followed by a postictal phase the bed with good eye contact and a calm lasting 3 minutes to 1 hour. Her last general- demeanor. She seems to be difficult to engage ized tonic-clonic seizure was 1 month before because of her reserved nature. admission. Ms. A displays some psychomotor retarda- Ms. A had 3 MRI studies of the brain over tion. She reports her mood as tired, and her the past 3 years, which showed consistent and affect is flat and mood incongruent. She is unchanged multifocal punctate white matter alert and oriented to person only; not to place, lesions. The findings represented gliosis from time, or situation. She can do a simple spell- an old perivascular inflammation, trauma, or ing task, perform 5-minute recall of 3 words, ischemic damage. There is no history of trau- complete serial 3 subtractions, repeat phrases, matic brain injury. read aloud, focus on a coin task, and name Her perinatal history is unremarkable, with simple objects. She does not compare similar normal vaginal delivery at 36 weeks (pre-term objects or answer simple historical or factual birth). All developmental milestones were on questions. target. Ms. A replies “I don’t know” to most his- Ms. A lives at home with her mother, torical questions, such as her birthday, favor- 6-year-old brother, and stepfather. Her par- ite color, and family members; she does not ents are divorced, but her biological father answer when asked how many legs a dog Discuss this article at has been involved in her upbringing. She is has, who is the current or past president, www.facebook.com/ in seventh grade, but is home schooled after what month the Fourth of July is in, or when CurrentPsychiatry she withdrew from school because of mul- Christmas is. She can complete some memory tiple seizure episodes. Ms. A denied bullying tasks on the Mini-Mental State Examination, at school although she had been punched by but does not attempt many others. Ms. A says a peer. It was unclear if it was a single incident she is upset about her memory deficit, but her or bullying continued and she was hesitant to affect was flat. Her mood and her affect were Current Psychiatry 44 March 2015 disclose it. incongruent. She describes a vision of a “girl continued Cases That Test Your Skills with black holes [for eyes]” in the corner of her Which diagnosis does Ms. A’s presentation and hospital room telling her not to believe any- history suggest? one and that the interviewers are lying to her. a) dissociative amnesia Also, she reports that “the girl” tells her to hurt b) factitious disorder imposed on self herself and others, but she is not going to act c) conversion disorder (neurological symp- on the commands because she knows it is not tom disorder) the right thing to do. When we ask Ms. A about d) psychosis not otherwise specified a history of substance abuse, she says she has e) malingering never heard of drugs or alcohol. Overall, she displays multiple apparent The authors’ observations deficits in declarative memory, both episodic The history of unwitnessed seizures, sud- and semantic. Regarding non-declarative or den onset of visual hallucinations, and procedural memory, she can dress herself, use transient amnesia points to a possible post- Clinical Point the bathroom independently, order meals off ictal cause. Selective amnesia brings up the the menu, and feed herself, among other rou- question of whether psychological compo- Her psychotic tine tasks, without difficulty. nents are driving the symptoms. symptoms appear According to Ms. A’s mother, Ms. A has Her psychotic symptoms appear to be to be mediated by shown a decline in overall functioning and mediated by anxiety and possibly related anxiety and possibly personality changes during the past 5 months. to the trauma of losing her only sister related to the trauma She started to cut herself superficially on when her mother relinquished custody to of losing her only her forearms 6 months ago and also tried to the state; the circumstances might have change her appearance with a new hairstyle aroused feelings of insecurity or fear of sister when school started. She displayed noticeably abandonment and raised questions about intense and disturbing writings, artwork, and her mother’s love toward her. Her sis- conversations with others over 3 to 4 months. ter’s abuse by a family member might She started experiencing seizures, with 3 have created reticence to trust others. to 4 seizures a day; however, she could attend These background experiences could be sleepovers seizure-free. She had prolonged intensely conflicting at this age when the periods of seizures lasting up to an hour, much second separation individuation process longer than would be expected clinically. She commences, especially in an emotionally also had requested to go to the cemetery for immature adolescent. unclear reasons (because the spirit wanted continued her to visit), and was observed mumbling under her breath.