55 year old chronic alcoholic male with involuntary movements of upper and lower limbs

 55 year old male, farmer by occupation who is a chronic alcoholic since 25 years presented to casuality with C/O involuntary movement of hands and legs - 2 episodes since yesterday

HOPI:

Patient was apparently asymptomatic 1 year ago and then he developed 

First Episode:

Patient had clonic movements of upper limb for 1 minute at 11:00 am on 22/12/2020

H/O stared look for 5 mins associated with involuntary micturition 

H/O tongue bite +

Postictal frothing +

Postictal Confusion for 30 minutes +

No H/O Pain Abdomen, burning micturition

Tremors +

BP was found to be 180/100 mmHg

Patient was advised to stop alcohol and was sent for psychiatry opinion in view of alcohol withdrawal

Patient later again had clonic movements of upper limb at 4 pm leading to sudden fall causing injury to the right frontal region

Postictal Confusion for 10 minutes +

Uprolling of eyeballs +

Tongue bite +

Frothing +

Involuntary micturition +

No H/O Vomitings

Patient had binge of alcohol for 10 days continuously and had stopped that morning

MRI Brain was done on 22/12/2021 which showed features suggestive of Late Subacute to Chronic Haemorrhage in Left Putamen/External Capsule

Patient was started on TAB. LEVIPIL 500 mg/PO/BD and was asked to continue medication till 2 years of seizure free period but he had stopped taking medication one week after being discharged

On 9/12/2021:

Patient came to casuality with C/O 2 episodes (one episode on 8/12/21 at 7:30 pm and second episode on 9/12/21 at 10:30 am) of involuntary movements of upper and lower limbs since yesterday, each episode lasting for 2-2 1/2 mins associated with -

Drooling of saliva +

Involuntary micturition +

Tongue bite +

No uprolling of eyeballs

No involuntary defecation

H/O Alcohol binge present before both the episodes of seizures.

Patient consumed alcohol for 10 days (12 units - 360 ml whiskey) followed by abstinence for a day or two, leading into seizures.

Last alcoholic drink - 30 ml (1 unit whiskey) after seizure episode

Psychiatry referral I/v/o ?Alcohol withdrawal seizures with alcohol dependence syndrome

Advice given:

Patient is not a K/C/O DM/HTN/TB

PERSONAL HISTORY:

Diet - mixed

Appetite - no food intake from the last 10 days

Sleep - disturbed

Bowel habits - regular

Micturition - normal

No known allergies

Chronic Alcoholic since the last 25 years with daily intake of 90-180 ml increasing quantity progressively

No H/O Smoking

Family History - Not significant

GENERAL EXAMINATION:

No pallor, icterus, cyanosis,clubbing lymphadenopathy, edema

Patient is Afebrile

PR - 92 bpm

RR - 18 cpm

BP - 150/90 mmHg

SpO2 - 99% at RA

GRBS - 199 mg/dL

SYSTEMIC EXAMINATION:

CVS - S1, S2 heard , No murmurs

RS - BAE +, NVBS +

P/A - Soft, Non tender

CNS -

Patient in a confused state and is irritable

Speech- Incoherent

Gait-

No signs of meningeal irritation

Cranial nerves - intact

Motor and sensory systems - intact

Reflexes   RIGHT       LEFT          

Biceps         2+             2+

Triceps        2+             2+

Supinator    2+             2+

Knee            2+             2+

Ankle           2+             2+

Plantar    Flexion      Flexion

INVESTIGATIONS on 09/12/2021:

USG Abdomen:

2D ECHO:

ECG

PROVISIONAL DIAGNOSIS:

?Alcohol Withdrawal Seizures with Alcohol dependence syndrome/?Epileptic Disorder

TREATMENT GIVEN:

1. Inj. Thiamine 200 mg IV/TID in 100 ml NS

2. Inj. LEVIPIL 1 gm IV/STAT

3. Inj. Optineuron 1 amp in 100 ml NS IV/OD

4. Inj. Lorazepam 2 cc IV SOS