A 62-year-old male, ex-smoker with no other history of interest, was admitted to the ICU of our centre for convulsive status. According to his family, in recent weeks he had been irritable and childish, and in the last few days he had complained of heaviness and numbness in his right limbs. The seizures were controlled with i.v. phenytoin. There were no notable findings in the tests (laboratory tests, ECG, brain CT) performed in the emergency, except for right basal atelectasis in the chest X-ray. A lumbar puncture showed acellular CSF but with hyperproteinorrache (72 mg/dl protein) and EEG with left temporal irritative activity. A brain MRI study showed a hypersignal lesion on the left temporal lobe (FLAIR and diffusion sequences), which did not change after administration of paramagnetic contrast, nor did it present foci of haemorrhage in the evolution.

Treatment with phenytoin, acyclovir (pending PCR for herpes simplex) and antibiotherapy (pneumonia) with Tazocel and Teicoplanin was added. He did not present seizures again and remained afebrile, and was transferred to the Internal Medicine ward. On admission there were no notable findings in the physical examination and in the neurological examination he was conscious, with nominal dysphasia, inappropriate mood, attention deficit and tendency to fabulate and slight right hemiparesis. In the following days he improved (he recovered paresis and his language normalised) although he persisted with moria and Korsakoff's syndrome. Treatment was completed with acyclovir (on the sixth day he received a negative PCR for HSV) and antibiotherapy.
Laboratory studies were irrelevant, except for mild elevation of CEA (3.9 ng/ml). Anti-Hu antibodies, antithyroid antibodies, serology (lupus, HIV, neurotropic virus) were negative. Screening for occult neoplasia began with thoracoabdominal CT (normal except for atelectasis/ILD pneumonia), bronchoscopy with bronchoalveolar lavage (negative), upper and lower gastrointestinal endoscopy, intestinal transit, urological assessment, bone scintigraphy and bone marrow biopsy. Given the normality of these studies, and with the diagnosis of ELP, a whole-body PET scan was requested, which revealed the presence of fluoroglucose hyperuptake at the pharyngolaryngeal level, as well as small satellite lymphadenopathies. The finding of PET was confirmed with a CT scan of the neck and an anatomo-pathological study of the lesion, which was diagnostic of epidermoid carcinoma of the pyriform sinus.