From emergency intubation to functional status epilepticus: diagnostic and pharmacological challenges in a renal transplant recipient

Introduction

The clinical differentiation between epileptic and functional seizures remains a significant challenge in neuropsychopharmacology, particularly when patients present with episodes resembling status epilepticus. [1] In medically complex cases, such as organ transplant recipients, diagnostic overshadowing may lead to aggressive but unnecessary interventions. This report describes a diagnostic dilemma in which functional seizures mimicking status epilepticus resulted in emergency intubation, highlighting the importance of careful clinical semiology in preventing iatrogenic harm.

Case Presentation

A 39-year-old female, a renal transplant recipient since 2006, presented to the emergency department in May 2025 with a 25-minute episode of generalised motor activity. At presentation, she was receiving lacosamide 150 mg/day and clonazepam 2 mg/day under a prior diagnosis of epilepsy. Despite treatment, the severity of the event led to emergency management, including 20 mg diazepam and a 1500 mg levetiracetam loading dose, followed by intubation.

During the episode, several clinical features were inconsistent with epileptic status, including preserved airway reflexes, absence of cyanosis, and lack of post-ictal lactic acidosis. Serum sodium was 128 mmol/L. Notably, motor activity persisted despite propofol infusion and manifested as semi-purposeful movements; these appeared voluntary, featuring purposeful attempts to remove the endotracheal tube and resistance to mechanical ventilation, all while maintaining haemodynamic stability.

Retrospective history revealed her paroxysmal events began in 2018 following a head injury. A review of previous EEG recordings from 2018, 2022, and 2024 confirmed the absence of ictal activity during captured events. Over the years, multiple antiseizure medications (including carbamazepine, oxcarbazepine, and lamotrigine) were tried but failed due to adverse effects like lymphadenopathy, hyponatremia, and rash. The patient had a history of suboptimal compliance, medication-free periods, and multiple neurological evaluations with psychiatric referrals without sustained engagement. Consequently, the lack of electrographic evidence and the clinical course indicate that the primary diagnosis of epilepsy remained unsubstantiated throughout her history.

During her emergency admission in 2025, an interictal EEG demonstrated diffuse background slowing and frontal intermittent rhythmic delta activity (FIRDA); however, these were attributed to metabolic disturbances and sedative effects rather than primary epileptiform discharges. A subsequent video-EEG study confirmed the diagnosis of functional seizures; the recording captured a habitual event following hyperventilation. During this episode, the patient remained responsive via eye blinking and was able to recall test keywords. The event was terminated through clinical suggestion without any ictal EEG correlate. Despite this evidence, the patient declined further psychiatric follow-up.

Discussion

Establishing a diagnosis of functional seizures requires high clinical suspicion, a meticulous history review, and an integrated multidisciplinary approach. In medically complex patients, this is essential to prevent iatrogenic harm, including unnecessary intensive care and aggressive antiseizure loading. Beyond preventing physical complications, timely diagnosis is vital, as diagnostic uncertainty may reinforce maladaptive illness beliefs and contribute to medical mistrust, hindering therapeutic alliance formation. [2], [3] Early recognition remains a key strategy to reduce unnecessary medical risk and improve long-term outcomes in this population. [1]

References

1. Asadi-Pooya, A.A., Sperling, M.R., 2015. Psychogenic non-epileptic seizures: a concise review. Neurol. Sci. 36 (6), 859-867.
2. Reuber, M., 2008. The etiology of psychogenic non-epileptic seizures: toward a biopsychosocial model. Neurol. Clin. 26 (3), 667-682.
3. Bodde, N.M., et al., 2009. Psychogenic non-epileptic seizures—definition, etiology, treatment and prognostic issues. Seizure 18 (8), 543-553.