728 - A 23 Year Delay: A Case Report of Antiepileptic Sedation

Case Diagnosis: A patient with thalamic stroke, encephalopathy from urosepsis, and COVID-19 presents with antiepileptic sedation.

Case Description: This case covers a previously independent 81 yo male with a history of hypertension and AVM post-resection in 1998 with preoperative seizures well-controlled with phenobarbital and carbamazepine. He presents to inpatient rehabilitation after prolonged hospitalization for left thalamic stroke with multiple readmissions to acute hospitals from outside rehabilitation facilities for somnolence and disorientation. With each hospitalization, he was continued on his home medication regimen. Repeated stroke workups were negative. He was found to have COVID-19 and Proteus urosepsis, fully treated with antibiotics without resolution of his fluctuating mental status. Multiple EEGs demonstrated diffuse slowing, without focal seizures.

Discussions: During acute rehabilitation, he would be unable to be aroused for up to 90 minute episodes at inconsistent points during the day. At these times, he would miss antiepileptic medications and his symptoms would improve. Noting the association between improvement of mentation and missed doses of medications, separate histories were obtained from the family and PCP revealing that he had not been compliant with medications at home and had been seizure-free since 1998.

Conclusions: Both antiepileptic medications were slowly tapered over 12 days with marked improvement in mentation including resolution of somnolent episodes. He was able to return home at a supervision level.

This case highlights the importance of completing a thorough history and medication reconciliation, particularly anti-epileptics, on admission. Patients who have been seizure free for two years may be able to discontinue their anti-epileptics. The differential for altered mentation is broad. In this patient, thalamic stroke, encephalopathy from urosepsis, and COVID-19 delayed the discovery of his medication sedation at other hospitals. In acute rehabilitation, we were able to observe this patient over time and gather key points of his medical history, thus exposing his underlying antiepileptic sedation.