Case Report on Epilepsy with Cough Aura

The case study is aimed at providing a more thorough analysis of a case of Epilepsy presented with an unusual aura of cough. The study hopes to generate an interest for further studies into the topic and focuses on abnormal unusual presentations of auras. Cough as an aura is not a common presentation. Any stereotyped repeated clinical phenomenon should consider being epileptic in its origin.


Introduction
The definition of Epilepsy and Epileptic seizures, as per the International League Against Epilepsy (ILAE) in 2005, states that an epileptic seizure is a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain [1].Epilepsy is a disease characterized by an enduring predisposition to generate epileptic seizures and by the neurobiological, cognitive, psychological, and social consequences of this condition [1].

Case Presentation
A 45-year-old Comoros man presents to the hospital with history of attacks of seizure 2 to 3 times a day since the past 20 days.He also gives history of a dry cough for the first 15 days followed by a productive cough with white sputum associated with fever and dyspnea for the next 5 days.According to the patient's wife, he would lose consciousness after severe cough followed by development of a tonic-clonic jerk of the right arm.The seizure is also associated with dripping saliva and foaming from the mouth.The entire episode lasts for around 60 seconds.
The patients' past medical and surgical history includes an appendectomy done in 2011.He does not have any allergies or co-morbidities.His family history is significant for type 2 diabetes mellitus.He gives history of smoking one pack of cigarette per day and says he quit drinking alcohol.
On examination the patient had a pulse of 72 beats/minute, blood pressure of 120/70 mmHg, temperature of 36.2˚C and respiratory rate of 21 breaths/minute.He is alert, oriented, conscious and stable.There are no signs of dehydration of peripheral edema.
Respiratory examination revealed bilateral equal air entry with scattered sonorous rhonchi.CNS examination revealed intact sensation with a power of 5/5.
MRI of the brain without contrast as seen in Figure 1 revealed bilateral basal ganglia calcifications.It also revealed bilateral maxillary and left ethmoid sinusitis along with hypertrophied left inferior nasal turbinate.
EEG report in Figures 2-4 shows no significant changes upon photic stimulation.During hyperventilation the patient developed an unexplained episode of cough, which was followed by a myoclonic jerk of the right arm and a post-ictal confusion state making automatic movements.The scan revealed simultaneous bouts of spikes and slow waves lasting for a few seconds during this event.The patient was not able to recall any part of the event.As a whole the EEG picture is suggestive of generalized epileptic activity.
Upon follow-up, the patient was compliant with the medication and revealed that the frequency of seizure attacks had drastically reduced along with the cough.

Discussion
Although studies have shown cases of epilepsy with aura such as somatosensory aura [2], olfactory aura [3], abdominal aura [4], etc., no case regarding epilepsy with cough aura has been reported.Several studies reported that any aura involved with epilepsy was developed mostly in a mesial temporal epilepsy.A study showed that majority of their patients with a mesial temporal epilepsy developed some sort of somatosensory aura mostly in the form of a tingling sensation in the upper extremities [5].The study based on abdominal aura showed that development of an abdominal aura was more common in patients with temporal lobe epilepsies compared to those patients with an extra temporal epilepsy.Among the temporal lobe epilepsies it was also reported that aura was more common in mesial temporal epilepsy than neocortical epilepsy [4].The study based on olfactory aura reported that their patients MRI scans revealed structural lesions in the mesial temporal structures and two of their patient's scans even revealed structural lesions in the amygdale [3].
The presentation of Epilepsy with a cough aura is uncommon and not many studies report of similar cases.For this reason, it is essential that more research must be done, as it is highly probable that Epilepsy can present with other unusual symptoms besides cough.

Conclusion
Epileptic seizures are transient occurrences of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain.The patient in this case lost consciousness after hyperventilation with severe cough followed by development of a tonic-clonic jerk of the right arm, which lasted for around 60 seconds.MRI revealed bilateral basal ganglia calcifications with bilateral maxillary and left ethmoid sinusitis along with hypertrophied left inferior nasal turbinate.Frequency of the attacks decreased dramatically with nebulization, antibiotics, steroids and anti-epileptics.There have been many studies showing epilepsy with somatosensory, olfactory and abdominal auras, but not particularly with cough.More evidence-based research must be conducted with regard to this case presentation.

Figure 2 .
Figure 2. EEG report showing normal rhythm before cough.