An unusual case of a patient with epilepsia partialis continua (EPC) who presented with abdominal spasm and hypoxemic respiratory failure necessitating intubation. 

EPC, also known as focal motor status epilepticus, is a is a rare, recurrent, focal seizure disorder that has a wide range of clinical presentation. EPC usually manifests with treatment-resistant seizures with retained awareness and unilateral motor symptoms. The differential diagnosis of the underlying causes of EPC is broad, including structural etiologies such as malignancy, focal cortical dysplasia, and ischemic stroke, and metabolic disorders such as non-ketotic hyperglycemia.

Case Presentation: Our patient is a 23-year-old woman with a history of a steroid responsive encephalitis complicated by focal aware and focal impaired awareness seizures as well as psychogenic non-epileptic seizures. She presented to a regional emergency department three times over a 48 hours period for episodes of abdominal spasms that spread through all of her limbs equally and occurred very briefly every two to three minutes. She was told each time that her episodes were non-epileptic.

Upon transfer to our center, she continued to have frequent episodes of diaphragmatic spasm without EEG correlate until she developed respiratory failure and altered mental status. She was intubated and placed on continuous EEG. After a paralytic trial, she was found to have focal electrographic seizures with bilateral (left > right) parasaggital, sharp rhythmic, alpha activity evolving to theta activity.

EPC is frequently silent on EEG.  This patient had a rare form of abdominal and diaphragmatic epilepsy with preserved awareness that ultimately progressed to respiratory failure.  The ictal nature of her symptoms only became apparent on EEG after administration of paralytics. In patients with abdominal spasm, it is important to consider ictal causes that may not be electrographically evident.