Status Epilepticus

EMM is a 67-year-old female presented to an outlying hospital with unresponsiveness for 2 h. At the emergency department she had generalized tonic-clonic seizure lasting 60 min. She was treated with intravenous (IV) lorazepam, levetiracetam, and fosphenytoin. Recurrent seizures did not respond to anti-seizure medication and subsequently she was intubated and begun on a propofol infusion. She was also noted to have a temperature of 104 °F, neck rigidity, and leukocytosis. Lumbar puncture was performed which drained purulent CSF. CSF white blood cell count (WBC) was 15,315/μL with 96% neutrophils and 3% lymphocytes. Gram stain was 2+ for gram-positive cocci representing streptococcus pneumoniae. CT of the head did not reveal an acute structural abnormality. She was started on ceftriaxone, vancomycin, and dexamethasone. When she presented to our facility she was intubated and sedated with propofol. Her neurological exam was unremarkable except for subtle horizontal nystagmus and meningismus. Status epilepticus (SE) with bacterial meningitis was her initial diagnosis and she was monitored with continuous EEG (CEEG). CEEG demonstrated nonconvulsive status epilepticus (NCSE). She was reloaded with fosphenytoin and levetriacetam and continued with propofol for 24 h with a CEEG target of 2–3 bursts per 15 s epoch on a suppressed background. During the next 24 h she was seizure-free. A slow taper of the propofol infusion with CEEG monitoring was done. After 3 days of hospitalization, she was awake and followed commands. Following spontaneous breathing trial, she was subsequently extubated without complications. After 1 week she was transferred to a rehabilitation facility because of generalized weakness. Three months later she was seen in the neurology clinic and appeared neurologically intact except for a mild cognitive deficit. She was able to return to full-time employment with steady improvement.