Tommy, a robust 7-year-old second grader is brought to the Emergency Room after experiencing a seizure on
the playground during morning recess.
Patient History:
● Tommy was apparently walking out of his school onto the playground in the company of his second
grade teacher at the onset of the seizure. The seizure was not in response to any physical trauma. ● The
patient has never demonstrated any form of seizure in his lifetime. Mother and father, upon questioning, do not
remember any instances of Tommy “blacking out”, even for a second or two. He has an unremarkable
neurological history, no history of developmental delay and is at the top of his class in school.
Physical Examination:
● Physical exam confirms the lack of any evidence of physical trauma. No bruises or bumps are evident
upon physical examination. ● ECG: normal ● CBC: normal ● HEENT examination: normal ● Lungs: normal
● Cardiovascular examination: normal ● Abdomen: normal
● Genitourinary examination: normal ● Musculoskeletal examination: normal ● Skin/Integument: normal, with
no evidence of neurocutaneous syndromes.
Tommy is admitted to the hospital for observation and a neurological work-up. The following are the
neurological findings:

● EEG ○ Awake EEG demonstrates a normal background with minimal focal or generalized slowing.
Intermittent focal discharges were observed in the temporal and parietal lobes.
○ Sleep EEG demonstrated the appearance of more generalized paroxysmal abnormalities. Drowsiness or
early sleep produced an increase in frequency and generalization of the discharges. Maximal activation of the
EEG abnormalities occurred initially in stages 1 and 2 or non-REM sleep, but did not maximize until stages 3
and 4 of REM sleep.
Tommy was put on a regimen of anticonvulsant medication in an effort to stabilize the EEG findings. He was
scheduled for a follow-up neurological consult in the next 30-90 days. He was scheduled for a 2-week follow-up
appointment with his primary care physician, and a follow-up with the neurologist in three months.
Tommy was readmitted to the hospital within 4 weeks of his initial neurological work-up by his parents. No new
seizures had been observed. However, Tommy’s language skills had demonstrated marked deterioration within
the past 7-10 days. In addition, Tommy had started to demonstrate behavioral and neuropsychological
problems. Tommy’s parents, as well as his school counselor, described him as aggressive, hyperactive and
with a decreased attention span. Indeed, Tommy’s school counselor stated in his I.E.P. (individualized
educational plan) as “demonstrating autistic characteristics within the last 10 days”.
A second neurological work-up was conducted, with the following results:
● Reading and writing skills were preserved
● Tommy demonstrated a significant loss in the ability to recognize familiar sounds. However, alert
responses to sound and tonal audiograms were normal.
● Tommy demonstrated a reduced capability to localize sounds.
● In the intervening time since his first consult Tommy’s language skills have deteriorated significantly.
● An MRI was repeated, and like the initial MRI, all results were normal.
● EEG results were clinically identical to those seen at the initial consult.
● A fluoro-deoxyglucose positron emission tomography (FDG-PET) test revealed decreased metabolism in the
left temporal lobe. Hypometabolism was especially prominent in the middle temporal gyrus of the left temporal
lobe.
Utilizing sound anatomical logic, consider the following questions:
1.What is your diagnosis for this patient?
2.What were the key symptoms that lead you to this diagnosis?
3.Give a detailed explanation of the part or parts of the brain involved, and how this/these location(s)
participate together in normal speech patterns.
4.Explain how Tommy’s diagnosis causes an alteration, if any, in the process you outlined in question #3
above.If his diagnosis does not tie in with #3, then outline how the affected portion of the brain and processes
involved would function in a neurologically normal individual, and then compare and contrast them to Tommy’s
current condition.