77 year old female with diabetes and hypertension was found unresponsive at her nursing home. Family had noticed a progressive decline in mental status over the past two weeks. Patient appeared lethargic, wandered off during conversation, tried to grab nonexistent objects and her speech was nonsensical occasionally.
On initial assessment by EMS, patient had bradycardia (42 bpm), temperature 84 F, blood pressure 101/54 and saturation 94%. Patient was obtunded, and noted to have myoclonus of bilateral upper and lower extremities.
Initial differentials for jerky movements included seizures, focal CNS pathology, hypoxic injury, and metabolic or infectious etiology. CT head and ABG were normal. Patient was loaded with Levetiracetam and continuous video EEG monitoring was started. It demonstrated tri-phasic waves and multifocal myoclonus did not have any electrographic correlation. Detailed encephalopathy workup ordered on admission revealed TSH 126 and low FT4. Endocrinology was consulted and patient started on IV levothyroxine at 100mcg daily and IV hydrocortisone. Patient’s mentation gradually improved. Decrease in frequency and amplitude of myoclonic jerks was noted in response to maintenance therapy with Levetiracetam.