A 45-year-old woman with systemic lupus erythematosus and hypertension, treated with hydroxychloroquine, warfarin, and irbesartan, initially presented with daily paroxysmal episodes of ascending electric-shock sensations that began two weeks after an ischemic stroke.
These events were then interpreted as epileptic crises, and levetiracetam 1000 mg twice daily was started. The patient presented to the outpatient neurology consult due to a continuous series of episodes. Each episode lasted 1-5 seconds, with bilateral arm extension, clenched fists, transient speech arrest, and preserved awareness, followed by fatigue but no confusion or postictal signs. Routine laboratory studies (CBC, BMP, and LFTs) were unremarkable.
Brain MRI revealed a T2/FLAIR hyperintense lesion in the right middle cerebellar peduncle with restricted diffusion and low ADC signal, consistent with acute ischemia and mild perilesional edema. The diagnosis of a reverse Lhermitte’s phenomenon rather than epileptic activity was made. Treatment with gabapentin 400 mg twice a day initially reduced episode frequency; recurrence required escalation to 400 mg AM / 800 mg PM.
At one-year follow-up, MRI showed new T2 hyperintensities extending from the pons to the cervical spinal cord C4 level, with cord enlargement from edema. Oligoclonal bands were negative in CSF. Rheumatology later confirmed secondary antiphospholipid syndrome, establishing a vascular autoimmune etiology for the recurrent reverse Lhermitte’s phenomenon.