Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 26-year-old woman is evaluated for a 10-year history of recurrent episodes of acute-onset feelings of fear and anxiety. These episodes initially occurred approximately 4 times per year but for the past 3 months have been occurring once or twice per month, especially when she is under stress. She describes the episodes as paroxysmal attacks of fear and anxiety associated with a dry mouth and a consistent “roller coaster” sensation in her stomach that typically last 15 seconds to 1 minute. With more intense attacks, she becomes momentarily confused; her boyfriend says she seems “fidgety” when this occurs. She feels well between episodes. Medical history is otherwise negative, and she takes no medication.

On physical examination, vital signs are normal. All other findings from the general physical and neurologic examinations are unremarkable.

A brain MRI and electroencephalogram are normal.

Which of the following is the most likely diagnosis?

A: Frontal lobe epilepsy
B: Juvenile absence epilepsy
C: Panic disorder
D: Psychogenic nonepileptic seizures
E: Temporal lobe epilepsy

MKSAP Answer and Critique

The correct answer is E: Temporal lobe epilepsy.

This patient most likely has temporal lobe epilepsy. The rising epigastric sensation she describes is the most common epileptic aura that originates in the temporal lobe. Brief episodic anxiety with or without autonomic symptoms, such as dry mouth, also is characteristic of a temporal lobe seizure. These symptoms can occur independently or together (as in this patient) but are typically stereotyped in a given patient. The aura is a simple partial seizure, which can become a complex partial seizure and lead to altered sensorium and automatisms (such as “fidgety” behavior). The absence of focal findings on MRI and electroencephalography (EEG) does not rule out a diagnosis of epilepsy and is in fact a common finding in temporal lobe epilepsy.

Frontal lobe epilepsy can present with different types of seizures, but a fearful and epigastric aura is not typical. Classically, frontal lobe seizures cause motor manifestations (focal jerking, bicycling movements) that awaken patients from sleep.

Juvenile absence epilepsy is a form of generalized epilepsy beginning at or after puberty that is characterized by absence seizures with or without convulsive seizures. An absence seizure is a brief loss of awareness, typically lasting 3 to 10 seconds. This type of seizure is not preceded by an aura.

Temporal lobe epilepsy is often misdiagnosed as panic disorder, which has some similar features. However, this patient’s events are stereotyped and short in duration, characteristics that are more associated with temporal lobe seizures than panic attacks.

Although psychogenic nonepileptic seizures (PNES) can have numerous manifestations and should be part of the differential diagnosis, they are not the most likely cause of this patient’s symptoms. PNES are less likely than epileptic seizures to be consistently stereotyped and brief in duration. The fact that episodes can be triggered by stress does not necessarily distinguish between epileptic and nonepileptic seizures. Given the characteristic and consistent features of this patient’s events, she should be treated for presumed epilepsy. If the patient does not respond to treatment, inpatient video EEG monitoring should be considered to make a definitive diagnosis.

Key Point

• A rising epigastric sensation is the most common epileptic aura that originates in the temporal lobe; electroencephalographic and MRI findings are often normal.

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