“Recurrent Episodic Weakness in a Young Patient With Epilepsy and Neuropsychiatric Manifestations: A Diagnostic Challenge.”
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Case History
CASE RECORD
Patient Profile
A 21-year-old male, born to a non-consanguineous marriage, presented with a history of developmental and behavioural abnormalities, recurrent seizures, episodic focal neurological deficits, and recurrent episodes of acute flaccid quadriparesis associated with hypokalemia.
Antenatal and Perinatal History
The patient was reportedly delivered at approximately 9 months of gestation. His mother had a history of schizophrenia and was receiving treatment during pregnancy.
The delivery was reportedly complicated by an episode described by the family as maternal shock. Details regarding the nature, duration, and management of the shock are unavailable.
He was the second child. The first child had died approximately one year before his birth. The cause of death is not known.
Developmental History
The patient reportedly achieved early developmental milestones with mild delay. He attained independent walking at approximately 1 year of age and developed speech by approximately 1½ years of age.
Subsequently, abnormalities in behaviour and social functioning became apparent. At approximately 6 years of age, the family noted unusual behaviour at school, including repeatedly bathing himself while engaged in washing plates.
By approximately 8 years of age, his teacher reported that he had difficulty understanding instructions and frequently fought with others. The family subsequently described him as having child-like behaviour.
Seizure History
The patient has a history of recurrent seizures since childhood.
According to the patient's mother, the episodes predominantly occur at night and are characterized by involvement of one upper limb and one lower limb, associated with upward rolling of the eyes, excessive salivation/drooling, and urinary incontinence.
Approximately three episodes may occur in a cluster, with each episode reportedly lasting around 5 minutes. The degree of recovery of consciousness between individual episodes is not clearly established.
The semiology is suggestive of focal-onset motor seizures. Details regarding impaired awareness, secondary bilateral tonic-clonic progression, postictal confusion, tongue biting, injuries, and postictal weakness are unavailable.
History of Focal Neurological Deficits
The patient has also experienced recurrent episodes of right-sided weakness involving the right upper and lower limbs.
On at least one occasion, the weakness was associated with deviation of the angle of the mouth. One episode reportedly required approximately 19 days of hospitalization.
The exact neurological findings during these episodes, including tone, power, reflexes, plantar responses, sensory findings, and duration of recovery, are not available.
History of Episodic Flaccid Quadriparesis
The patient has had at least two episodes of acute flaccid quadriparesis.
Current episode
The patient was apparently well until a recent social function, following which he consumed fish and subsequently developed approximately 12 episodes of vomiting.
On the following day, he developed urinary incontinence followed by acute-onset weakness involving all four limbs. According to the family, he remained conscious and aware despite being unable to move his limbs.
On evaluation, he was found to have severe hypokalemia, with serum potassium of 2.1 mmol/L. The weakness was described as flaccid.
He was evaluated for hypokalemia-associated paralysis, including evaluation for possible renal potassium wasting and renal tubular acidosis. Potassium replacement was administered, following which the patient's limb weakness improved significantly with correction of hypokalemia.
The clinical course is therefore suggestive of hypokalemia-associated acute flaccid paralysis.
Previous episode
A similar episode of acute flaccid weakness had reportedly occurred approximately one year earlier. Previous documentation described the patient as having paraparesis under evaluation in the setting of hypokalemia.
The documented potassium values available from previous/current records include 2.1 mmol/L and 3.1 mmol/L; the exact timing corresponding to each value should be confirmed from the laboratory records.
Previous records also indicate evaluation for renal tubular acidosis and consideration of drug-related potassium wasting, including possible association with previous sodium valproate therapy.
Psychiatric History
The patient has a history of behavioural abnormalities and psychotic symptoms and has been receiving psychiatric treatment for approximately one year.
There is a significant family history of psychiatric illness, with the patient's mother reportedly having schizophrenia.
Drug History
For approximately the last year, the patient has reportedly been receiving:
- Carbamazepine 200 mg PO twice daily
- Risperidone PO at bedtime — dose to be confirmed
- Trihexyphenidyl PO — dose and frequency to be confirmed
He was previously treated with sodium valproate for seizure control. The dose, duration of treatment, and date of discontinuation are currently unavailable.
Previous Relevant Documentation
Available previous records document:
- Admission for paraparesis/quadriparesis
- Significant hypokalemia
- Evaluation for possible renal tubular acidosis
- Consideration of drug-related renal potassium wasting
- Previous treatment with sodium valproate
- Previous treatment for seizures
Previous EEG, neuroimaging, detailed neurological examination findings, and complete seizure-treatment records are currently unavailable.
Relevant Positive History
- Developmental and behavioural abnormalities
- Recurrent focal-onset seizures, predominantly nocturnal
- Unilateral upper- and lower-limb involvement during seizures
- Drooling/hypersalivation
- Upward rolling of eyes
- Urinary incontinence during seizures
- Recurrent right-sided weakness
- Occasional facial deviation during neurological episodes
- Prolonged previous neurological deficit requiring hospitalization
- Recurrent acute flaccid quadriparesis
- Severe hypokalemia during episodes of quadriparesis
- Improvement of weakness following potassium correction
- Psychotic symptoms
- Previous sodium valproate exposure
- Current treatment with carbamazepine, risperidone and trihexyphenidyl
- Maternal history of schizophrenia
Relevant Negative/Unclear History
The following require clarification from the patient, family, or previous records:
- Exact age at first seizure
- Awareness during seizures
- Duration of postictal state
- Presence and duration of postictal weakness
- Exact duration of each episode of focal weakness
- Tone and reflexes during episodes of weakness
- Presence of sensory symptoms or a sensory level
- Bladder/bowel involvement during previous episodes
- Respiratory involvement during episodes of quadriparesis
- Previous EEG findings
- Previous MRI/CT brain findings
- Serum potassium and other electrolyte values during each episode
- Serum bicarbonate/ABG findings
- Urinary potassium excretion
- Urine pH and urine chloride
- Results of evaluation for RTA/Fanconi syndrome
- Exact dose and duration of previous sodium valproate therapy
- Carbamazepine and risperidone doses beyond those currently documented
- History of fever/infection preceding neurological episodes
- History of toxin/drug exposure
- Family history of seizures, developmental disorders, movement disorders or episodic paralysis
- History suggestive of chronic liver disease or other systemic disease
1. General Examination
General condition: moderately built moderately nourished
Pallor: absent
Icterus: absent
Cyanosis:/absent
Clubbing: /absent
Lymphadenopathy: absent
Pedal edema: absent
Pulse: 101beats per min, regular rhythm
BP: 110/70mmHg
RR: 16/min
SpO₂: 99% on room air/O₂
Temperature: afebrile
Hydration: adequate
Thyroid: normal
Skin: pigmentation + in bilateral lower limbs due to scars of previous iv cannulations
Oral cavity: gingival hypertrophy / history of cheilitis / glossitis / ulcers
-
2. Higher Mental Functions
Level of consciousness: conscious
Orientation
- Time: intact
- Place: intact
- Person: intact
Attention and concentration
---
Memory
- Immediate: intact
- Recent: intact
- Remote: intact
Intelligence/cognition
---
Speech
- Fluency: normal
- Comprehension: cannot be done
- Naming: normal
- Repetition: sometimes sometimes not
- Dysarthria:absent
- Aphasia: /absent
Behaviour and affect
---
Thought
- Delusions: /absent
- Hallucinations: present/
- Thought disorder:
Insight and judgment
---
---
3. Cranial Nerves
CN I – Olfactory
Smell: intact
CN II – Optic
- Visual acuity: R 6/6 / L 6/6
- Visual fields: normal
- Pupils: size 3mm, equal
- Direct/consensual reflex: reacting to loght
- RAPD: absent
CN III, IV, VI – Oculomotor/Trochlear/Abducens
- Ptosis: no
- Primary position: normal
- Extraocular movements:present
- Nystagmus:no nystagmus
- Diplopia: no
- _
CN V – Trigeminal
- Facial sensation V1/V2/V3: _present
- Corneal reflex:presesnt
- Masseter presnt good power good tone reflex normal
CN VII – Facial
- Forehead: normal
- Eye closure: normal
- Nasolabial fold:normal
- Smile/show teeth:normal
- Puff cheeks: normal
UMN/LMN facial palsy: nond
CN VIII – Vestibulocochlear
- Hearing: normal
- Rinne: ___not assessissinle
- Weber: not assessible
CN IX/X
- Palatal movement:normal
- Uvula: notmal
- Gag: norrmal
- Voice: normal
- Swallowing: normal
CN XI
- Shoulder shrug: R __4/5_ / L _5/5
- Head turning: R ___ 4/5/ L _5/5
CN XII
- Tongue wasting: _none
- Fasciculations: ___nonr
- Deviation: ___nonr
- Movements: ___normal
---
4. Motor System
Inspection
Look for:
- Muscle wasting
- Fasciculations
- Abnormal posture of left hand present
- Tremor
- Chorea
- Athetosis
- Dystonia
- Myoclonus
- Involuntary movements
Tone
| Right| Left
Upper limb| ___| ___
Lower limb| ___| ___
Characterize as:
- Normal
- Hypotonia
- Spasticity
- Rigidity
---
5. Power – MRC Grading
Upper limbs
Movement| Right| Left
Shoulder abduction|5 /5|5 /5
Shoulder adduction| 5/5| 5/5
Elbow flexion| 5/5| 5/5
Elbow extension| 5/5| 5/5
Wrist flexion| 5/5| 5/5
Wrist extension| 5/5| 5/5
Finger flexion| 5/5| 5/5
Finger extension| 4/5|4/5
Finger abduction| 5/5| 5/5
Grip| 5/5| 5/5
Lower limbs
Movement| Right| Left
Hip flexion|4/5| 5/5
Hip extension| 5/5| 5/5
Hip abduction| 5/5| 5/5
Hip adduction| 5/5| 5/5
Knee flexion|5 /5| 5/5
Knee extension| 5/5| 5/5
Ankle dorsiflexioncannot be assessed
Ankle plantar flexioncannot be assessed
Great toe extension cannot be assessed
---
6. Reflexes
Deep tendon reflexes
Reflex| Right| Left
Biceps| _2/5_| ___2/5
Supinator| __2/5_| ___2/5
Triceps| _2/5__| ___2/5
Knee| ___3/5| ___3/5
Ankle| ___2/5| ___2/5
Grade: 0 absent, 1+ reduced, 2+ normal, 3+ brisk, 4+ very brisk/clonus
Clonus: ankle absent
Plantar response
Right: flexor
Left: flexor/
---
7. Sensory System
Superficial sensations
- Light touch: ___
- Pain: ___
- Temperature: ___
Deep sensations
- Joint position: ___
- Vibration: ___
Cortical sensations
- Two-point discrimination: ___
- Graphesthesia: ___
- Stereognosis: ___
- Extinction: ___
Sensory level: absent/present at ___
---
8. Cerebellar Examination
- Finger–nose test: normal
- Dysmetria: none
- Dysdiadochokinesia: normal to right hand left hand cannot be assesible
- Heel–shin test: cannot be done
- Rebound phenomenon: nonr
- Intention tremor: nonr
- Nystagmus: nonr
- Truncal ataxia: patient light swaying to rig
ht
- Speech: _normal
---
9. Tremor / Movement Disorder Examination
Tremor present: Yes
- Resting: no
- Postural: Yes
- Kinetic/action: Yes
- Intention: Yes/No
- Symmetry: symmetrical
- Frequency: high
- Amplitude: low
- Distribution: symmetrical distal upper limbs
- Effect of distraction: ___
- Effect of movement: ___
Parkinsonism
None
- Bradykinesia: ___
- Rigidity: ___
- Masked facies: ___
- Reduced arm swing: ___
- Rest tremor: ___
Tardive dyskinesia nonr
- Orofacial movements: ___
- Tongue movements: ___
- Lip smacking/puckering: ___
- Limb/trunk movements: ___
Akathisia
Present/absent
---
10. Gait
If patient is ambulant:
- Normal/abnormal
- Base: narrow/wide
- Arm swing: ___
- Turning: ___
- Tandem walking: cannot be done patient is not cooperative
- Heel walking: ___
- Toe walking: ___
Type of gait: ___
---
11. Autonomic Examination none
- Urinary incontinence:
- Urinary retention: ___
- Bowel dysfunction: ___
- Orthostatic BP: ___
- Sweating abnormality: ___
---
12. Spine Examination
Normal
- Deformity: ___
- Tenderness: ___
- Step deformity: ___
- Paraspinal wasting: ___
If clinically indicated:
- Perianal sensation: ___
- Anal tone: ___
---
13. Meningeal Signs
- Neck stiffness: absent
- Kernig: negative
- Brudzinski: negative
---
14. Examination During Weakness
This examination is after potassium correction present potassium is 3.1mq/l
Because this patient has recurrent
Neurological Examination Summary
«Patient is conscious and ___ oriented. Higher mental functions reveal ___. Cranial nerves are ___. Motor examination reveals ___ weakness involving ___, with tone ___, power ___/5, and reflexes ___. Plantars are ___. Sensory examination reveals ___ with/without a sensory level. Cerebellar examination is ___. Gait is ___. There is ___ postural/action tremor. Autonomic examination reveals ___.»
Provisional Localization
Brain / spinal cord / peripheral nerve / neuromuscular junction / muscle-
metabolic: its metabolic
Provisional Clinical Impression
Recurrent acute flaccid quadriparesis associated with severe hypokalemia, with improvement following potassium correctionsuggestive of hypokalemia-associated paralysis.
Coexisting focal-onset epilepsy with recurrent right-sided neurological deficits and developmental/psychiatric abnormalities — etiology/localization under evaluation.
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