A teen with seizures, amnesia, and troubled family dynamics

Ms. A, age 13, is admitted for acute-onset amnesia. She has been treated for intractable seizures for 5 months. What could be causing her amnesia? CASE Seizures, amnesia Ms. A, age 13, who has a history of seizures, presents to the emergency department (ED) with sudden onset of memory loss. Her family reports that she had been spending a normal evening at home with family and friends. After going to the bathroom, Ms. A became acutely confused and extremely upset, had slurred speech, and did not recognize anyone in the room except her mother. Initial neurologic examination in the ED reports that Ms. A does not remember recent or remote past events. Her family denies any recent stressors. Vital signs are within normal range. She has mild muscle soreness and gait instability, which is attributed to a presumed postictal phase. Her medication regimen includes: levetiracetam, 500 mg, 3 times a day; valproic acid, 1,000 mg/d; and oxcarbazepine, 2,400 mg/d, for seizure management. Complete blood count and comprehensive metabolic panel are within normal limits. Pregnancy test is negative. Urine toxicology report is negative. Serum valproic acid level is 71 [micro]g/mL; oxcarbazepine level, Ms. A is admitted to the inpatient medical unit for further work up. Along with the memory loss and seizures, she reports visual hallucinations. What could be causing Ms. A's amnesia? a) a seizure disorder b) malingering c) posttraumatic stress disorder d) traumatic brain injury HISTORY Repeat ED visits Ms. A's mother reports that 3 years ago her daughter was treated for tics with quetiapine and aripiprazole, prescribed by a primary care physician. She received a short course of counseling 6 years ago after her sister was sexually abused by her grandfather. Approximately 6 months ago, Ms. A engaged in self-injurious behavior by cutting herself, and she briefly received counseling. There is no history of suicide attempts, psychiatric hospitalization, or a psychiatric diagnosis. Medical and surgical history include viral meningitis at age 6 months. Medical records show a visit to the ED for abdominal pain after a classmate punched her in the abdomen, which resolved with supportive care. She was given a diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections 6 years ago. Ms. A developed multiple recurrent methicillin-resistant Staphylococcus aureus abscesses a year ago, which lasted for 4 months; it was noted that she was self-inoculating by scratching eczema. She had a possible syncopal episode 5 months ago, but the medical work-up was normal. The pediatric neurology service diagnosed and treated seizures 4 months ago. Levetiracetam was prescribed after a possible syncopal episode followed by a tonicclonic seizure. Because she was still having seizure-like episodes with a single antiepileptic drug (AED), oxcarbazepine, then valproic acid were added. Whether her seizures were generalized or partial was inconclusive. The seizures were followed by a postictal phase lasting 3 minutes to 1 hour. Her last generalized tonic-clonic seizure was 1 month before admission. Ms. A had 3 MRI studies of the brain over the past 3 years, which showed consistent and unchanged multifocal punctate white matter lesions. The findings represented gliosis from an old perivascular inflammation, trauma, or ischemic damage. There is no history of traumatic brain injury. Her perinatal history is unremarkable, with normal vaginal delivery at 36 weeks (pre-term birth). All developmental milestones were on target. …