What is the best course of action for a patient with a seizure disorder, PTSD, and mixed connective tissue disorder presenting with olfactory hallucinations, tunnel vision, and morning headaches while taking Keppra (levetiracetam), gabapentin, and sertraline?

Urgent Neuroimaging and Neurological Evaluation Required

This patient requires immediate brain MRI with and without contrast to evaluate for a structural lesion, as the combination of olfactory hallucinations (olfactory aura), progressive visual field defects (tunnel vision), and positional morning headaches strongly suggests a space-occupying lesion, most likely a brain tumor. 1

Clinical Red Flags Present

This symptom constellation represents classic warning signs for increased intracranial pressure and/or a focal brain lesion:

• Olfactory hallucinations (phantosmia) for 5 months suggest temporal lobe involvement, which can represent either seizure aura or direct tumor involvement 1
• Progressive tunnel vision (bilateral peripheral visual field loss) for 3 weeks indicates possible papilledema from elevated intracranial pressure or compression of visual pathways 1
• Morning headaches that worsen with position are characteristic of increased intracranial pressure, as intracranial pressure rises during recumbent sleep 1

Immediate Diagnostic Workup

Neuroimaging Priority

• Brain MRI with and without contrast is the gold standard and should be obtained urgently 1
• If MRI is unavailable or contraindicated, CT scan of the brain with contrast is acceptable but less sensitive 1
• The imaging should specifically evaluate for mass lesions, particularly in temporal and occipital regions given the olfactory and visual symptoms 1

Ophthalmologic Examination

• Fundoscopic examination must be performed immediately to assess for papilledema, which would confirm elevated intracranial pressure 1
• Formal visual field testing should be obtained if papilledema is present 1

Neurological Consultation

• Immediate neurology consultation is warranted given the progressive nature and constellation of symptoms 1

Seizure Medication Considerations

Current Regimen Assessment

The patient's current Keppra (levetiracetam) dose of 1000 mg twice daily is within therapeutic range 2, 3. However:

• Levetiracetam does not interact with her other medications (gabapentin, sertraline) and has a favorable safety profile 2, 4
• Sertraline is appropriate for PTSD and is considered safe in epilepsy patients, with low seizure risk 4
• The combination of levetiracetam and sertraline is acceptable, as SSRIs like sertraline are first-line antidepressants in people with epilepsy 4

Medication Adjustments to Avoid

• Do not empirically increase antiseizure medications until structural pathology is ruled out, as these symptoms may represent tumor-related phenomena rather than breakthrough seizures 1
• Avoid adding enzyme-inducing antiepileptic drugs (phenytoin, carbamazepine, phenobarbital) that could complicate future treatment if a tumor is found 2

Management Algorithm

Step 1: Emergency Evaluation (Within 24 Hours)

1. Obtain brain MRI with and without contrast 1
2. Perform fundoscopic examination for papilledema 1
3. Complete neurological examination with formal visual field assessment 1

Step 2: If Structural Lesion Identified

• Neurosurgical consultation for potential biopsy or resection 1
• Continue current antiseizure medication (levetiracetam) as seizure prophylaxis 1
• Initiate dexamethasone 4-16 mg daily in divided doses if significant vasogenic edema is present 1

Step 3: If No Structural Lesion Found

• Consider EEG to evaluate for non-convulsive seizures or temporal lobe epilepsy 1
• Evaluate for other causes of olfactory hallucinations (sinusitis, migraine with aura) 1
• Reassess visual symptoms with formal ophthalmology evaluation 1

Critical Pitfalls to Avoid

• Do not attribute these symptoms to psychiatric causes (PTSD) without excluding structural pathology first 1
• Do not delay imaging based on "stable" seizure control, as these are new and progressive neurological symptoms 1
• Do not start prophylactic anticonvulsants if the patient has no history of seizures related to these new symptoms, but continue current therapy 1
• Avoid medications that lower seizure threshold if a tumor is found, including avoiding bupropion, clomipramine, or high-dose antipsychotics 5, 4

Mixed Connective Tissue Disease Considerations

While MCTD can cause neurological complications, these typically manifest as myelopathy (spinal cord involvement) rather than brain lesions 6, 7. However:

• MCTD patients may have increased risk of CNS vasculitis, which could present with focal neurological symptoms 6
• If imaging shows inflammatory changes rather than mass lesion, consider high-dose corticosteroids and rheumatology consultation 6, 7

The temporal progression of symptoms (olfactory hallucinations for 5 months, followed by tunnel vision for 3 weeks, and now morning headaches) suggests an expanding mass lesion until proven otherwise, making urgent neuroimaging the absolute priority. 1