(PO-017) Major Depressive Episode Presentation of Frontal Lobe Status Epilepticus Resolved with Levetiracetam Monotherapy
Title: Major Depressive Episode Presentation of Frontal Lobe Status Epilepticus Resolved with Levetiracetam Monotherapy
Frontal lobe epilepsy (FLE) can elicit various clinical presentations, although the most common presentation is rapid onset of unilateral clonic seizures or tonic asymmetric seizures with short postictal periods (Beleza 2011). Due to the diverse and complex functions of the frontal lobe, FLE can also present with primarily neuropsychiatric symptoms, leading to misdiagnoses of primary psychiatric conditions such as bipolar disorder, antisocial personality disorder, and obsessive compulsive disorder (Gold 2016). We describe a patient presenting with complex depressive symptoms and failure to thrive who was found to have left frontal lobe epilepsy on electroencephalogram (EEG), and whose psychiatric symptoms and epileptiform promptly de-escalated with levetiracetam administration.
A 74 year old female with one remote major depressive episode and a past medical history of breast cancer (in remission; on tamoxifen and trastuzumab) was admitted for failure to thrive. She reported 30 lbs weight loss over 3 months in the setting of progressive depressed mood, confusion and memory impairment, decreasing appetite and oral intake, diffuse abdominal pain and nausea, and fatigue. Mild hyponatremia (129 mEq/L) was corrected with saline. CT scans (chest, abdomen and pelvis) were unremarkable, as well as right upper quadrant and mesenteric ultrasounds. MRI brain demonstrated moderate generalized atrophy and a remote right basal ganglia hemorrhagic stroke.
On psychiatric evaluation, the patient was fully oriented, but demonstrated flat affect, psychomotor retardation, cognitive slowing, poor eye contact, anhedonia, and depressed mood with passive death wish. She declined oral intake and all medications, and was evaluated to be incapacitated in the setting of vacant reasoning. Despite high intellectual baseline, cognitive testing demonstrated deficits in delayed recall, fluency, attention, and visuospatial cognition. CSF was unremarkable, with negative paraneoplastic antibodies, flow cytometry, and infectious testing. Electroencephalogram (EEG) with sphenoidal leads was recommended by psychiatry and demonstrated lateralized rhythmic delta activity plus sharp waves in the bilateral frontal lobes (left > right), which normalized after loading with levetiracetam. Cognition, speech, hunger, oral intake and mood improved over a few days. Plans for electroconvulsive therapy were discontinued, and the patient discharged the hospital euthymic and without any psychotropic regimen. She has remained seizure free and euthymic on leviteracetam monotherapy over the past year.
In the rare scenario of frontal lobe status epilepticus presenting as a neuropsychiatric syndrome without motor semiology, a major depressive episode may promptly abate with antiepileptic drug normalization of epileptiform activity, without requirement for psychiatric medications or electroconvulsive therapy.
Gold JA, Sher Y, Maldonado JR; Frontal Lobe Epilepsy: A Primer for Psychiatrists and a Systematic Review of Psychiatric Manifestations. Psychosomatics 2016;57(5):445-64.