MF5 - Ethel Lepky Global Objectives Upon completion of this case, students will become familiar with the

anatomy and physiology of the limbic system. Case Overview Ethel Lepky is a 10 year old girl who has been brought to the Emergency Department with a new onset of seizures. Ethel is reported by her parents to have been previously healthy and developmentally normal. She began complaining of headache and fatigue yesterday. She was given some acetaminophen and went to bed. When her mother checked on her, she had an oral temperature of 39.9C. She was very sleepy, but took more acetaminophen. This morning, when her mother was going past Ethels room, she heard s ome unusual thumping and gurgling noises. When she entered the room, she found Ethel laying in bed stiff as a board, frothing at the mouth, with her whole body shaking and her eyes rolled back in her head. From when her mother found her, the event lasted an additional 2-3 minutes. After the shaking stopped, Ethel became limp and unresponsive. She was still febrile. EMS was called and Ethel was brought to the hospital. While the Emergency Physician is taking the history, Ethel has an episode of sustained extension of her left arm and gaze deviation to the left. This lasts approximately one minute, and then her whole body stiffens and begins to shake. The ER team supports her breathing and gives her two loads of IV lorazepam. Unfortunately, this does not stop the episode, and an additional bolus of IV phenytoin is given. Her seizure finally resolves after approximately 35 minutes. At that point, she is intubated and taken to the PICU. She is started on vancomycin and cefuroxime at meningitic doses. She is also started on acyclovir. Once she is felt to be stable, an urgent MRI is acquired. This is reported to show an extensive T2 hyperintense lesion in the mesial temporal lobe on the right. The neuroradiologist feels that the lesion is in keeping with viral encephalitis. A lumbar puncture is performed which shows 50 WBC, 75 RBC, mildly elevated protein, and a normal glucose. The HSV PCR is subsequently found to be positive. During her stay in hospital, Ethel continues to have seizures. She is started on carbamazepine and the seizures stop over the next few days. She is initially very sleep, confused, and agitated. Over time, she starts to act somewhat more like her normal self, although she has been using inappropriate language and keeps asking why she is in the hospital. Her mother raises concerns about her lack of short-term memory and her dysinhibited behaviour. She wants to know how Ethel got Herpes; when she can come off of the anticonvulsant; and whether her memory and behaviour will ever return to normal. Downloads
EEG Showing Focal Seizure With Secondary Generalization Download

Ethel Lepkey Radiology and Pathology Download

Resources
Viral encephalitis Kennedy PG. Viral encephalitis. J Neurol. 2005 Mar;252(3):268-72. Journal article

Ethel Lepkey Seizure Video link

Classifying seizures and epilepsy: A synopsis Sirven JI. Classifying seizures and epilepsy: A synopsis. Semin Neurol. 2002 Sep;22(3):237-46. Journal article

Practice parameter: Evaluating a first nonfebrile seizure in children Hirtz D, Ashwal S, Berg A, Bettis D, Camfield C, Camfield P, Crumrine P, Elterman R, Schneider S, Shinnar S. Practice parameter: Evaluating a first nonfebrile seizure in children: Report of the quality standards subcommittee of the american academy of neurology, the child neurology society, and the american epilepsy society. Neurology. 2000 Sep 12;55(5):616-23 Journal article

Neuroimaging of herpesvirus infections in children Baskin HJ, Hedlund G. Neuroimaging of herpesvirus infections in children. Pediatr Radiol. 2007 Oct;37(10):949-63. Journal article

New generation anticonvulsants for the treatment of epilepsy in children Donner EJ, Snead OC,3rd. New generation anticonvulsants for the treatment of epilepsy in children. NeuroRx. 2006 Apr;3(2):170-80 Journal article

Nelson textbook of pediatrics Kliegman R, Nelson WE. Nelson textbook of pediatrics / 19th ed. Philadelphia, PA: Elsevier/Saunders; c2011. eBook

Neuroanatomy through clinical cases Blumenfeld, H. Neuroanatomy through clinical cases/2nd ed. Sunderland, Mass.: Sinauer Associates c 2010. (Call number WL 141 .B658N 2010) Book

Special Instructions In Nelson Textbook of Pediatrics, read Chapter 593: Seizures in Childhood.