Visual Diagnosis: Recurrent Seizures and Concomitant Skin Changes in a 16-year-old Boy

Presentation

A 16-year-old Hispanic boy with a history of intermittent asthma presents to the emergency department (ED) with recurrent unprovoked seizures. The first episode was 2 weeks before this visit and was characterized by generalized tonic-clonic seizures (GCTSs), with a postictal phase of 10 minutes. He was seen in the ED during that episode, with normal findings on examination and evaluation, including a complete blood cell count, chemistry, liver function tests, urine toxicology, and a computed tomographic (CT) scan. During the current visit, he presents with a history of 2 episodes of unprovoked GTCSs 4 hours apart. The first episode lasted 5 minutes, followed by a postictal phase of 5 minutes. In the ED, he has normal physical examination findings and is discharged on oral oxcarbazepine with a diagnosis of idiopathic epilepsy. Before starting the prescribed medication, he develops another episode of GCTSs, approximately 7 to 8 minutes, with no postictal phase. Each of these episodes were preceded by coughing spells lasting 10 to 20 minutes. He has no history of fever, head trauma, recent travel, drug intake, medication use, or sick contacts.

In the ED, his vital signs are normal except for intermittent bradycardia (heart rate, 60 beats/min). Physical examination findings are normal except for bite marks on the right side of the tongue. Results of a complete blood cell count, chemistry, liver function tests, and urinalysis are within normal limits. Urine toxicology results are negative. Findings from electrocardiography (ECG), electroencephalography (EEG), and brain magnetic resonance imaging (MRI) are normal. The patient is started on divalproex. Primary generalized epilepsy is suspected by the ED physician for undocumented reasons, …