Author: Thomas Mac Mahon / Editor: Sarah Edwards / Codes: MHC5, NeuC6, NeuP3, SLO3 / Published: 18/11/2022

A 29-year-old woman is referred to your Emergency Department (ED) from the local Mental Health team for medical clearance prior to further treatment. She had attended them on two occasions with a six-week history of agitation, anxiety, intermittently slurred speech, and increasingly bizarre behaviour, screaming, running impulsively from rooms and making pouting facial grimaces. She had been treated with a combination of sertraline, haloperidol and as-required lorazepam for acute depression with no benefit. In your department she has a two-minute episode of generalised tonic-clonic seizure-like activity, with no incontinence or tongue biting.

There is no personal or family psychiatric history. Prior to the onset of these symptoms six weeks previously, she was perfectly well, in full time employment, on no regular medication, and with a fulfilling social network.

On examination she is drowsy but rousable, with no lateralising signs. Her pupils are equal and reactive. She has no signs of meningism and no rash. Her heart rate is 110bpm, she is normothermic and the remainder of her vital signs are within normal limits.

Her serum and urinary toxicology screens are positive only for benzodiazepines. Her full blood count, renal and liver function, electrolytes, lactate and coagulation profile are within normal limits. Her CRP is elevated at 80mg/l (normal 0-5mg//l). Her ECG shows a sinus tachycardia. Her CT-Brain is normal.