A 15 year old girl presented to the ER with coma following several tonic–clonic convulsions.\nThe patient was previously healthy with no personal or familial medical history. During her visit to a dentist for endodontic treatment, the dentist injected 1.5 ml of 2 % lidocaine (the total dose was 30 mg) and epinephrine 1:100,000 for local anesthesia. The solution was injected on the left side by an expert hand without prior aspiration.\nThe injection lasted about 2 min. By the end of the injection, the girl collapsed and several intermittent tonic–clonic convulsions ensued. These lasted about 30 min and were followed by deep coma.\nGlasgow coma scale (GCS) was three, brainstem reflexes were intact, and no fever was noticed. Vital signs were within normal limits.\nHer left cheek and gingiva were edematous and a giant gingival hematoma was noticed.\nOptic disc examination showed no edema.\nElectrocardiogram (ECG) was normal except for sinus tachycardia (120 beat per minute).\nElectroencephalography (EEG) showed diffuse slow activity, predominately theta rhythms, with no signs of continuous status epilepticus.\nBrain computed tomography (CT) revealed reduced white–gray matter differentiation with effacement of cerebral sulci which was compatible with cerebral edema.\nBrain magnetic resonance imaging with venogram (Fig. ) and angiogram (Fig. ) MRI + MRV + MRA showed cerebral edema, bilateral and almost symmetric hyperintense T2 lesions with restricted diffusion in both frontal and occipital lobes (Fig. ), and no underlying cerebral venous thrombosis CVT.\nLumbar puncture was performed and revealed the following results: 10 lymphocytes, elevated protein (50 mg/dl), no RBCs, and negative gram stain. Whereas blood glucose was 50 mg/dl, CSF glucose was 70.\nOrdinary labs including Calcium, Albumin, MG, Na, K, creatinine, urea, LFTs, CBC, Plt, PT, PTT, and INR were all normal and troponin was negative.\nThe patient was admitted to the ICU and intubated.\nPhenytoin at dose 15 mg/kg was loaded with close cardiac monitoring, and a maintenance dose of 100 mg twice daily was initiated in the second day.\nA bolus (1 g/kg) of Mannitol was given intravenously, followed by a maintenance dose of 0.5 g/kg/8 h. GCS, consequently, improved to nine in 2 days.\nThe patient recovered completely and was discharged after a week of admission.
A 4-year-old boy with 25 kg weight presented to the Emergency Department of Imam Hospital of Sari in December 2013 due to tonic-clonic generalized seizures approximately 30 min ago. 3 h before seizure, his mother mistakenly gave him 2 spoons (amount 20–25 cc) lidocaine hydrochloride 2% solution instead of pediatric gripe. Seizure with generalized tonic-clonic occurred 3 times in home. On arrival at our Emergency Department, she was agitated and had confused speech with Glasgow coma scale score of 14/15. His initial blood pressure was 90/55 mmHg with a pulse rate of 130 beats/min.\nHis temperature was 36.9°C axial. Respiratory rate was 20 per min with a SpO2 of 96% on 2 L of nasal oxygen. Twitching movement with muscle spasm was noticed in the limbs. The pupils were 4 mm in diameter, equal and reactive, and no focal neurological deficit was found. His skin was normal. Bowel sound was normal, and the bladder was not palpable. An electrocardiogram (ECG) showed sinus tachycardia with a heart rate of 139 beats/min, and QT interval was 0.89 s. Neurologic examination was essentially unremarkable except for the depressed level of consciousness. The personal and medical history was unremarkable; including the absence of birthing trauma or febrile seizures. He had no history of use of other drugs.\nLaboratory studies while the patient received supplemental oxygen included an arterial blood gas with pH 7.30; pO2104 mm Hg; pCO239 mmHg; and HCO321. A complete blood count revealed white blood cells 10,400/mm3(31% polymorphonuclear leukocytes, 64% lymphocytes, 5% monocytes); hemoglobin 12 g; and hematocrit 35%. Blood chemistry studies were unremarkable except for an elevated glucose (219 mg %) obtained while the patient was receiving an IV line with 5% glucose. One day after admission; a repeat glucose level was 89 mg%.\nShortly after arrival at the Emergency Department, he developed one episode of brief generalized convulsion with upward gaze and episode lasting for around 30 s, 5 mg of IV diazepam was administered and a contrast-enhanced computed tomography (CT) scan of the brain was promptly performed. The latter showed no evidence of intracranial ischemic or hemorrhagic lesions. Serum lidocaine concentration 30 min after the onset of seizures was 5.1 μg/ml. There were no further seizures; the patient remained stable and was discharged 2 days after admission.