Case Presentation: A 34-year-old male with a history of asthma, depression, and anxiety treated with fluoxetine presented to the ED following a motor vehicle accident. Prior to the accident, he felt anxious and lost awareness. He could not remember the collision. Trauma screen revealed extremity abrasions and sternal tenderness. There were no traumatic findings on abdominal/pelvic CT, CT of the neck, or chest x-ray. CBC, BMP, lactic acid, and PT/PTT were unremarkable. ECG notable for sinus bradycardia. He was sent home in stable condition. Follow-up with PCP deemed the cause of the accident to be syncope due to bradycardia caused by fluoxetine and he was switched to bupropion.Four days after the MVA, he represented to the ED after his wife found him minimally responsive. He was afebrile and normotensive with pulses ranging from 57-68 bpm. Physical exam was without acute findings. BMP and CBC were within normal limits. TSH was 1.880 ulU/mL and magnesium was 2.3 mg/dL. Urine drug screen was positive for cannabinoids. POC EEG was negative for one hour. EKG was unchanged from prior. Echocardiogram showed a normal study. MRI of the brain was unremarkable. He reported daily use of nicotine vape, 14 alcoholic drinks per week, weekly cannabis use, and 1-2 cold brew coffees daily. He endorsed a history of generalized anxiety and panic disorder, and attributed increased panic attacks to his wife’s recent premature delivery of twins, one of whom did not survive. He describes his panic attacks as being preceded by déjà vu and followed by diaphoresis, palpitations, chest tightness, and stomach discomfort. He was placed on continuous EEG and was found to have four electroclinical seizures from sleep with onset in the right temporal region. He was loaded with levetiracetam 30 mg/kg and started on maintenance dose of 1000 mg BID. Bupropion was discontinued due to seizure threshold lowering effect. He reported no further episodes of panic after starting levetiracetam and was discharged home.
Discussion: Temporal lobe epilepsy is the most common subset of epilepsy and can present with a wide variety of symptomatology1. There is significant overlap between the symptoms of panic disorder and seizures as both may present with diaphoresis, vital sign irregularities, flushing, feelings of terror, or depersonalization2. Patients with focal temporal lobe epilepsy may experience an aura of fear due to activation of the amygdala which can make clinical differentiation a challenge3. The new prodrome of altered consciousness after that occurred during this patient’s MVA suggests a secondary presentation and warranted further workup. However, it is important to recognize that the uncovering of this patient’s epilepsy did not rule out the presence of comorbid panic disorder. Patients with epilepsy have disproportionately higher rates of anxiety disorders than the general population4. Comorbid epilepsy and panic disorder is not uncommon and thus should be considered when new or atypical features of panic attacks arise.
Conclusions: Temporal lobe seizures can present similarly to panic attacks. It is important to keep epilepsy on one’s differential when evaluating a clinical picture concerning for panic attacks, particularly in patients who experience atypical features.