B48-29 An Interesting Diagnostic Case of Cefepime Induced Nonconvulsive Status Epilepticus in an Immunocompromised Patient

Introduction Altered mental status in immunocompromised patients requires broad diagnostic considerations, which includes infectious, metabolic, structural, as well as toxic causes. We present a case of cefepime-induced nonconvulsive status epilepticus (NCSE) in an HIV-positive patient which highlights the diagnostic challenge and clinical significance of recognizing this condition. Case Presentation A 58-year-old male with HIV on bictegravir, emtricitabine & tenofovir alafenamide (Biktarvy), atovaquone for PJP prophylaxis, prior CABG, neurosyphilis s/p IV penicillin G, chronic kidney disease secondary to diabetic glomerulosclerosis presented with encephalopathy, bilateral upper extremity tremulousness, and family-reported “staring spells” for 24 hours. He had recently been hospitalized with Pseudomonas bacteremia and a Serratia urinary tract infection and sent home with intravenous cefepime three days prior. On arrival, urine drug screen was negative; imaging of the brain and head were unremarkable; blood gas was unrevealing. Complete blood count and comprehensive metabolic panel were benign. Exam of the patient in the emergency room prior to admission revealed a disheveled, nonverbal man responsive only to painful stimuli. Pupils were equal and reactive. He was empirically covered for meningitis. Hours later, he exhibited right gaze deviation and rhythmic bilateral upper extremity movements. Following this discovery he was given lorazepam which he was unresponsive to, then loaded with levetiracetam, intubated for airway protection, and started on propofol infusion with continuous EEG monitoring. EEG obtained revealed “2-2.5 Hz generalized periodic discharges lasting for several seconds” confirming nonconvulsive status epilepticus. MRI of the brain and lumbar puncture were unremarkable. He was managed with antiepileptic medication, transitioned from cefepime to piperacillin-tazobactam for his aforementioned bacteremia, a marked improvement in his mental status was noted in the next twenty four hours and he was subsequently liberated from mechanical ventilation. Following exclusion of infectious, vascular, and metabolic causes as the cause of his seizures, the final diagnosis by exclusion was deemed to be cefepime induced nonconvulsive status epilepticus. He was discharged on antiepileptic medication, with plans for outpatient tapering. Discussion Cefepime, a fourth-generation cephalosporin with antipseudomonal coverage, is known to cause neurotoxicity—especially in patients with renal impairment. Symptoms include confusion, myoclonus, and NCSE, the latter requiring EEG for diagnosis. This case highlights the importance of reviewing medication history in encephalopathic patients admitted to the ICU, particularly those with immunocompromise or renal dysfunction. If the diagnosis of cefepime induced NCSE is made, it is crucial to treat the NCSE and withhold the offending medication. This abstract is funded by: none