Super refractory epilepticus in a patient with post-ictal psychosis

Abstract

Post-ictal psychosis occurring with super refractory epilepticus is an uncommon neuropsychiatric phenomenon. The purpose of this article is to describe the clinical management in an adult male of a protracted post-ictal psychotic disorder, which complicated a super-refractory status epilepticus in a resource poor country. The case describes the clinical presentation of a young man on an anti epileptic drug, diagnosed with secondarily generalized complex partial seizure disorder following a head injury. The index episode, which the patient presented days later for orthodox care, manifested after some days with post-ictal psychotic mental disturbances. Despite the cautious use of antipsychotic and antiepileptic drugs, super-refractory status epilepticus complicated seizure. On admission to the ICU, intravenous midazolam was given to the patient, but could not be maintained due to unavailability and substituted with magnesium sulphate infusion. The magnesium sulphate infusion was maintained due to break through seizures on return of patient to the psychiatric ward. The psychosis and refractory seizures were controlled after 8 weeks by joint magnesium titration, intravenous diazepam, high dose oral anti epileptics, and atypical antipsychotic drugs. A combined therapy of magnesium, benzodiazepine, and atypical antipsychotics might be an effective treatment option in post-ictal psychosis with super- refractory status epilepticus.