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Dr. Andrew Rynne

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What causes seizure like episode after a dental procedure?

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Dr. Sunil Gupta

Psychiatrist

Practicing since :2005

Answered : 637 Questions

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Posted on Sat, 23 Aug 2014 in Mental Health
Question: Hi, my name's XXXXXXX and I'd like to ask you for help with the diagnosis of my symptoms.

About a year ago I started having some sort of 'seizures' (I'll call them seizures but I don't know what they actually are). The first time they happened was after I had my wisdom teeth taken out about 1 year ago. (I also have orthodontic braces on my teeth). The episodes usually come in the morning (but sometimes they wake me up during night) and happen 3-5 times a day on that day. I get such 'seizure' days in about once in six weeks, always 2-3 days after an orthodontic appointment. During the seizure, I feel a strange sense of pleasure coming from my stomach, then I get something like a dream while awake. It's a sequence combined of memories (things that actually happened) but there are also things which don't exist in the real world. It's extremely fast and lasts for about 10 seconds. There's so many things that happen in the episode that I rarely remember the content afterwards. As the dream approaches the end, I start feeling nausea, but I never actually vomit. After the episode I'm extremely tired. These episodes come completely out of the blue with no possible trigger I'm aware of. (they happen in different times of the day in different places).

I've been feeling extremely tired for the last two years and it's been getting worse and worse. It's a strange type of fatigue - my body works OK, I can even do exercise as usual but it's like there's some sort of fog on my eyes (but no distorted vision). I have difficulty concentrating, remembering things (including my friend's and family's names occasionally). I have difficulty finding words to say in a sentence. I feel some sort of pressure at the back of my eyes and it makes my eyes hurt and makes me blink a lot. The fatigue is the worst after sleeping in the morning, after eating lunch in the afternoon; and it's least bad at about 9pm for an hour when I almost suddenly 'wake up' for a while and most of the symptoms remit by 50%. So the fatigue is mainly psychological rather than physical, it feels like I'm heavily drunk or after a lot of mental work. The fatigue has a regular daily cycle and is independent of what I do during the day. Sometime it's so bad I can't even get out of bed until the evening. Strangely, sometimes it helps to drink a glass of wine.

I'm getting occasional twitches all over my body, especially in fingers. I have difficulty reading as can't coordinate my eyes properly - they jump over words at wrong intervals so I either misread words for something else or I omit them. My handwriting is also quite strange as my hands are stiff. In addition, I have all body tremor, but especially prominent in my hands. It’s greatest when I use my muscles with low to moderate strength, when I rotate my wrists or when I’m holding something such as fork and knife. I constantly feel all body internal resting tremor, which is, however, not visible. I get most tremor when using my muscles.

I saw a neurologist a month ago, who ran the following blood tests: basic bloodwork (red, white cells, lymphocytes, basophil, and many others), liver function test, Serum electrolytes, Thyroid function test, urine microscopy, vit B12, serum ACE, folate, Serum C protein, Complement C3 C4, erythrocyte sedimentation rate

ALL TESTS CAME OK WITHIN RANGE

In addition, the neurologist did a physical examination:

“on neurological examination, there was no neck stiffness. Fundoscopy did not reveal any signs of papilledema. His pupils were wide but light reactive. His visual fields were full to confrontation. He had full external ocular movements without nystagmus. His visual acuity was normal. There was no facial asymmetry. The lower cranial nerve exam was normal. On the limb exam there was no weakness, no evidence of ataxia, reflexes were symmetrical, plantar response was flexion, sensory was normal, Romberg was negative, gait was normal. In summary, I think the recurrent episodes can be clinical presentation of temporal seizures. "

I also had a MRI of brain done, and NOTHING WAS FOUND.

I further saw an otorhinolaryngologist, who did one sleep study and FOUND (no fluctuation of oxygen during sleep or heart rate).

What do you think could be happening to me and what would you suggest that I should do?

I don't take or have ever taken any drugs, except alcohol and caffeine in small amounts and very occasionally. No history of any illness or epilepsy. No family history of any illness.


Thanks for your help.
XXXXXXX
doctor
Answered by Dr. Sunil Gupta 27 hours later
Brief Answer:
Please see details below.

Detailed Answer:
Dear Mr. XXXXXXX

I went through your question in detail and can understand your concern regarding your symptoms. I am glad that you have provided information in a very coherent way which has helped me come to following conclusions:

1. You seem to be having symptoms of anxiety and may be even depression which are manifested by feeling tired, difficulty concentrating and forgetfulness. Since, all investigations mentioned by you have been found to be normal, it is mostly psychological.

2. The episodes that you have mentioned can be due to either the underlying anxiety as such or can be due to episodes of seizures, in your case, probably temporal lobe seizures.

Before considering any psychological cause of your symptoms, I would want to be absolutely sure of any organic brain lesion disease like temporal lobe epilepsy. The temporal lobe epilepsy can even have the anxiety and depressive symptoms as well in between the episodes.

Since your MRI brain has come out to be normal (which may happen in case of temporal lobe epilepsy), I would recommend further investigations in form of PET (positron emission tomography) scan of brain and an EEG(electroencephalogram) to rule out underlying brain disease.

In any case, a trial run of anti-epileptic medications like carbamazepine or oxacarbezepine would be worthwhile. In addition, anti-anxiety medications like escitalopram to control your anxiety and depressive symptoms can be added.

I would recommend that you should be treated by a team of doctors consisting of a neurologist and a psychiatrist rather than a single specialist alone to be able to maximize response to treatment.

I do hope that I was able yo answer your query. Please feel free to ask any further query that you might have.

Best wishes,

Dr. Sunil Gupta





Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
doctor
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Follow up: Dr. Sunil Gupta 2 hours later
Thank you so much for such a detailed answer!

I have one follow-up question. My neurologist said that the episodes are probably temporal lobe epilepsy.

What probability in your opinion is there that these are anxiety-related episodes and not temporal lobe epilepsy? In that case, what are they?

Thank you again,
XXXXXXX
doctor
Answered by Dr. Sunil Gupta 3 hours later
Brief Answer:
More chances to be temporal lobe epilepsy

Detailed Answer:
Dear Mr. XXXXXXX

Thanks for following up. I would consider your symptoms to be more due to temporal lobe epilepsy rather than anxiety. I will consider anxiety only as an option, if we confidently rule out temporal lobe epilepsy.

If it is not due to temporal lobe epilepsy, it can be depersonalisation -derealisation episodes which occur quite commonly in anxiety. These are episodes in which a person feels as if he has lost contact with reality and he feels disconnected.

As I said in my last response, a trial of anti-epileptic medications is definitely warranted in your case.

I do hope that answers your query. Please feel free to ask any further query that you might have. In case you don't have any more questions, you can close the discussion and please do rate the answer.

Best wishes,

Dr. Sunil Gupta
Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
doctor
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Follow up: Dr. Sunil Gupta 6 hours later
Thanks again!

So if nothing is found on PET and EEG recording and anti-epilepsy medications don't help then it's most likely anxiety disorder, am I right?

If the anti-epilepsy medications, on the other hand, do alleviate my symptoms such as fatigue, then it is epilepsy.

Thank you!
doctor
Answered by Dr. Sunil Gupta 10 minutes later
Brief Answer:
You got it right.

Detailed Answer:
Dear Mr. XXXXXXX

Thanks for following up. You got it absolutely right. One more thing. You will have to be patient about the response to the medications. Often the medications are started at a low dose and gradually build up. So, you may not see immediate improvement in your symptoms. Just give time for them to act and further course of action can be decided accordingly.

Please let me know if you have any further queries. I will be happy to help.

Wishing you a speedy recovery,

Dr. Sunil Gupta.
Above answer was peer-reviewed by : Dr. Bhagyalaxmi Nalaparaju
doctor
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Follow up: Dr. Sunil Gupta 3 hours later
One more observation that may contribute to diagnosis - I've noticed that if I sleep fewer than 6 hours, although my body feels tired, I feel much better (sharper and less heavy in the head). Strange indeed.

One more question. I've read about the Chronic Fatigue Syndrome, which some doctors believe might be caused by a hidden infection (or so I have read). Is there a chance that I could have that instead of anxiety/epilepsy and if so, would you recommend a virus/bacterial screen (and what kind of)?

Thanks so much. You've been the most helpful from all the doctors I've spoken too. I'll make sure to give you the best possible rating and review.

doctor
Answered by Dr. Sunil Gupta 44 minutes later
Brief Answer:
Very less likely to be Chronic Fatigue Syndrome

Detailed Answer:
Dear Mr XXXXXXX

First of all, let me thank you for your kind words of appreciation. Your feedback means a lot to me and motivates me further to continue trying to help others in the best possible way.

Its difficult to say why sleeping less makes you feel better. One possible explanation may be that you area short sleeper (people who need less sleep to keep themselves active).

Regarding Chronic Fatigue Syndrome (CFS), it is a highly debatable entity currently. We still are not sure about the actual cause. Infection was though to be one of the causes but current scientific literature doesn't prove it. It is also considered to be psychological in origin. Currently there is no test to confirm CFS. Anemia, hypothyroidism and nutritional deficiencies can be associated but in your case they have been tested and found normal.

Also, CFS won't be explain the episodes that you are having. So, considering all evidences, i will not think of it initially as your diagnosis.

I will still recommend you to go ahead with our initial plan of action and further course could be decided according to response.

I do hope you are able to get over these symptoms real fast. Please feel free to contact me any time ahead on this forum if you need any help/guidance.

Thanking you once again for your kind words for me,

Best wishes,

Dr. Sunil Gupta



Above answer was peer-reviewed by : Dr. Bhagyalaxmi Nalaparaju
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