A 24-year-old female patient has a known diagnosis of Localization-related epilepsy. Her focal seizures were ultimately controlled using an antiepileptic drug combination of levetiracetam and carbamazepine. The patient was brought to the emergency room 1 day by her mother when she noted that her daughter had "not been herself". On examination, the patient was confused and did not answer questions appropriately. She appeared to be awake and her neurological examination was without focal features. When asked questions, she parroted the words of the questions back to the examiner. According to her mother, she was compliant with her antiepileptic medications. There had been no other recent major changes in her activities, other than taking the ginseng extract that she had obtained from a coworker. Her coworker had apparently been growing natural remedies at home to use as medicinal agents. Our patient took the extract in an effort to improve her memory performance. In addition, she had obtained cannabis because she thought that it helped improve her epilepsy. When she arrived in the emergency department, laboratory testing revealed no significant abnormalities in her complete blood count and metabolic profile. The levetiracetam level was found to be within the ranges supplied by the laboratory. The carbamazepine level was low at 2 mg/dL. Neuroimaging studies were unremarkable. A urine drug toxicology screen was positive for cannabis. Subsequently, an EEG was obtained (Fig. 40.1).
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