Epileptic asystole

AHEALTHY 28 YEARold man developed acute pharyngitis and fever. Three days later he experienced a prolonged generalized tonicclonic seizure that required admission into the intensive care unit. Neurological examination findings were unremarkable. Analysis of his cerebrospinal fluid identified herpes simplex DNA. Other laboratory findings from cerebrospinal fluid analysis were a glucose level of 69 mg/dL; a protein level of 44 mg/dL; and leukocytes, 18/mm3. Results from electrocardiographic monitoring showed episodes of progressive slowing of the heart rate that lead to severe bradycardia (30 beats/min) and sometimes brief periods of asystole. These episodes lasted 1 to 2 minutes. Interictal electrocardiographic findings were normal, in particular long QT syndrome was ruled out. Electroencephalographic monitoring revealed nonconvulsive epileptic seizures, withoutmotormanifestations. Epileptic discharges arose from the right temporal lobe and spread contralaterally (Figure 1). These seizures recurred up to 20 times per day and were controlled with high doses of valproate sodium and carbamazepine. Magnetic resonance imaging showed a small area of abnormal signal below the right insular cortex (Figure 2). In 6 weeks the patient fully recovered without any neurological impairment. Antiepileptic treatment was continued, and he experienced no seizures in the following 6 months.