How to manage a 21-year-old epileptic patient with recent seizure activity, on Levetiracetam, presenting with left lateral chest pain and a sensation of bone popping when breathing?

Management of Left Lateral Chest Pain with Seizure History in a Young Epileptic Patient

Immediate Priority: Optimize Seizure Control

Your patient's chest pain is likely musculoskeletal from seizure-related muscle contractions, but the critical issue is inadequate seizure control due to running out of levetiracetam—address this immediately before pursuing extensive chest pain workup. 1

Restore Adequate Antiepileptic Therapy

• Resume levetiracetam 1000mg BD immediately as the patient ran out last week and experienced seizure aura with near-collapse, indicating breakthrough seizure activity 2, 3
• The current dosing (1000mg BD = 2000mg/day total) is appropriate for maintenance therapy in established epilepsy, though some patients require up to 3000mg/day 1, 2
• Levetiracetam has rapid and complete absorption with high oral bioavailability, so therapeutic levels should be restored within 24-48 hours of resuming medication 2
• Verify medication compliance and access—the fact that the patient "ran out" suggests potential barriers to medication adherence that must be addressed to prevent future breakthrough seizures 1

Chest Pain Etiology Assessment

The left lateral chest pain with "bone popping" sensation is most consistent with intercostal muscle strain or costochondritis from tonic-clonic seizure activity rather than cardiac or pulmonary pathology, given: 4

• Temporal relationship to seizure (occurred after first seizure, recurred 3/7 ago coinciding with seizure aura episode) 4
• Mechanical characteristics (popping sensation with breathing, worse with deep inspiration, positional variation)
• Absence of trauma, normal vital signs (SpO2 99%, BP 118/70), clear lung fields, and no respiratory distress
• Tenderness and sensation of movement on palpation of left lateral chest wall
• Patient is young (21 years), ex-smoker who quit at 18-19 years

However, chest discomfort can rarely be an ictal phenomenon originating from temporal lobe seizures involving the amygdala 4. This patient's chest pain warrants consideration of this possibility given:

• Stereotyped nature of symptoms (recurrent, similar pattern)
• Association with seizure activity
• Temporal lobe epilepsy can present with autonomic symptoms including chest discomfort 4

Diagnostic Approach

Complete the ECG you've already ordered to exclude cardiac pathology, though this is low probability given age, presentation, and normal vital signs 1

If chest pain episodes are stereotyped and recurrent, consider:

• Neurology referral for evaluation of possible ictal chest discomfort 4
• Video EEG monitoring if episodes continue despite optimized seizure control, to determine if chest pain represents seizure semiology 4
• Brain MRI to evaluate for structural abnormalities (the patient has known epilepsy but etiology/imaging history not documented) 4

For the current musculoskeletal pain:

• NSAIDs (ibuprofen 400-600mg TDS PRN) for analgesia and anti-inflammatory effect
• Avoid opioids which lower seizure threshold
• Reassurance that post-ictal musculoskeletal pain typically resolves over 7-14 days
• Heat application and gentle stretching as tolerated

Critical Safety Measures

Address seizure risk factors immediately: 1

• Ensure patient has adequate supply of levetiracetam with prescription refills arranged
• Counsel on seizure precautions: avoid heights, swimming alone, driving restrictions per local regulations
• Educate about importance of medication adherence—missing doses significantly increases seizure risk 1
• Assess for other seizure triggers: sleep deprivation, alcohol use, stress 1

Monitor for status epilepticus risk: 1

• Patient experienced seizure aura with near-collapse last week, indicating high seizure susceptibility
• If seizure occurs lasting >5 minutes or recurrent seizures without full recovery between episodes, this constitutes status epilepticus requiring emergency treatment 1
• First-line treatment would be benzodiazepines (lorazepam 4mg IV), followed by additional levetiracetam 30mg/kg IV if seizures continue 1

Follow-Up Plan

• Neurology referral for optimization of seizure management, particularly given recent breakthrough activity and medication non-adherence 1
• Consider checking levetiracetam serum levels at follow-up to confirm therapeutic range and assess compliance 1
• Re-evaluate chest pain in 1-2 weeks—if persistent or worsening despite seizure control, pursue further investigation including possible video EEG 4
• Provide medical certificate as requested, but emphasize importance of medication adherence and seizure precautions for safety

Common Pitfalls to Avoid

• Do not attribute all symptoms to anxiety or musculoskeletal causes without ensuring adequate seizure control first—breakthrough seizures are the immediate threat to this patient 1
• Do not prescribe medications that lower seizure threshold (tramadol, bupropion, certain antibiotics) for chest pain management 1
• Do not overlook medication access barriers—if cost or availability caused the patient to run out, address this with social work referral or alternative medication access programs 1
• Do not dismiss the possibility of ictal chest discomfort, though rare, as this can lead to delayed diagnosis and inappropriate cardiac workup 4