Thread by @hyderabaddoctor

Uncontrolled #epileptic fits stopped by #insulin

1. A man aged 75 had for five days experienced tonic-clonic #seizures involving the right side of the face and right upper and lower limbs at a frequency of 20-30 per day. He had mild weakness of right arm and leg.
#MedTwitter

2. Patient was admitted in ICU under Medicine Unit. MRI brain and lumbar puncture were normal. New onset diabetes was detected for which he was treated with subcutaenous insulin.
Fits persisted despite treatment with midazolam and phenytoin. He was referred for neurology opinion

3. Patient was conscious but appeared exhausted. Review of blood tests showed high glucose of 350 mg/dL and mildly low sodium levels.
The diagnosis was obvious by now.

4. The cause of epileptic fits was high blood sugars, a condition known as epileptia partialis continua. Medicine chosen (phenytoin) to treat fits could further increase his blood sugar levels.
I suggested to stop phenytoin and start insulin (actrapid) infusion.
#diabetes

5. Fits completely stopped when blood sugar level reduced to 150 mg/dL.
All anti-epileptic drugs were stopped, and he was maintained only on S/C insulin.
He had no further seizure episodes and was discharged to home soon.

6. High blood sugar (hyperglycemia) can cause repeated focal motor seizures (fits).
Hyperglycaemia increases the metabolism of gamma-aminobutyric acid and thereby lowers seizure threshold.

7. It is particularly important to remember non-ketotic hyperglycaemia as a cause of persistent focal motor seizures since administration of phenytoin may do harm by worsening blood sugar control.
These patients do not require long-term antiepileptic drug prophylaxis.

8. I had treated this patient more than two decades ago, and this patient report was published in the Journal of Royal Society of Medicine (JRSM)
doi.org/10.1258%2Fjrsm…