A 44-year-old man with Crohn's disease diagnosed 15 years previously, who was admitted to the general surgery department for abdominal pain and diarrhoea of one week's duration, compatible with a flare-up of his disease. Under home treatment with corticoids and mesalazine, the patient has had an ileostomy for 2 years following a subtotal colectomy with a closed rectal stump following a flare-up of his disease. He had previously undergone several resective operations such as removal of the last 40 centimetres of the ileum, ileocaecal valve and cecum, following ileocaecal perforation, as well as other operations for anal fistula with abscess in the buttock, for drainage. During the current admission, he developed a polymicrobial perianal infection resistant to medical treatment with antibiotics, so he underwent surgery in which he underwent an abdominoperineal amputation, resecting his rectum. The postoperative course was uneventful until, on the tenth day, he suffered a generalised tonic-clonic seizure lasting 3 minutes, without sphincter incontinence. A general biochemistry was performed, showing a calcium corrected for albumin of 8.42 mg/dl (rn: 8.7-10.6), K 2.6 mg/dl (rn: 3.6-4.9), albumin 2.5 mg/dl (rn 4-5.2), glucose and sodium within the reference values. Subsequently, a cranial CAT scan was performed, which showed no abnormalities. An electrocardiogram on the day of admission showed a normal sinus rhythm at 79 bpm, without QT or PR space elongation. Two days later, he again presented with a generalised tonic-clonic seizure lasting one minute. After being assessed by the Neurology Department, an electroencephalogram was performed with no pathological findings and treatment with carbamazepine was started. Given the persistence of seizures of the same characteristics despite medical treatment, a 24-hour electroencephalographic recording was performed, which showed no alterations. Given that the patient showed signs of dehydration and malnutrition, as well as decreased intake and asthenia, a referral was made to the Nutrition Unit for assessment of nutritional support if necessary.
On questioning, she reported paresthesia in the lower limbs, which she recently perceived more as intense pruritus, with no other symptoms. He also refers that he has had 3 convulsive episodes of similar characteristics to the current ones in the last 5 months, with no subsequent clinical repercussions, having consulted the Emergency Department on one occasion, where, as it was the first convulsive episode, no antiepileptic treatment was prescribed.
On examination, the patient weighed 55.1 kg and was 172 cm tall (BMI 18.63 kg/m2). He reported a weight loss of 7 kg in the last 6 months, which represents a weight loss/time ratio of 15.23%, implying severe malnutrition. The examination revealed mild cutaneous-mucosal dehydration and a moderate decrease in fat and muscle mass, which was subsequently diagnosed as moderate mixed energy-protein malnutrition, according to the anthropometric and biochemical parameters of the classic nutritional assessment. The rest of the physical examination was normal, with no clinical signs of hypocalcaemia or hypomagnesaemia such as Trosseau's sign, Chovstek's sign, muscle spasms, tremor or tendon hyporeflexia.
A dietary history for the months prior to admission showed that his calorie intake was insufficient for his needs and that he was also deficient in certain food groups such as dairy products, fruit, vegetables and red meat.
Given the existence of dehydration with negative water balances due to a high ileostomy debit, and low blood electrolyte levels, monitored parenteral treatment was started to replace volume, electrolytes and other micronutrients, including phosphorus and magnesium. Prior to this, a blood sample was taken to determine these micronutrients in view of the suspicion of a possible deficiency. That same day the patient suffered a seizure similar to the previous ones. The blood test showed a magnesium level of 0.76 mg/dl (rn: 2.40-5.40) with phosphorus, calcium, potassium and sodium within the reference values. A perfusion with high doses of magnesium sulphate was prescribed with progressive normalisation of her blood levels, with high doses of oral magnesium lactate being sufficient for maintenance treatment, as maintenance treatment. After stabilising the figures with oral administration, the patient was taken off the anti-epileptic medication, and no further episodes of seizures occurred.