Kerala Medical Journal | April-June 2011 | Vol IV Issue 2 64 An Unusual Case of Status Epilepticus Sadanandavally Ratnaswamy Chandra a , Ashraf Ali b , Krishnan Suresh b , Devadas Krishnadas b , P Chithra b , K A Kabeer b a. Department of Neurology, NIMHANS, Bangalore, Karnataka b. Indian Medical Association, Anayara PO, Trivandrum CASE REPORT KERALA MEDICAL JOURNAL INTRODUCTION A ffty year old male politician, with hypertension, diabetes mellitus, coronary artery disease and chronic alcoholic liver disease, was admitted with a history of altered sensorium of twenty four hours duration. On admission he was stuporous with episodes of hyperven- tilation, dystonic posturing and violent behavior; which was recurrent with no return to normal sensorium in between. He also experienced overt tonic clonic convulsions repeatedly. All investigations for infections and metabolic causes turned out to be negative but ictal EEG showed surprisingly beta coma. The relatives then revealed that he was in the habit of taking one thousand and fve hundred mg of zolpidem daily in addition to alcohol. He was started on zolpidem two hundred mg daily and the patient returned to normal within six hours, thus indicating that this was a rare case of zolpidem dependence withdrawal seizure and life saved with zolpidem only. CASE REPORT A ffty year old male politician presented to the medical casualty with history of repeated seizures. He was suffering from diabetes mellitus, hypertension, coronary artery disease and alcoholic liver disease. He was de-addicted six years ago. He had been using one thousand and fve hundred milligrams of zolpidem daily, costing nine hundred rupees per day. He was without the drug for nearly twenty-four hours and became unconscious with repeated seizures. General examination revealed well built individual. He was comatose with large pupils reacting to light. Optic fundi were normal. There were no signs of meningeal irritation. All four limbs were faccid, hyporefexic with normal plantars. Blood pressure was 170/100 mm of mercury. In the hospital he developed repeated generalized seizures (more than twenty fve times per day) for the next four days. In between he was showing violent behaviour and dystonic posturing of upper and lower limbs. He also had mild hepatomegaly, spider naevi and gynecomastia. His laboratory parameters showed – Hemoglobin- 17.1, Total count-15710, Polymorphs-90, Lymphocyte- 10, ESR-8,Platelet-1.61 lacs, INR-1.15,Blood sugar- 224 and normal renal, electrolytes and liver function tests. Ultrasound abdomen was suggestive of chronic liver disease. Chest Xray, CT Brain was normal. EEG showed diffuse beta activity. He was treated with insulin, nasogastric feeds,, fosphe- nytoin 15 mg/kg loading followed by 100 mg every fourth hourly, Injection lorazepam 8 mg and injection Levetiracetam as per recommendation. The seizures could not be controlled with any of these measures. Pentothal and mechanical ventilation was considered, but the relatives were not consenting for this option. Oral replacement zolpidem was attempted at a dose of 200 mg in three divided doses and patient became completely seizure free in six hours. There was no signifcant post ictal confusion. He was transferred to the psychiatrist for de-addiction. The drug was slowly Corresponding Author: Dr. Sadanandavally Ratnaswamy Chandra, MD DM (Neurology), Professor, Department of Neurology, NIMHANS, Bangalore, Karnataka. Phone: 09449106799. Email: drchandrasasi@yahoo.com Published on 30 th June 2011 ABSTRACT Status epilepticus is a common neurological emergency. We report a ffty year old male who presented in status epilepticus with twenty fve episodes per day which lasted for four days. This was controlled by using two hundred mg of zolpidem per day, which was subsequently slowly weaned off. Keywords: Status epilepticus, Zolpidem, Withdrawal *See End Note for complete author details