Clinical reasoning: a 35-year-old woman with acute seizures and behavior change.

A previously healthy 35-year-old Sudanese woman was admitted with new-onset right hemispheric seizures with secondary generalization. The patient’s vital signs were temperature 100.2°F, blood pressure 133/96 mm Hg, pulse 83 beats per minute, respirations 18 per minute, and oxygen saturation 100% on room air. Additionally, a complete neurologic examination was within normal limits. She was discharged on phenytoin and levetiracetam but returned 4 days later with repeated generalized tonic-clonic seizures and altered behavior. Shortly after admission, she became progressively confused with severe insomnia, amnesia, cognitive decline, and delirium, which included bouts of hypersexuality, hyperreligiosity, and auditory hallucinations; her neurologic examination continued to be unremarkable other than mental status fluctuations. Continuous EEG revealed several subclinical seizures along with 3 clinically evident seizures. These seizures progressed to become bilateral with 10-Hz rhythmic spike and wave complexes involving the left frontotemporal head region, and this spread to the left hemisphere and evolved to 4- to 5-Hz theta activity with amplitude of 60 μV.