Nystagmus, dysphasia, somnolence | Figure 1

Case Presentation

36 yo male with a history of:

• Type 1 DM
• Right MCA stroke in 2017
• Juvenile myoclonic epilepsy (on lamotrigine and topiramate)

Chief Complaint:
Presented in DKA 2/2 missed medications due to increased sleeping.

Clinical Synopsis

• Symptoms:
  • Almost daily episodes of:
    • Blurred vision
    • Dizziness
    • Slurred speech
    • Upbeating nystagmus lasting about twenty minutes
  • Notable dysdiadochokinesia and dilated pupils during episodes
  • No focal deficits
  • Patient oriented and able to speak/follow commands
  • Extremely fatigued post episode for 10+ hours
  • Associated nausea and vomiting
  • No tinnitus or room spinning

Investigations

• EEG: Unremarkable
• MRI: Negative
• Lab Results:
  • TSH, ammonia, CK, renal function, CBC: WNL
  • Denies all infectious symptoms
  • Urine drug screen: Negative
  • Lactate elevated to 3.7 during one episode but not in subsequent ones

Assessment

• Consultation:
  • Hospital epileptologist assessed and stated it is not a seizure.
  • Considering differential diagnosis including autoimmune encephalitis, lumbar puncture is pending.

Request for Help

As a very confused PGY2, assistance is needed to understand the situation of this patient before discharge, which could lead to further episodes, missing insulin, and recurring DKA.