Nocturnal Episodes with Respiratory Distress in Adolescent with Epilepsy History

Case at a Glance

A 17-year-old female with a history of epilepsy presents with nocturnal episodes characterized by gasping awakenings, chest pain, and daytime fatigue, along with recurrent absence-like episodes while awake.

Patient's Story

The patient has a documented history of epilepsy diagnosed through abnormal EEGs, including one that captured a focal seizure with secondary generalization and another showing generalized spike-wave activity during sleep. She previously experienced absence seizures and was successfully managed with antiepileptic medication. Following a series of normal EEGs in 2023, her medications were discontinued. Recently, she has been experiencing disturbing nocturnal episodes where she dreams of having seizures and being unable to breathe, awakening suddenly with gasping respirations and chest pain. These episodes are often accompanied by muscle soreness in her extremities and result in significant daytime mental fogginess and fatigue. Additionally, she reports brief daytime episodes reminiscent of her previous absence seizures, characterized by déjà vu sensations, epigastric auras (stomach-drop feeling), altered consciousness, followed by post-ictal headache and exhaustion.

Initial Assessment

The patient presents with a complex constellation of symptoms including nocturnal respiratory distress, chest pain, muscle soreness, cognitive impairment, and recurrent absence-like episodes. Her primary care physician initially considered anxiety as a potential etiology given the patient's age and symptom presentation.

The Diagnostic Journey

Given the patient's established history of epilepsy and the nature of her current symptoms, there was clinical suspicion for either breakthrough seizure activity or sleep-related epileptic phenomena. The differential diagnosis included nocturnal seizures, sleep apnea, anxiety disorders, or a combination thereof. The presence of both nocturnal and diurnal symptoms with post-ictal features raised particular concern for recurrent epileptic activity.

Final Diagnosis

Suspected breakthrough epileptic seizures with nocturnal and diurnal components, likely representing complex partial seizures with secondary sleep disruption

Treatment Plan

Neurological consultation was recommended for comprehensive evaluation including repeat EEG monitoring, consideration of sleep study to rule out concurrent sleep disorders, and potential reinitiation of antiepileptic therapy. Video EEG monitoring was considered to capture and characterize the nocturnal episodes.

Outcome and Follow-up

Patient was advised to maintain seizure precautions and avoid known triggers while awaiting specialist evaluation. Further neurological assessment was deemed necessary to determine appropriate management strategy and medication optimization.