Seizures and AIDS: A Serious Combination
ABSTRACT & COMMENTARY
Source: Pesola GR, Westfal RE. New-onset generalized seizures in patients with AIDS presenting to an emergency department. Acad Emerg Med 1998;9:905-911.
One of the greatest challenges for emergency physicians caring for patients with AIDS is recognizing the subtle presentations of potentially life-threatening illnesses, many of which present in atypical fashion. Pesola and Westfal, in a retrospective review of adult AIDS patients presenting with new-onset generalized seizures, sought to determine if previously established American College of Emergency Physicians (ACEP) guidelines, which were published in 1997,1 could be safely used in the AIDS population. Their two-year review included all 151 patients presenting to the Saint Vincent’s Hospital and Medical Center of New York Emergency Department with a complaint of new-onset generalized seizures. Twenty-six of the patients evaluated had AIDS. Of these patients, seizure etiologies were determined as follows: eight, idiopathic; eight, HIV encephalopathy; five, CNS toxoplasmosis; two, alcohol withdrawal; two, progressive multifocal leukoencephalopathy; and one, CNS lymphoma. ACEP guidelines failed to identify the need for admission in four of the six patients (3 patients with CNS toxoplasmosis and 1 patient with CNS lymphoma). Pesola and Westfal conclude that the 1997 ACEP guidelines for the evaluation and management of patients with new-onset generalized seizures would have failed to identify some AIDS patients presenting with new-onset generalized seizures due to treatable etiologies. They recommend neuroimaging, along with lumbar puncture if indicated, or admission work up for all patients with AIDS (or a strong suspicion of AIDS) who present to the emergency department (ED) with new-onset generalized seizures.
Comment by Frederic H. Kauffman, MD
In our ED, caring for patients with AIDS is a daily occurrence. Over the past 15 years, I have been impressed by how often common illnesses present in atypical fashion in these patients, and how easy it is to miss serious illness in patients who present with relatively benign presentations. For instance, it is common knowledge that new-onset headache in a non-toxic appearing AIDS patient without meningismus, altered mental status, or abnormal routine CSF findings may still be due to cryptococcal meningitis. As such, the question posed by Pesola and Westfal is an important one. Despite the retrospective nature of their study, they have added evidence to support the recently revised ACEP guidelines, which now include emergent neuroimaging for the evaluation of AIDS (or suspected AIDS) patients with new-onset generalized seizures.
Though not necessarily supported by this study, but based on general experience, I would make even more stringent recommendations than Pesola and Westfal. It is well known that non-contrast CT scans can miss potentially treatable lesions in AIDS patients with neurologic complaints. If MRI (the actual neuroimaging study of choice in these patients) is not immediately available or safe for the AIDS patient with new-onset seizure, CT with contrast is, in my opinion, mandatory. In addition, if neuroimaging is negative, lumbar puncture must be performed to rule out those treatable infectious etiologies that immunocompromised patients are at such great risk for acquiring. Finally, a nonfocal neurologic examination should never be used to decide against pursuing either neuroimaging or lumbar puncture. AIDS patients do not always follow "textbook presentations" of serious illness; a simple new headache or a new seizure may be the earliest clue that a potentially life-threatening condition exists, even in the patient who otherwise does not appear ill.
Reference
1. Clinical policy for the initial approach to patients presenting with a chief complaint of seizure who are not in status epilepticus. Ann Emerg Med 1997;29:706-724.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content