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A middle-aged woman became unresponsive while speaking to her son on the phone and was subsequently found at home unconscious with foam around her mouth. En route to the emergency department, paramedics witnessed a generalised tonic-clonic seizure with left eye deviation and left arm flexion. In the emergency department, she remained unresponsive, was intubated, received a loading dose of levetiracetam and was transferred to the neurosciences intensive care unit. On examination, she was drowsy. There was an increased tone in all four limbs but particularly in the right arm, failure of the left arm to withdraw to pain and generally brisk reflexes. Pertinent results included significant lactic acidosis (plasma lactate 19.6 mmol/L (0.6–1.8)) and elevated serum creatine kinase at 1181 U/L (24–170). CT/CT angiogram/CT venogram head showed a small sulcal subarachnoid haemorrhage in the right precentral sulcus and a small arteriovenous malformation in the same region. Cerebrospinal fluid examination found no evidence of infection or xanthochromia. She remained intubated and sedated in the intensive care unit for several hours, where continuous video electroencephalography showed diffuse delta waves due to sedative effect with no …
Contributors EAF contributed to the authorship of manuscript content. EFMW was involved in the study concept and design and acquisition of data. All the authors contributed to the patient care, diagnosis and treatment, critical review and revision of manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.
Provenance and peer review Not commissioned; externally peer reviewed. This paper was reviewed by Rhys Thomas, Newcastle-upon-Tyne, UK.
Data sharing statement The authors take full responsibility for the data, images, analyses, interpretation and conduct of this study. Information used to inform this submission is contained in our hospital electronic health record, which is only available to medical staff at our institution providing care for this patient. Authors had full access to all of the data and have the right to publish any and all data separate and apart from any sponsor.