Epilepsy in Kids: Problems Beyond Seizures

Soniya Tambe*

Consultant Neurologist, Kauvery Hospital, Banglore-Electronic City, India

*Correspondence: soniyatambe04@gmail.com

An illustrative case report

An 8-year-old male child, second child born of non-consanguineous parentage, presented with history of seizures since the age of 5 years. There were total of five episodes of seizures since then. Semiology was described as Generalised Tonic-Clonic seizures, the trigger being fever most of the time. Last episode was one month prior, during which child had seizure cluster during tapering of Valproate. He required ICU care. Child was started on phenytoin during admission as he had gained weight and lost hair while on Valproate. He was placed on phenytoin 5mg/kg/day and valproate 30mg/kg/day.

He had also been diagnosed as Attention Deficit Hyperactivity Disorder (ADHD) and Learning Disability and was given Atomoxetine, Risperidone and Clonidine in the past. As he had significant drowsiness on those medications, currently he was only on tablet clonidine adjusted to weight.

He was brought to Neurology clinic with history of itchy skin rash for 2 weeks, imbalance while walking, drowsiness, nausea and vomiting for 3 days.

On examination, he preferred to lie on examination bed, conscious and oriented. There was no nystagmus or focal deficits. However, gait was grossly ataxic with swaying to either side while walking. He also had papular rash over limbs and trunk, with scabbing.  He had also neurocutaneous markers in the form of Café au lait spots mainly over lower trunk, and recently noticed over chest as well.

Clinically he was suspected to have Phenytoin induced Ataxia. He was advised tapering of Phenytoin and was continued on Tab Valproate.

Blood investigations showed normal counts, normal LFTs except mildly elevated alkaline phosphatase and elevated Blood Ammonia – 172 umol/L (16-60 umol/L). Blood levels of Phenytoin were borderline while on tapering doses at 19 ug/ml (10-20 ug/ml) while Valproate levels were normal at 89 ug/ml (50-100 ug/ml). MRI Brain was normal and so was the EEG.

Take home lesson

Epilepsy frequently comorbids with ADHD in pediatric age group. Treating epilepsy in ADHD can be challenging. Only few antiepileptic drugs are considered safe in presence of ADHD. Sodium Valproate, Lamotrigine and Carbamazepine are considered safe in ADHD. Some antiepileptics adversely affect ADHD, for example, Phenobarbitone, Gabapentine and Topiramate. Our patient had weight gain issues and elevated Ammonia while on Valproate. He is prone for antiepileptics induced skin rash; hence Lamotrigine and Carbamazepine are to be used carefully. His HLA 1502 has been sent to look for susceptibility for Steven Johnson syndrome and plan is to switch to Carbamazepine.

With advent of recent development of connectomes and frequent use of functional use of MRI, Epilepsy is no more considered to be a focal brain problem. Epilepsy affects many networks in the brain like networks involved in language, learning and attention. Hence comorbidities are frequent. Child is under follow up with paediatric psychiatrist for ADHD. He has significant problems in attending school. IQ assessed was 92. His verbal learning has been good. He needs more training in writing area.

In recent times Genetics studies in epilepsy are not an exception, but the norm. As this patient has Neurocutaneous markers, Clinical Exome sequencing for Epilepsy has been sent. It helps us in prognostication and anticipation of associated disorders.

References

  1. Parisi P, Moavero R, Verotti A, et al. Attention deficit hyperactivity disorder in children with epilepsy. Brain Dev 2010;32:10-6.
  2. Matricardi S, Farello G, Operto FF, et al. What are the challenges with pharmacological management of epilepsy in patients with ADHS. Expert Opin Pharmacother. 2020;21:737-9.
  3.  Andrade DM, Minassian BA. Genetics of epilepsies. Exp Rev Neurother. 2007;7:727-34.
Dr.-Soniya-Tambe

Dr. Soniya Tambe

Consultant Neurologist

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