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DartmouthDave

Seizure with Hematuria

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Hello,

Here is an interesting patient from a couple of nights ago that came through the ED.

You are dispatched for an 18 year-old female patient who has had a seizure. On arrival the Paramedics find her postictal. Her eyes are open, she is moving all extremities and is moaning in pain. She is drowsy but know who she is but can not remember the seizure.

Her airway and breathing are fine. She is incontinent of urine (...her pants are wet...). However, the urine stain appears to be bloody (gross heaturia).

She is from out of town visiting her Aunt. Her Aunt tells the crew that she had a seizure yesterday. But, it wasn't this bad. Also, she says that she has a rare renal condition know as 'Loin-Pain-Hematuria Syndrome' (LPHS). She has a small folder filled with information on the condition for the crew to read. =)

Here is the easy version:

My link

The Aunt says that since arriving the patient's flank pain has been poorly controlled with Demerol pills. She has had to take more than normal. Also, she states that the patient is unable to attend school now due to her illness. In fact, the patient has been depressed as of late.

Her only medications are Demerol 100mg PO for pain and Immovaine 7.5mg QHS.

A head-to-toe reveals an healthy looking 18 year-old female (50kg) with a few old IV sites on her hands and arms. Her Aunt states that they are from old IV that she had done in her home town hospital for pain.

BP 140/92 HR 130 SPO2 98% Temp 37.5 BGL 6.7

So, what is causing these seizures? What now?

Cheers....

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First off..... Thanks for re-igniting the scenario's section as of late, Dave!!

Need a bit more Hx.

Any seizures in the past?

Either of the meds new? or discontinued any recently?

When was the last Demerol taken?

What were they giving IV? When was the last dose?

Assessment.

Pupils?

Neuro?

Overall strength?

How much blood is present?

Any complaints outside the pain right now?

O2, IV, cardiac monitor, move to ambulance.

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I like mobey's line of thinking... so will add to that..

More on the hx..

- what time of day is it?

- has the girl been out with friends in very recent past? any chance of recreational drugs?

The Aunt said the girl had a seizure yesterday... I want to know more about that... did she call 911? Was the girl assessed by a medical professional?

I agree with what mobey wants for assessment, and would also ask:

- last menstrual cycle

- any chance of pregnancy?

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I like mobey's line of thinking... so will add to that..

More on the hx..

- what time of day is it?

- has the girl been out with friends in very recent past? any chance of recreational drugs?

The Aunt said the girl had a seizure yesterday... I want to know more about that... did she call 911? Was the girl assessed by a medical professional?

I agree with what mobey wants for assessment, and would also ask:

- last menstrual cycle

- any chance of pregnancy?

Cheers

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First off..... Thanks for re-igniting the scenario's section as of late, Dave!!

Need a bit more Hx.

Any seizures in the past?

Either of the meds new? or discontinued any recently?

When was the last Demerol taken?

What were they giving IV? When was the last dose?

Assessment.

Pupils?

Neuro?

Overall strength?

How much blood is present?

Any complaints outside the pain right now?

O2, IV, cardiac monitor, move to ambulance.

Cheers

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Hello,

So, what is a possible cause of this patient's seizures?

Would you treat the pain?

The patient's LOC improves quickly. She is c/o pain. She wants to take Demerol 200mg PO before you leave to the hospital. She says the Drs and Nurses never believe her pain is that bad and that her Dx isn't real. What do you think?

Cheers

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Hello,

So, what is a possible cause of this patient's seizures?

Would you treat the pain?

The patient's LOC improves quickly. She is c/o pain. She wants to take Demerol 200mg PO before you leave to the hospital. She says the Drs and Nurses never believe her pain is that bad and that her Dx isn't real. What do you think?

Cheers

As for treating the pain prehospital, I doubt it, but I would leave it up to medical control. Too many questions about the patient, it's a nebulous and rare condition, and in many systems, there is still reluctance to treat abdominal pain in a prehospital setting- as in my system. If she's routinely taking 200 mg or more of Demerol PO, then I would bet the only thing that would touch her pain is something like Fentanyl. Not available in many systems.

I suggest she needs a complete neuro work up EEG, CT, MRI, etc to rule out anything going on there. The seizures may be totally unrelated to her Dx of LPHS, or there is a missing piece of the puzzle.

She also may be self medicating since she said many doctors don't believe her pain is real and may be reluctant to give her adequate pain relief. There may be an interaction between the analgesics and renal function- especially if she's also using OTC pain relievers and/or illicit drugs to manage her pain. I don't know if renal function is compromised by this disease.

That link said the diagnosis of LPHS is one of exclusion- akin to MS, chronic fatigue syndrome, or fibromyalgia, so a diagnosis with a simple test from an ER is not possible. Thus, the ER folks need to also guard against feeding a drug seeker. Sad, but true.

Interesting case.

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First off did anyone see the seizures? Can they describe to you what these seizures looked like? People in the public are often not very reliable when it comes to identifying seizures vs. syncope with some post-syncopal clonic activity, or other problems too.

One rule that we are taught to follow when making a differential is to always consider the vasculitides in your diagnosis when there are multiple organ systems involved with an unexplained connection. Has she ever been assessed for a vasculitic condition like lupus? It wouldn't be a bad idea to check for anti nuclear antibodies, as SLE could explain both the seizures and hematuria.

Meperidine can also lead to seizures because of one of its metabolites (normeperidine). There could be some sort of relation to her drug use. Has anything changed with her demerol usage in the past while?

Cool case...let us know if you have any more info!

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How much oral meperidine has this patient been taking? Oral meperidine typically undergoes fairly extensive first pass metabolism and a metabolite known as normeperidine is produced. Only problem being, normeperidine is rather neurotoxic and can cause seizures.

Take care,

chbare.

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Hello,

Levi and Chbare are right on target. Once in the ED the seizures were attributed to Demerol toxicity. The patient has been taking excessive doses of oral Demerol. Plus, prior to visiting her Aunt she had three ED visits and was given IV Demerol as well.

No CT was done.

A urine screen was only positive for Opiates. Her urine was +3 for blood, lukes and proteins.

Her Serum HCG was negative. As well as Tyl and ASA.

She was give NS and Dilaudid IV (2-4mg IV) for pain control. She stated that she felt nauseated and wanted some Gravol IV as well. She was given 50mg IV and stared on Septra DS for a UTI.

She also c/o a history of urine retention as well. In fact, she stated that she has needed In & Out caths from time to time. This could be from the narcotic or Gravol use I though. Also, I question her how much Gravol and Demerol she took per day. She was vague on these points.

This girl was in pain, for sure. But, there is some mental health issues as well.

Cheers....

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