In a case study published last week in The New England Journal of Medicine, experts from Massachusetts General Hospital and Harvard Medical School said the 38-year-old man was initially evaluated following his first seizure and had been "speaking gibberish."
The man, who had immigrated from rural Guatemala, was combative and disoriented until he arrived at the hospital, where he had a witnessed generalized tonic-clonic seizure.
Although the patient's eyes were open – with an involuntary upward gaze – he did not verbally respond to questions or follow commands.
The doctors gave him two doses of lorazepam administered intravenously seven minutes apart, and an endotracheal tube was placed for airway protection.
A chest radiograph taken was normal, and the team eventually diagnosed the patient, noting in the study that among patients presenting with an apparent first seizure, obtaining the clinical history is key.
Laboratory testing ruled out hyponatremia, renal dysfunction and liver dysfunction, and the man's urine and serum toxicology panels were negative. However, further evaluation revealed leukocytosis and lactic acidosis.
Although an MRI has higher sensitivity and specificity than a CT scan of the head for the detection of brain parenchymal lesions, a CT is more commonly used in the emergency department.
"It is likely that this patient underwent CT after arrival and stabilization in the emergency department, but if the CT study was negative, MRI would ultimately help us to carefully assess for a causative anatomical abnormality," wrote Dr. Andrew Cole.
Cole also noted that electroencephalography (EEG), which is "extremely useful in classifying the seizure problem," is also rarely performed rapidly in the emergency department.
Cole wrote that cysticercosis is the most common cause of acquired epilepsy worldwide, resulting from the ingesting of tapeworm eggs.
"On the basis of the features of the patient’s presentation, the fact that he had been healthy the day before the seizure, and his history of living in a rural area of Guatemala, neurocysticercosis is the most likely diagnosis in this case. To establish this diagnosis, CT was most likely performed, followed by MRI and EEG," Cole said.
During imaging, Dr. George Eng wrote that when findings are suggestive of cysticercosis, the diagnosis can be confirmed with serologic studies.
In testing for anti-cysticercal antibodies with the use of an enzyme-linked immunoelectrotransfer blot (EITB) assay, the presence of those antibodies was negative.
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