Abstracts

Rationale: There is a single report of EEG findings in human rabies encephalitis from 1981, they describe a first EEG done the second day of admission that showed diffuse slowing, and a third EEG done several days after, when the patient had a seizure and the EEG showed a high amplitude periodic discharges on the right side. We present the video EEG findings on a case of human rabies encephalitis, later confirmed (July 18, 2011) by the CDC as a canine rabies virus present in Haiti. Methods: Describe the video EEG findings of human rabies encephalitis. Results: On June 30, a 73 y/o woman Haitian woman presented to our ER with shortness of breath, poor balance and hallucinations, she was admitted with a presumptive diagnosis of UTI. Head CT was normal. She become progressively more combative, on the next day she developed fever T 38.5, respiratory depression and tremors. Epilepsy consultation was requested; she was found combative, and restless, she was awake but could not maintain a conversation, she was having frequent episodes of jaw quivering and bilateral upper and lower extremity tremors, lasting 1 to 3 minutes. She was transferred to the ICU and intubated. CSF was unremarkable except for a slight elevation of with cells (7/ul). Video EEG was begun and she was found to be in non convulsive status epilepticus. Encephalitis was diagnosed, CSF encephalitis panel was negative. Serum, CSF, saliva and skin biopsy was sent to the CDC for rabies testing. Rabies virus antigen was detected in the skin biopsy and saliva. On July 18 she was declared brain dead. Video EEG findings; On day 1 of monitoring, the EEG showed bilateral diffuse slowing, without proper organization. She had multiple seizures arising from the left temporal area, (figure 1) without generalization; the electrical changes would coincide with her clinical episodes of mouth quivering and tremor like activity of the upper and lower extremities, treatment was initiated with cerebyx IV, on the next day she was still having frequent seizures and she was started on Versed 0.05 mg Kg hour, and keppra was added, burst suppression was reached, and attempt to lower Versed cause the reappearance of seizure activity, Vimpat was added and Versed was re-started. On July 14th, status epilepticus had resolved and versed was tapered, however her EEG continued to show a burst suppression pattern (figure 2) 4 days after Versed was stopped, on July 19th the EEG showed electro cerebral silence, at that point the patient met criteria for brain dead. Conclusions: There has been no documented cases of video EEG monitoring in human rabies encephalitis. Our patient had seizures that clinically were difficult to identify as such, with mouth quivering and bilateral upper more than lower extremity tremors, on EEG this were proven to be left hemispheric seizures. The evolution of the EEG, showed a progression to a burst suppression pattern (while off sedatives) and finally electro cerebral silence.