Abstract
A fifty-year-old male was diagnosed as having systemic lupus erythematosus (SLE), complicated by Lupus nephritis, which was confirmed on kidney biopsy to be classV of the WHO classification in January 1986. The patient began to develop epilepsy seizures since September 2004. Brain MRI scan findings suggested that the epilepsy was likely associated with multiple intracranial ischemic lesions. Afterwards, the patient had the repetition of epilepsy seizures on an irregular basis, regardless of his regular taking of an oral anticonvulsant such as phenobarbital. In addition, his renal dysfunction advanced slowly, and reached end-stage renal disease in July 2006. On November 16, 2007, he was emergently admitted to our hospital due to a generalzed epileptic seizure after hemodialysis treatment at a dialysis clinic. Blood examination showed that blood concentrations of phenobarbital rather varied among the measurements after taking the drug. After switching the route of drug administration to intramuscular injection, the blood concentration of phenobarbital increased and stablized, and then the seizures disappeared. We thought that this could be associated with poor control of epilepsy despite taking regular oral medication. To study concurrent gastroduodenal illness, endoscopic examination was performed and the existence of a large Zenker's diverticulum was detected in the upper part of esophagus. It was likely that an orally administered anticonvulsant tablet could become trapped in the esophageal diverticulm, resulting in a decrease in drug concentration levels in blood. This might have been a cause of poor epilepsy control in this case. Therefore, an endscopic stapler was used to perform esophagodiverticulostomy, since this stapling technique is considered safe and effective in such compromised individuals as dialysis patients, compared with other surgical techniques. The prevalence of Zenker's diverticulum is quite low in the Japanese population, and it is often overlooked because it hardly ever causes clinical symptoms. To our knowledge, there are no previous reports that the existence of Zenker's diverticulum significantly affected treatment of a comorbidity. We herein report a hemodialysis patient with a large Zenker's diverticlum that was considered responsible for poor control of epilepsy being treated by an oral anticonvulsant.
