Refractory status epilepticus.

TL;DR: A31-YEAR-old COMPUTER CONSULTant was admitted to the hospital for intractable nausea and vomiting and several hours after admission he developed myoclonus, hyperreflexia, agitation, delirium, and eventually, tonic-clonic seizures.

Abstract: A31-YEAR-OLD COMPUTER CONSULTANT was admitted to the hospital for intractable nausea and vomiting. He had presented 18 months earlier with a perforated bowel after a long history of Crohn’s disease. At surgical exploration he was found to have a perforated appendiceal cancer with omental and peritoneal metastases treated with a right hemicolectomy and diverting ileostomy. He received systemic chemotherapy and experienced stable disease, as well as an excellent performance status, for approximately 15 months. He then developed small bowel obstruction caused by diffuse peritoneal carcinomatosis that was treated with a venting gastrostomy tube and nutrition support with total parenteral nutrition. Abdominal pain was treated with intravenous hydromorphone 26 mg/hr with 26 mg every 15 minutes as needed. He experienced nausea and vomiting treated with lorazepam (Ativan, Wyeth Pharmaceuticals, Collegeville, PA), dolasetron (Anzemet, Hoechst Marion Roussel, Bridgewater, NJ), and promethazine (Phenergan, Wyeth Pharmaceuticals). Other medications included pantoprazole (Protonix, Wyeth-Ayerst, Madison, NJ), nystatin, and zolpidem (Ambien, Sanofi-Synthelabo, Inc., New York, NY). He was admitted to the oncology unit of an acute care hospital for management of intractable vomiting. Several hours after admission he developed myoclonus, hyperreflexia, agitation, delirium, and eventually, tonic-clonic seizures. An initial intravenous loading dose of phenytoin (Dilantin, Pfizer, Toronto, Ontario, Canada) 1 g followed by a 200 mg intravenous bolus every 12 hours did not stop the seizures, nor did valproate sodium (Depacon, Abbott Pharmaceuticals, Abbott Park, IL) 500 mg intravenous infusion every 12 hours, chlorpromazine (Thorazine, SmithKline Beecham, Cambridge, U.K.) 25 mg slow intravenous push every 6 hours, lorazepam 2 mg intravenous every 2 hours, and diazepam 5 mg every 5–10 minutes. Despite these medications, and a reduction in the hydromorphone dose by 50% to 13 mg/hr and discontinuation of the bolus dose, the generalized tonic-clonic movements increased in intensity and frequency (every 8 to 10 minutes) to status epilepticus. The patient remained arousable, following simple commands, yet was disoriented. Evaluation revealed acute obstructive renal failure (blood urea nitrogen [BUN] 37 mg/dL, creatinine 4.2 mg/dL) secondary to diffuse carcinomatosis. The family’s goals were to keep the patient comfortable.