A Report of Grand Mal Epilepsy in a Man with ‌‌‌‌‌Basal Cell Carcinoma

Dr. Hassan Jazayeri Neurolgue*

*Correspondence to: Dr. Hassan Jazayeri Neurolgue, Albania.

Copyright

© 2023 Dr. Hassan Jazayeri Neurolgue. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 17  November 2023

Published: 30 November 2023

There are still uncertainties for me, who has been visiting neuropsychology patients professionally for more than 4 decades, when I write a report about this case, it is very surprising. I know that in medical science, unlike mathematics, the number of two is multiplied by two, it does not become a perfect four. The number may be three or even five, and I always try to think of this rule when dealing with similar cases. But this time, no matter how much I wanted to put the issue and draw a conclusion in this law of medical numbers, it was difficult.

Now what was the issue?

I want to report it A 54Y/O man who, three years after surgery on the 5^th toe of his left foot, due to chronic wound and gangrene, was finally amputated by an orthopedic surgeon. Until then, conservative treatments, including various antibiotics and NSADs drugs, could not control the patient's local pain and swelling. He did not have diabetes, but he suffered from problems such as osteoporosis, fatty liver, and rheumatoid arthritis.

Of course, he used different treatments sporadically, according to the problems he had.

He was a sportsman, active and innovative, creative and strong and at the same time kind and loving. He was active from the first hours of the morning when he woke up until the end of the night. 9 months ago, a local adenopathy was suddenly found in the left inguinal area, which was also painful. Local ultrasound confirmed this adenopathy, and after a biopsy, it was found to be a cancerous lesion under the title: Basal Cell Carcinoma (B.C.C).

Hearing this, was very difficult and unimaginable for the patient. But in the process, he accepts it and adapt himself to it. For treatment, considering that the adenopathy lesion was localized in the groin, the oncologists who monitored the patient decided to surgically remove the adenopathy, which was done under general anesthesia. But unfortunately, when the patient went to the operating room, the surgeons who decided to remove the adenopathy refused to do the operation. Their reasoning was that, because the adenopathy was attached to the Lt femoral artery, they could not practically remove the lymph node completely. Because they could not control the patient's condition in that situation and only took a complete sample to give to the pathology. When they received the pathology results, they chose radiotherapy for treatment 30 consecutive sessions were performed in the oncology department of Nene Teresa Hospital. And more wounds were created in that area. Oncologists believed that the extent of the wounds was caused by the side effects of radiotherapy, which was inevitable for this patient.

Figure 1

They sought to assess the cause of cancer cell migration.

 One theory was that perhaps the main cause was basal cell carcinoma, due to the operation of amputation of the fifth toe of the left foot, which was performed two years ago by an orthopedic surgeon. The efforts of the patient's relatives and the oncology department of the hospital to find the documents of amputation did not reach a result. It was found that at that time, even the amputated tissue was not given to the pathology. Because no one thought that this lesion might be carcinogenic or contain basal cell carcinoma cells.

Therefore, it was only recorded as a theory in the patient's file. But the wounds not only didn't heal at all, but they continued to spread.

 Severe local pains that could not be tolerated by the patient despite the use of strong painkillers such as Tramadol. Along with the increase in local secretions and movement restrictions, which was caused by the complications of the wound in the left inguinal region.

 The discussion was that how should the patient's treatment be continued? Should chemotherapy treatment be emphasized? Or does radiotherapy again and stop the treatment?

In the end, the issue was resolved by performing a PET scan to decide on the type of treatment. They solved it by performing a total body PET scan.

The result of pet Scan of total body

Conclusion:

- No data on pathological fixation of 18F-FDG in liver, bones, breast.

- Pathological external left  iliac and left supraclavicular lymph nodes in PET. p

-Solid lesion in the medial part of the left thigh, from the box and adipose tissue towards the vastus medialis muscle is observed.

lesion 6x4.5cm irregular, Suvmax 7.8, suggestion of tumoral tissue, no interest in bone structure.

left thigh, for better local staging.

-Pulmonary lesions some of these, small to be characterized, not present in CT June 2023, two larger ones with SuV high LIS and LID suggest bilateral pulmonary metastases

In Albania, pet scan is performed only in a private hospital and it has not yet entered in public departments, which was done after the consent of the patient's family. Of course, we had previously done a culture and antibiogrmme from the secretions of the inguinal region, which revealed that the wound was full of streptococci, which had been treated with broad-spectrum injectable antibiotics such as ceftriaxone and...

I want to raise a topic that was very unexpected for me, This also made me share the report of this case with my colleagues.

The topic was Grand Mal's epileptic attack, which the patient suddenly encountered. While the patient's condition was getting better, they transferred the patient to the hospital where I was there at midnight. The patient was completely comatose. He did not answer any questions and the neurological examinations indicated the critical condition of the patient.

 People around the patient said:

He was sleeping as usual and we were worried that we didn't see any reaction from him because on other nights, he always raised his problems due to local pains.

When we shook him, we got worried and immediately took him to the hospital with an Ambulance. When we could not determine the main problem of the patient in our own hospital, we sent him to Nene Teresa Hospital to more evaluations

We recommended that specific diagnostic measures and necessary work be done for him. There was the same state of confusion among the doctors. After four hours, the patient finally opened his eyes and asked:

Where am I?

And almost in those four hours, he could not remember anything. He was asked about the foods he had eaten, or the possible new drugs he might have used, or even if he had a concussion while driving, etc.

Finally, all the doctors and medical staff who had seen the patient, especially the brain scan that was performed It was reported to be completely normal and no CVA or stroke was reported, especially that the neurological examinations were still completely normal in terms of sensation and movements.

Finally, with the suspicion that the patient may have grand mal epilepsy, he was discharged from the hospital, but there was still a big question before me and the rest of my colleagues who knew the patient closely. I even asked about his family history very carefully. he completely denied, or even a history of epilepsy in the past, or even concussions, and all these questions were negative.

In these years, wherever I had doubts about some cases, I took help from my very good colleague, Mrs. Drs. Mimosa Spahio, a neurologist, and I must admit that, in many cases, she was of great help in diagnosis and control. She has made my patients. This time I went to her and asked to visit this patient together.

At that time, like the rest of my colleagues, we talked in detail about the patient's coma, especially after a week, when almost all the necessary tests to investigate the cause of the coma were done and were negative. We ruled out metastasis in this patient. Because we didn't have any documented reason for the presence of metastasis in the brain, or the history of traumatic brain injury, etc…

Despite this, because the diagnosis of this disease was important to us, we decided to take a E.E.G, which we did, and to our surprise, we found out that the case was a Grand Mal epilepsy case, which presented itself in this way. The figure showed.

  Later, when we talked to the patient, he explained to us. and said:

Before I fainted, I felt certain states in my head that I could not even focus on a subject.

Figure 2

We thought about this matter, even though he himself did not know what we mean by ``ora''. Although the E.E.G test showed Grand Mal's epilepsy, Dr. Mimosa and I could not start antiepileptic treatment for him. Because it happened only once and at the same time considering the heavy treatments he was using for his cancer, we preferred to wait, if we face a new attack again, we will do so.  In these years, I have dealt with Grand mal epileptic patients a lot, and even at the beginning of the new year, a number of nearly 24 epileptic patients who we re-examined were chronic patients, some of whom had had epileptic attacks for more than twenty years. They didn't have any, but because the cause of their epilepsies was obviously caused by concussions, I couldn't stop their medications completely. Because I knew that secondary epilepsies are usually reversible. For this reason, I tried to create a balanced situation by keeping their medicines in one dose.

Figure 3

But in this plan, I was finally convinced that we should gradually reduce the medication of the patients who did not have an attack for a long time and reach the point of stopping the medication.

That's why I decided to test this patient and adjust his medication. It was interesting to me that I was only able to adjust his medication for one month and not stop it because the protocol for stopping it was five months away. Unfortunately, we encountered a severe epileptic attack, without any background, and in this case, when we took a E.E.G, there was still active epilepsy.

In a 64-year-old man who suffered from epileptic attacks due to being hit by a baton in prison and had been treated with Tegratol (Carbamazepine ) and Depakine for more than 35 years, and he had an attack in the past 29 years, when I knew the patient closely. It was not reported.

This experience taught me that one should not take risks in the case of epileptic patients whose epilepsies were caused by strokes. Because epileptic stimulation centers do not disappear even with time and this was proven for me.

Since these two experiences about epileptic patients were interesting to me, I preferred to share them with the rest of my colleagues.

The End