Case Study 2: Smelling Burning Rubber

Home » MEDCLIN530 » Virtual Neurology Clinical Case Studies: MEDCLIN530 » 10. Seizure » Case Study 2: Smelling Burning Rubber
Headshot of Dawn Elise DeWitt, MD, MSc, CMedEd, MACP, FRACP, FRCP-London · Senior Associate Dean, Collaboration for InterProfessional Health Education Research & Scholarship (CIPHERS)
Dawn Elise DeWitt
MD, MSc, CMedEd, MACP, FRACP, FRCP-London · Senior Associate Dean, Collaboration for InterProfessional Health Education Research & Scholarship (CIPHERS)
envelope icon

Case study 2: Rebekah—Smelling burning rubber

Tap the image to view the case.
A 37-year-old female presents to clinic to discuss a year-long history of brief episodes of “speaking gibberish,” which are preceded by a subtle smell of burning rubber. She says her husband never smells the burning smell, and says that during her “spells,” she will stare into space and appear to have word-finding difficulty. If she does form sentences, they are either incoherent or don’t “track with the conversation.” The patient says she isn’t aware of the changes in speech, but does endorse “spacing out” sometimes after she smells burning rubber.

She has no medical history, no substance use, and no family history of neurologic conditions. Her only medication is a combination OCP.

Question

This patient’s “spells” are most likely which of the following?

This patient’s presentation is classic for a focal seizure with altered awareness, involving altered awareness of her surroundings. It is very common for patients to report a “burning” smell prior to or during their seizures. They may not realize they have lost awareness of their surroundings.

follow-up Questions

The next step in evaluation for this patient (after a complete history and examination) would include an EEG and neuroimaging.

Assuming no mass lesion is found, this woman has a history of multiple episodes, and therapy is virtually always indicated after a second seizure (treatment after a single seizure is often deferred, but decisions should be individualized). First-line therapy would include choosing an appropriate medication. There are an increasing number of agents, and the choice of agent depends on expert evaluation and consideration of side effects and risks (e.g., pregnancy—Valproate should be avoided in women who are considering child-bearing, and folic acid supplementation is recommended in women who may become pregnant)—costs, and medication interactions, patient preference, etc. Broad-spectrum agents could include Valproate, Lamotrigine, Levetiracetam, Topiramate, etc. Narrow-spectrum agents (for focal seizures) include carbamazepine, gabapentin, etc. UpToDate has a detailed article on “Initial treatment of epilepsy in adults,” if you wish to explore this further.

Image credits

Unless otherwise noted, images are from Adobe Stock.