Diagnostic Challenges in a Patient Presenting with Postictal and Interictal Psychosis: a case report and review

Epilepsy and psychotic disorders have a bidirectional correlation that is established in the literature. Psychosis of epilepsy (POE) describes a group of psychoses such as interictal and postictal psychosis. We present a case of overlapping symptoms of postictal and interictal psychosis making diagnostic clarification difficult. A 58-year-old female with a history of epilepsy since childhood, blunt traumatic brain injury, glioma status post right temporoparietal craniotomy and resection, HIV on HAART, depression, and alcohol use disorder, presented to the emergency room with hallucinations, paranoia, delusions, and agitated behavior after a seizure. The patient had an increase in seizure frequency over the past 9 months, now having one seizure a week. The disorientation, agitation, and hallucinations would resolve spontaneously in a short period of time but have persisted after recent seizures. Recent MRI revealed focal cortical and subcortical encephalomalacia with gliosis in the right superior temporal gyrus extending into the lingual gyrus and mesial temporal sclerosis. EEG showed multifocal 1 Hz sharp discharges in a ratio of 3:1 coming from the right temporal region, not correlated to any tonic-clonic events. This case has risk factors and presenting features for both interictal and postictal psychosis making accurate diagnostic clarification difficult during their stay. Differentiating between various POE can prove challenging as the evidence-based management differs. When an antipsychotic needs to be provided, we recommend risperidone as a suitable option given its relative safety in both seizure disorders and traumatic brain injuries secondary to neurosurgery.