Overcoming Diagnostic Uncertainty: A Case of Temporal Lobe Epilepsy With Normal MRI and EEG

Temporal lobe epilepsy (TLE) can present in a variety of ways and is challenging to diagnose. While MRIs are the gold standard for detecting structural lesions and EEGs can identify epileptiform discharges, relying solely on these diagnostic methods can result in underdiagnosis or misdiagnosis of the condition. Seizures with motor components may manifest as unusual behavior; anxiety, psychosis, and other psychiatric conditions can occur in conjunction with or independently of seizure activity. In cases where diagnostic testing yields negative results but the history strongly suggests seizure-like activity, practitioners should not hesitate to initiate antiepileptic medications. Here, we present the case of a patient who exhibited behavioral problems, including shouting religious slogans and experiencing recurrent loss of consciousness, either occurring together or separately, while lacking awareness. The patient had a history of type 2 diabetes and no relevant family history. An extensive multidisciplinary evaluation was performed, including EEG and MRI, all of which returned normal results. Given the high clinical suspicion of TLE, the patient was started on the antiepileptic medication divalproex sodium. After six months of treatment, there was a significant improvement in all symptoms. This case highlights the importance of considering TLE in patients with suggestive clinical features even when initial diagnostic tests are normal and underscores the potential efficacy of early antiepileptic treatment in managing symptoms effectively.