A Previously Healthy 27-Year-Old Man With New-Onset Seizure

A 27-year-old man presented to the emergency department (ED) following a new-onset seizure.

History. The seizure was witnessed by his wife, who stated that he was standing at the kitchen sink, washing dishes, when he fell to the ground convulsing. The seizure spontaneously resolved upon emergency medical service arrival. The patient denied fever, fatigue, unexplained weight change, headaches, focal neurologic deficit, visual changes, cough, or rash. He denied prior illness, head trauma, or recent travel, except for travel to China about 2 years prior to visit family. He reported drinking alcohol socially and denied using tobacco or illicit drugs. He did not have children. Family history was noncontributory.

At the ED, the patient experienced another seizure, which resolved with lorazepam 4 mg intravenously. He was disoriented and combative postictally, necessitating sedation with intubation.

Diagnostic testing. A complete blood count, complete metabolic panel, troponin, HIV, toxicology, and tuberculosis screen were within normal limits, except for slight leukocytosis (white blood cell count, 11.8 k/µL). Lumbar puncture, parasitology report, blood cultures, and chest and cervical spine radiographs were negative. Brain computed tomography (CT) without contrast revealed a 3 to 4 mm calcified lesion in the right middle frontal gyrus with surrounding edema (Figure 1). Postcontrast T1-weighted brain magnetic resonance imaging (MRI) demonstrated ring-like enhancement of the lesion (Figure 2).

Figure 1. Brain CT without contrast. Calcified lesion (3-4 mm) noted in the right middle frontal lobe, with surrounding subcortical hypointense and hyperintense signal changes indicating vasogenic edema.

Figure 2. Post-contrast T1-weighted brain MRI. An eccentric 3-4 mm calcified lesion (3-4mm) with surrounding hyperechoic “ring-like” enhancement noted after gadolinium contrast.

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