A 24-year-old patient was admitted to hospital with acute asthma for the fourth time in the past six years. The asthma was usually precipitated by a coryzal illness or exposure to allergens. There was no other past medical history of note. The patient usually inhaled ventolin as required, salmeterol inhaler twice daily, becotide inhaler twice daily and had recently been prescribed aminophylline 450 mg twice daily. On admission she had a bilateral wheeze. The PEFR was 200 l/min. The oxygen saturation on air was 86% and on 28% oxygen it was 94%. The chest X-ray revealed hyperinflated lungs. The patient was commenced on nebulized bronchodilators, prednisolone 30 mg daily and amoxycillin. The following day she developed a rash therefore the amoxycillin was substituted with erythromycin.
The patient improved significantly over the next 48 hours but then suffered three successive grand mal seizures, which necessitated ventilation.
What was the most likely cause of the epileptic seizures?
a. Hypoxia.
b. Meningitis.
c. Benign intracranial hypertension.
d. Theophylline toxicity.
e. Herpes encephalitis.
Answer
Abdominal cramps, weight loss, erythema nodosum (raised circular skin lesions) and raised inflammatory markers are highly suggestive of inflammatory bowel disease. Tenderness in the right iliac fossa points to the possibility of terminal ileal disease and hence Crohn’s disease, although this is a non-specific feature since many conditions may cause right iliac fossa tenderness. Diarrhoea is not always a prominent feature in Crohn’s disease.
Although ileo-caecal TB may present in a similar fashion, her race and the presence of a BCG scar is against the diagnosis. Sarcoidosis enteropathy has been reported but this is very rare and usually in association with other features of this multi-system disorder. Small bowel lymphoma may present in a similar fashion; however, diarrhoea is a prominent feature. Raised inflammatory markers are against the diagnosis of irritable bowel disease, which is a functional rather than inflammatory disorder. (See Answers 31, 394.)