CASE 34: SEIZURES
History
A 23-year-old African-Caribbean woman is admitted to the emergency department hav-
ing had two tonic–clonic generalized seizures which were witnessed by her mother. Her
mother says that her daughter has been behaving increasingly strangely, and has been
hearing voices talking about her. Recently, she has complained of severe headaches. She
has lost weight and has noticed that her hair has been falling out. She has also complained
of night sweats and flitting joint pains affecting mainly the small joints of her hands and
feet. She works as a bank clerk. She smokes 5–10 cigarettes per day and consumes about
10 units of alcohol per week. She is taking no regular medication. She has no significant
medical or psychiatric history.
Examination
She is drowsy but responsive to pain. There is no neck stiffness. Her scalp hair is thin and
patchy. Her temperature is 38.5°C. She has numerous small palpable lymph nodes. Her
pulse rate is 104/min regular, blood pressure 164/102 mmHg. Examination of her cardio-
vascular, respiratory and abdominal systems is otherwise normal. Neurological examin-
ation reveals no focal abnormality and no papilloedema.
NormalHaemoglobin 7.2 g/dL 11.7–15.7 g/dL
Mean corpuscular volume (MCV) 85 fL 80–99 fL
White cell count 2.2% 109 /L 3.5–11.0% 109 /L
Platelets 72 % 109 /L 150–440% 109 /L
Erythrocyte sedimentation rate (ESR) 90 mm/h !10 mm/h
Sodium 136 mmol/L 135–145 mmol/L
Potassium 4.2 mmol/L 3.5–5.0 mmol/L
Urea 16.4 mmol/L 2.5–6.7 mmol/L
Creatinine 176 &mol/L 70–120&mol/L
Glucose 4.8 mmol/L 4.0–6.0 mmol/L
Lumbar puncture
Leucocytes 150/mL !5/mL
Cerebrospinal fluid (CSF) protein 1.2 g/L !0.4 g/L
CSF glucose 4.1 mmol/L #70 per cent
plasma glucose valueUrinalysis:'''protein;'''blood
Urine microscopy:''red cell; red cell casts present
Chest X-ray: normal
Electrocardiogram (ECG): sinus tachycardia
Computed tomography (CT) of the brain: normal
CSF Gram stain: negativeINVESTIGATIONS
Questions
- What is the likely diagnosis?
- How would you investigate and manage this patient?