A fitting tribute to Epilepsia partialis continua

• A case report of an elderly lady reported to be seizing in bed, with no past history of epilepsy but a history of alcoholism.
• The diagnosis of Epilepsia partialis continua was made following video evidence of evolution and prodrome.
• Video evidence is crucial in differentiating between the diagnosis of pseudoseizures and Epilepsia partialis continua.
• Always consider multiple hypotheses and remember that a patient's presentation can be atypical.
• Do not jump to conclusions and try to seek out evidence that challenges your initial diagnosis.

In July 2014, a 66 year-old lady presented to emergency department after having not been seen for 3 days. She was eventually found in bed not responding verbally. The ambulance service reported tonic-clonic seizures lasting 10–30 s every 3 min.The patient was treated for her seizures with phenytoin and additional benzodiazepines as required. Her seizure had temporarily resolved and she was admitted for investigations. She had no history of epilepsy or seizures.The history of alcoholism and lack of any substantial history of epilepsy, left the team considering whether this was an alcohol induced event or a pseudoseizure. The patient referred to no prodrome, no tongue biting/incontinence and lacked any convincing post-ictal phases. The seizures were no longer tonic-clonic but evolved into focal motor, with right-sided facial twitching lasting 2 min.Her investigations from bloods, lumbar puncture, computerised tomography scan and magnetic resonance imaging were all normal which led the team to consider whether this was a pseudoseizure. The patient appeared unconscious during seizures but was rousable during the episodes, although she claimed to have no recollection of them after.The seizures frequency settled at 30/day after being resistant to most antiepileptic regimes, except the eventual combination of Levetiracetam 1000 mg BD and Sodium Valproate 400 mg which left her seizure-free.However, the key evidence separating pseudoseizures and epilepsy partialis continua lay in collecting video evidence. This rare but important differential can often be overlooked but is especially important in the elderly, in whom this condition can mask serious underlying pathology.