Fatal grand mal seizure in a Dutch trekker.

A 35-year-old healthy Dutch woman went on a trek (Lang Tang) in Nepal up to an approximate altitude of about 3800 meters. She had no prior history of any medical problems except attacks of generalized epilepsy when she was 19 years old, which had been controlled with antiepileptic medications. She had had no attacks after the age of 20. A CT scan done around that time had apparently been normal. On this trek she had developed diarrhea which had been cured with norfloxacin 400 mg two times per day for 3 days. Two days later, while descending, she developed a grand mal seizure at an altitude of 3300 meters, after which she developed a classic postictal phase but gradually recovered. She developed grand mal seizures again the next day, but when she went to a travel clinic in Kathmandu, she had been seizure free for 72 hours. She also revealed that she had not suffered from acute mountain sickness on the trek. She also had a prior history of gastroenteritis at high altitude which improved significantly with norfloxacin, a quinolone antibiotic. This was corroborated by her party. Upon examination she was fully conscious and oriented to person, place and time. Her pulse was 70 beats per minute and her BP was 110/80 mm of Hg. Her fundi and cranial nerves exam were completely normal. Her abstract thinking, gait, power, tone, reflexes and other facets of her neurologic exam revealed absolutely no abnormalities. Her cardiovascular exam revealed a normal rhythm with no murmurs or bruits. The rest of her exam was also normal. She revealed that she played tennis on a regular basis and was an outdoor person. She had not trekked before in the Himalayas and it was uncertain if she had been to high altitude before. She was on no medications at the time. There was no history of drug abuse. She did not smoke and consumed few alcoholic beverages. She had not consumed any alcohol on the trek. She was advised to get a CT scan (she declined as she was going home to Holland in 2 days) and she was prescribed a loading dose of phenytoin 1 g orally spread over several hours and it was recommended she take 300 mg of phenytoin per day. She was going to see her neurologist in Holland on arrival there. She went to her hotel in Kathmandu while her friends went to fill the prescription of phenytoin. When her friends returned to the hotel she was having another grand mal seizure. Medical help was sought, but she died before the doctor arrived to control her seizures. When the doctor did arrive and carried out CPR for half an hour it was to no avail as she continued to have no pulse or blood pressure.