This is a retrospective case series performed at Johns Hopkins Bayview Medical Center from January 2016 to May 2018, which screened for patients with severe WMD, who had TWs on electroencephalography (EEG) without the presence of commonly cited provoking factors, including 1) hepatic disease; 2) severe uremia over baseline; 3) the drugs cefepime, ifosfamide, lithium, and baclofen; or 4) global hypoxic-ischemic injury.

Eight patients were identified. Out of this group, 100% had mild calcium derangement and 88% had infection (38% urinary tract infection [UTI], 25% respiratory infection, and 25% central nervous system [CNS] infection).

This is the first series to demonstrate convincingly the presence of TWs in patients with WMD in the absence of commonly cited risk factors. We hypothesize that WMD, combined with these less recognized and often mild risk factors, may be drivers of TW appearance. With a growing elderly population, the presence of white matter disease will increase, and treating physicians need to look beyond the common causes of TWs. The two lesser-recognized causes—white matter disease and metabolic or infectious abnormality—may account for the appearance of TWs.