A 30 year old white male was observed by three family members to have a first major motor seizure while eating breakfast at their home. His tonic-clonic movements and post-ictal lack of memory were similar to those of his wife's uncle, treated for epilepsy for many years. There was no significant history of fever, head trauma or dysglycemia, but he did describe recurrent headaches and asthma starting five years earlier, soon after he took up his present job. This work required him to chip slag from the walls of furnaces (1420oF) used to process aluminum bars into truck wheel castings, using an additive powder rich in aluminum and sodium fluoride. He wore a protective visor and leather apron but no respirator, despite repeated dust exposure. He was a heavy smoker and occasionally drank up to six beers a night at his home, but used no recreational drugs. Family history included no seizure disorders. His physical/neurological examination was normal except for obesity (BMI 45), a sore tongue and stocking-glove sensory deficits. Routine lab results were normal as were serum protein electrophoresis, lead, arsenic, mercury, cholesterol, triglycerides, antinuclear antibody screen, syphilis serology, thyroid-stimulating hormone, vitamin B-12, folic acid, and Lyme titer. An electrocardiogram and computed tomography of the brain were also normal. However, his blood aluminum was elevated (22 mcg/L; normal 0-9). Magnetic resonance imaging was normal except for two tiny areas of increased signal in the white matter of the left frontal lobe and pons. Electroencephalography showed frequent bursts of generalized high-voltage theta activity with photic stimulation, without focal abnormalities. The patient was advised to begin using respiratory protection and care in handling his work-clothes. Repeat blood aluminum was 5 mcg/L. He was treated with phenytoin but discontinued it after a few days because it affected his balance, despite sub-therapeutic blood levels. He has had no further seizures over the ensuing eight months.
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