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CSF and Seizures

Topic: Adult

Created on Sunday, November 4 2007 by jdmiles

Last modified on Sunday, November 4 2007.

A 35 year old male presents is brought to the ED after a generalized tonic-clonic seizure. The seizure occurred about 2 hours ago. He remains lethargic and confused. Physical exam reveals an afebrile, healthy-appearing male with no focal neurologic findings. EEG reveals generalized slowing with no epileptiform discharges.

As he has no history of seizures, a lumbar puncture is performed, which reveals 1 RBC and 125 WBCs in tube 1, and 0 RBCs and 120 WBCs in tube 2. Glucose and protein are normal. Gram stain and cultures are pending.

The ED attending comments that pleocytosis is common after a seizure, and recommends that the patient be started on an antiepileptic medication and discharged with an appointment to follow up with a neurologist as an outpatient.

What is the most appropriate course of action?


 
        A) Discharge the patient with an appointment for follow up, and a prescription for phenytoin
 
        B) Discharge the patient with an appointment for follow up and a prescription for levetiracetam
 
        C) Admit the patient for further workup
 
        D) Discharge the patient with an appointment for follow up, but do not start antiepileptic medications at this time
 
        E) Repeat the lumbar puncture
 

 


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This question was created on November 04, 2007 by jdmiles.
This question was last modified on November 04, 2007.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANSWERS AND EXPLANATIONS




A) Discharge the patient with an appointment for follow up, and a prescription for phenytoin

This answer is incorrect.


CSF pleocytosis after a seizure is not as common as this ED attending believes. Approximately 2% of LPs after seizures in otherwise healthy people showed pleocytosis. As this patient remains confused and lethargic, further workup and treatment is warranted.

Additionally, it is not usually necessary to start antiepileptic medications on a young person presenting with a first seizure.

  (See References)

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B) Discharge the patient with an appointment for follow up and a prescription for levetiracetam

This answer is incorrect.


CSF pleocytosis after a seizure is not as common as this ED attending believes. Approximately 2% of LPs after seizures in otherwise healthy people showed pleocytosis. As this patient remains confused and lethargic, further workup and treatment is warranted.

Additionally, it is not usually necessary to start antiepileptic medications on a young person presenting with a first seizure.

  (See References)

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C) Admit the patient for further workup

This answer is correct.


CSF pleocytosis after a seizure is not as common as this ED attending believes. Approximately 2% of LPs after seizures in otherwise healthy people showed pleocytosis. As this patient remains confused and lethargic, further workup and treatment is warranted.  (See References)

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D) Discharge the patient with an appointment for follow up, but do not start antiepileptic medications at this time

This answer is incorrect.


CSF pleocytosis after a seizure is not as common as this ED attending believes. Approximately 2% of LPs after seizures in otherwise healthy people showed pleocytosis. As this patient remains confused and lethargic, further workup and treatment is warranted.

Additionally, it is not usually necessary to start antiepileptic medications on a young person presenting with a first seizure.

  (See References)

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E) Repeat the lumbar puncture

This answer is incorrect.


CSF pleocytosis after a seizure is not as common as this ED attending believes. Approximately 2% of LPs after seizures in otherwise healthy people showed pleocytosis. As this patient remains confused and lethargic, further workup and treatment is warranted.

Repeating the lumbar puncture is not likely to reveal additional information.

  (See References)

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References:

1. Edwards, R., Schmidley, J.W., and Simon, R.P. (1983). "How often does a CSF pleocytosis follow generalized convulsions?" Ann Neurol, 13(4) 460-2. (PMID:6838178)
2. Trescher, W.H., and Lesser, R.P. (2004). The epilepsies. In Bradley, W.G., Daroff, R.B., Fenichel, G.M., and Jankovic, J. (Eds.). Neurology in Clinical Practice, Fourth Edition. Butterworth Heinemann, Philadelphia, pp. 1953-1992 (ISBN:0750674695).Advertising:
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adult
CSF and Seizures
Question ID: 110407085
Question written by J. Douglas Miles, (C) 2006-2009, all rights reserved.
Created: 11/04/2007
Modified: 11/04/2007
Estimated Permutations: 8400

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