An acquired source of seizures

A 35 year old man came to our hospital by ambulance after a first generalised tonic-clonic seizure witnessed by his wife, with further seizures in the ambulance. Earlier that day he had noticed transient left limb weakness with tremor. He had no symptoms of infection, headache, sore throat, or photophobia. He was independent, otherwise well, had no medical history of note, and was taking no regular drugs, although he had used steroids and protein supplements for body building purposes. He had moved to the United Kingdom from Nepal 12 years earlier but had not recently travelled. There were no other features in the history to suggest risk of immunosuppression.

On assessment, vital signs were within the normal range, with a temperature of 36.2°C. Cardiorespiratory and abdominal investigations were unremarkable. Neurological examination showed an unsteady gait but no neurological deficit. Full blood count, renal function, electrolytes, bone profile, liver function, C reactive protein, and retroviral testing were all normal. Figures 1⇓ and 2⇓ show neuroimaging scans. Lumbar puncture performed after brain scan showed an opening pressure of 20 cm of water, with normal cerebrospinal fluid biochemistry and negative microbiology analysis.