Ictal limbic Psychosis in a Case of Mesial Temporal Epilepsy

Temporal lobe epilepsy is frequently associated with neuropsychiatric manifestations, including psychosis. Psychosis is typically categorized as interictal or postictal as the direct ictal manifestation is a rare and diagnostically treacherous phenomenon. A 15-year-old male presented with an acute psychotic syndrome characterized by fluctuating orientation, paranoid delusions, auditory hallucinations, and aggression. Initial workup with computed tomography and routine electroencephalography (EEG) was unremarkable. A week later, the patient reported compulsive sniffing and olfactory auras. Subsequent video-EEG captured lip smacking and staring concurrent with right temporal epileptiform discharges. Magnetic resonance imaging confirmed right mesial temporal sclerosis. This case is novel in demonstrating that a pure sensory aura can also manifest as primary psychosis. The olfactory-limbic pathway serves as a direct conduit to generate perceptual and behavioral disturbances. It highlights the importance of detailed sensory symptom histories in first-episode psychosis and advocates video-EEG as a critical tool in these patients.