Monthly Case

A 32-year-old male patient had his first generalized tonic clonic seizures at age of 16 years. Most of the seizures manifested within the first 60 min after awakening. The former EEG demonstrated spike-wave-complexes at a frequency of 3 Hz. This constellation indicates genetic generalized epilepsy (formerly, idiopathic generalized epilepsy), the subsyndrome is epilepsy with grand mal on awakening. The patient was treated with valproic acid at 900 mg daily. This treatment resulted in seizure freedom, the EEG was free of signs of increased neuronal excitability, thus the antiepileptic drug – which was the patient’s wish – was withdrawn after 4 years. In the following 12 years, the patient was seizure-free. Within the context of febrile and probably bacterial bronchitis, the patient suffered from a seizure relapse. He reported spontaneously that due to the infection and associated strong coughing he had poor sleep in the two nights before the seizure. When asked for antibiotic treatment, the patient reported to be administered ampicillin, a derivate of penicilline.

In this constellation, the patient has three triggers that in sum may have resulted in seizure relapse. At first, sleep deprivation is a major trigger for seizures in genetic generalized epilepsy. Secondly, fever is another relevant trigger. Finally, many antibiotics have proconvulsant properties, this in particular accounts for penicilline and its derivates.

In the current case, the EEG was still normal. As the seizure likely was triggered by the three factors mentioned above, there was no need for restarting antiepileptic drug treatment. We informed the patient on the clinical significance of triggers for seizure relapses, in particular massive sleep deprivation and the antibiotics penicilline and its derivates should be avoided. As the seizure relapse occurred after more than 10 years of seizure freedom and triggers were clearly identified, driving restriction is limited to the next 3 months.

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