Clinical Practice and Cases in Emergency Medicine

Introduction: Seizures are a frequent reason for emergency department (ED) evaluation, and new-onset events carry a wide differential in which medication toxicity can be overlooked. Toxicity from seldomly prescribed drugs, such as theophylline, can be particularly challenging to recognize because they can cause nonspecific adverse effects, including palpitations, nausea, vomiting, and seizures. Although theophylline use was widespread in the 1980s, current prescribing patterns are unknown. Nevertheless, theophylline toxicity continues to result in ED visits and poison center calls. Because adverse effects may be acute or chronic, identifying theophylline toxicity remains difficult. 

Case Report: A 74-year-old woman presented to the ED with status epilepticus. After thorough history and extensive medical work-up, medication toxicity was suspected as the cause of her seizures. Upon further investigation, the patient was found to have theophylline toxicity. Prompt treatment was initiated resulting in cessation of seizures, highlighting the importance of considering medication toxicity in geriatric patients with new-onset seizures.

Conclusion: Theophylline toxicity can present with vague, multisystem symptoms, with status epilepticus being one of its most severe complications. Rapid identification of the underlying toxic etiology is essential to guide treatment and stop the seizures. Moreover, clinical suspicion should be elevated in the geriatric population related to frequent polypharmacy. In this case, confirming the medication history with a family member raised concerns for medication misuse, enabling timely intervention. Although rarely prescribed, physicians should counsel patients on the risks and adverse effects of theophylline and emphasize close monitoring.