A 42-year-old man with a history of traumatic brain injury and Krabbe disease carrier status arrived at our hospital intubated and sedated on propofol and midazolam infusions for presumed status epilepticus. Family reported several days of intermittent convulsion and involuntary movements. Continuous EEG revealed frontal intermittent rhythmic delta activity without epileptiform discharges or seizures. MRI brain showed minor gliosis of the left inferior frontal lobe. Routine labs including toxicology screens were normal. After extubation, he was agitated and impulsive. He left the hospital against medical advice when this spontaneously resolved. 

He returned with encephalopathy and abnormal movements two weeks later. On examination, he was lethargic and had asynchronous brief losses of postural tone of the bilateral upper extremities. Continuous EEG revealed generalized periodic discharges of triphasic morphology. Urinalysis, urine drug screen, and autoimmune encephalopathy panel were unrevealing. On day 3, his mentation returned to baseline. He reported kratom use for the last year combined with the recent addition of a supplement for restless legs. He was counseled on drug cessation and discharged in stable condition.