Epileptic seizures as a manifestation of cow's milk allergy: a studied relationship and description of our pediatric experience

Is Autonomic Nervous System Involved in the Epileptogenesis in Preterm Neonates?

Autonomic nervous system dysfunction has been described with focal and generalized epileptic seizures; occurring during their ictal, interictal, or postictal states. International League Against Epilepsy Seizure Classification Manual defines autonomic seizures as a distinct alteration of autonomic nervous system function involving cardiovascular, pupillary, gastrointestinal, sudomotor, vasomotor, and thermoregulatory functions. Autonomic seizures represent a great challenge for neonatologists and neurophysiologists; and distinguishing between ictal and non-ictal autonomic changes in neonates is rarely straightforward, especially in the premature ones. To avoid overdiagnosis and overtreatment, International League Against Epilepsy and the American Clinical Neurophysiology Society currently require electrographic correlation for any seizure diagnosis, including preterm neonates. There is very little scientific evidence about the pathophysiology of autonomic seizures. The data reporting on their incidence, clinical features, and diagnostic pathway is also insufficient. In this paper, we hypothesize that in the developing brain of preterm neonates, seizures involving deeper autonomic networks and subcortical structures might not propagate sufficiently to the cortex, and therefore the association of the seizures with specific ictal electrographic changes on surface electroencephalogram might be lacking. We propose considering autonomic seizures in the differential diagnosis of unexplained autonomic changes in neonates, especially preterm neonates, even in the absence of clear initial electrographic correlation. Unexplained autonomic changes could therefore be thought of as a “seizure alarm” in this population.

Narcolepsy-Like Sleepiness: A Symptom of Immediate-Type Reactions in Food-Allergic Children

BACKGROUND

It has been reported that sometimes children fall asleep and can barely be woken up during allergic reactions on food ingestion. Nevertheless, to date, there is scarce data on narcolepsy-like sleepiness as a symptom of allergic reactions.

OBJECTIVE

To investigate the frequency of narcolepsy-like sleepiness during oral food challenges and characterize this symptom regarding comorbidities, eliciting allergens, and severity of reactions.

METHODS

Children with immediate-type allergic reactions during oral food challenges (89% were double-blind, placebo-controlled) have been analyzed in this study. Narcolepsy-like sleepiness was defined as a somnolent condition during which patients could barely be woken up again, occurring within 2 hours of food intake and which was not due to drug side effects. Logistic generalized estimating equations were used to explore the effect of age, severity of reactions, and eliciting allergens on the occurrence of narcolepsy-like sleepiness.

RESULTS

In 106 (12.5%) of all 848 food-allergic children, narcolepsy-like sleepiness was observed during oral food challenges. Children with eczema had a higher risk of developing narcolepsy-like sleepiness (P = .006). Narcolepsy-like sleepiness occurred most often due to an allergic reaction to hazelnut (P = .009) or other tree nuts (P = .003). Moderate to severe reactions occurred more often than mild reactions (P = .026; odds ratio, 1.521; 95% CI, 1.051-2.202) in children with narcolepsy-like sleepiness.

CONCLUSIONS

We were able to show for the first time that narcolepsy-like sleepiness is a frequently occurring clinical manifestation of immediate-type allergic reactions on food ingestion in childhood. Further research is needed to unravel the underlying mechanisms to gain a deeper insight into this underestimated symptom.

Inflammation-related genes and immune infiltration landscape identified in kainite-induced temporal lobe epilepsy based on integrated bioinformatics analysis

BACKGROUND

Temporal lobe epilepsy (TLE) is a common brain disease. However, the pathogenesis of TLE and its relationship with immune infiltration remains unclear. We attempted to identify inflammation-related genes (IRGs) and the immune cell infiltration pattern involved in the pathological process of TLE via bioinformatics analysis.

MATERIALS AND METHODS

The GSE88992 dataset was downloaded from the Gene Expression Omnibus (GEO) database to perform differentially expressed genes screening and weighted gene co-expression network analysis (WGCNA). Subsequently, the functional enrichment analysis was performed to explore the biological function of the differentially expressed IRGs (DEIRGs). The hub genes were further identified by the CytoHubba algorithm and validated by an external dataset (GSE60772). Furthermore, the CIBERSORT algorithm was applied to assess the differential immune cell infiltration between control and TLE groups. Finally, we used the DGIbd database to screen the candidate drugs for TLE.

RESULTS

34 DEIRGs (33 up-regulated and 1 down-regulated gene) were identified, and they were significantly enriched in inflammation- and immune-related pathways. Subsequently, 4 hub DEIRGs (Ptgs2, Jun, Icam1, Il6) were further identified. Immune cell infiltration analysis revealed that T cells CD4 memory resting, NK cells activated, Monocytes and Dendritic cells activated were involved in the TLE development. Besides, there was a significant correlation between hub DEIRGs and some of the specific immune cells.

CONCLUSION

4 hub DEIRGs (Ptgs2, Jun, Icam1, Il6) were associated with the pathogenesis of TLE via regulation of immune cell functions, which provided a novel perspective for the understanding of TLE.

Hypoallergenic diet may control refractory epilepsy in allergic children: A quasi experimental study

Recent data has suggested a definitive role for inflammatory processes in the pathophysiology of epilepsy. In this study we hypothesized that food allergies, as chronic inflammatory processes, underlie the pathophysiology of refractory idiopathic epilepsy and investigated whether food elimination diets may assist in managing refractory epilepsy. The study was conducted on 34 patients up to 16 years of age with refractory convulsions who attended the Allergy Outpatient Clinic, Mofid Children Hospital between 2015 and 2016 with youngest and oldest participants at ages of 3 months and 16 years old, respectively. The participants were categorized into three groups according to the results of skin prick test and serum specific IgE measurements. Elimination diets were instituted for the patients with non IgE-mediated and mixed food allergies. The study was conducted for a period of 12 weeks. The participants were assessed for at least 50% reduction in number of seizures following the intervention. There was a significant reduction in number of seizures (p < 0.001) following the intervention. Seventeen patients (50%) did not experience any seizures after 8 weeks of treatment and 12 patients (35%) had a significant (51-99%) decrease in the number of their seizures. Five patients did not show any changes in their daily seizure frequency. The obtained data suggest that food allergy may play a role in triggering refractory epilepsies and their adequate response to treatment. A trial of elimination diet showed more than 50% seizure reduction in more than 85% of the children studied. However, we believe these results are preliminary and they motivate a fully controlled study in the future.

The effects of dairy products on seizure tendency in mice

Epilepsy is a common neurological disorder which occurs as a result of a spontaneous electrical discharge in the brain. According to recent studies there might be a relationship between specific diet and seizure occurrence. Casein is an important protein of milk which often causes hypersensitivity. It seems the release of inflammatory cytokines during the process of immune system response alter the blood-brain-barrier (BBB) integrity and lead to neuronal inflammation which could constitute on epileptogenic focus. On the other hand, several studies represent full-fat milk or higher fat dairy products as an effective anti-inflammatory factor which elevate seizure threshold. The aim of present study was investigation of acute and chronic effects of dairy products including dough (a yogurt-based beverage), cheese, low and high fat yogurt and milk on pentylenetetrazole (PTZ)-induced seizures or electroshock in mice. The results of study indicated that lower fat dairy products reduced seizure threshold in intravenous PTZ-induced seizure as well as reduction in myoclonic and clonic jerk latencies in intraperitoneal PTZ-induced seizure. High fat products or cheese reduced seizure activity in both PTZ-induced models. Meanwhile both acute and chronic administration of dairy products had no effect on an electroshock-induced seizure. Therefore, diet-related seizures may depend upon the method which seizures are provoked.

Milk nutrition and childhood epilepsy: An ex vivo study on cytokines and oxidative stress in response to milk protein fractions

We present a pilot study on the effects of milk protein fractions [αS1-casein (CN), αS2-CN, κ-CN, β-CN, and a mix of α-lactalbumin (α-LA) and β-lactoglobulin (β-LG)] from different animal species (bovine, ovine, and caprine) on pro- and anti-inflammatory cytokines and oxidative status in cultured peripheral blood mononuclear cells from children with generalized epilepsy. Peripheral blood mononuclear cells (PBMC) were obtained by density gradient from blood of 10 children with generalized epilepsy (5 males; mean age 33.6 ± 5.4 mo) and 10 controls (5 males; mean age 35.6 ± 6.8 mo). Children with epilepsy were grouped according to cytokine levels as follows: children with epilepsy having low levels of cytokines not different from those of control children (LL-EC); children with epilepsy having cytokine levels at least 5-fold higher (medium levels) than those of control children (ML-EC); and children with epilepsy having cytokine levels at least 10-fold higher (high levels) than those of control children (HL-EC). The production of tumor necrosis factor-α (TNF-α), IL-10, IL-6, and IL-1β was studied in cultured PBMC incubated with αS1-CN, αS2-CN, κ-CN, β-CN, and a mix of α-LA and β-LG from bovine, caprine, and ovine milks. The levels of reactive oxygen and nitrogen species (ROS/RNS) and catalase activity were assessed in cultured supernatant. In the HL-EC group, β-CN from small ruminant species (ovine and caprine) induced the highest levels of TNF-α, whereas PBMC incubated with αS2-CN from ovine milk and the mix of β-LG and α-LA from all tested milk species had the lowest levels of TNF-α. Within the HL-EC group, production of IL-1β was higher for bovine and ovine αS2-CN fractions and lower for caprine and ovine β-CN and κ-CN. In the HL-EC group, IL-6 was higher in cultured PBMC incubated with αS2-CN from bovine and ovine milk than from caprine milk. The cytokine IL-10 did not differ among milking species. The highest levels of ROS/RNS were found after incubation of PBMC with the β-CN fraction in bovine milk. Catalase activity was higher in PBMC cultured with β-CN isolated from bovine and caprine milk and with αS1-CN from ovine milk.

An unusual case of infant seizures with anaphylaxis to wheat

Wheat allergy is one of the commonest food allergies in childhood and it typically presents with IgE mediated reactions, including anaphylaxis. Seizures are not typically reported to be a direct manifestation of anaphylaxis, though it can occur secondary to hypoxia following significant haemodynamic compromise. We describe a case of a previously well infant, who presented with anaphylactic shock to wheat and responded well to the initial management, but subsequently developed a cluster of brief generalised tonic clonic seizures without any ongoing haemodynamic instability. The tryptase level that was performed at 4-5 hours post reaction was raised at 49.1 µg/L. Skin prick test to wheat, wheat specific IgE, the omega-5 gliadin IgE were positive. Extensive work-up was performed to look for an underlying cause of seizures and all returned negative. To our knowledge, this is the first case report describing an unusual presentation of multiple seizures in a young infant, in association with an anaphylactic episode. In the absence of any other seizure provoking factor and underlying cause, we believe the association is more likely causative than coincidental.

Epidemiology and diagnostic and therapeutic management of febrile seizures in the Italian pediatric emergency departments: A prospective observational study

AIM

Febrile seizures (FS) involve 2-5% of the paediatric population, among which Complex FS (CFS) account for one third of accesses for FS in Emergency Departments (EDs). The aim of our study was to define the epidemiology, the clinical, diagnostic and therapeutic approach to FS and CFSs in the Italian EDs.

METHODS

A multicenter prospective observational study was performed between April 2014 and March 2015. Patients between 1 and 60 months of age, randomly accessing to ED for ongoing FS or reported FS at home were included. Demographic features and diagnostic-therapeutic follow-up were recorded. FS were categorized in simple (<10min), prolonged (10-30min) and status epilepticus (>30min).

RESULTS

The study population consisted of 268 children. Most of the children experienced simple FS (71.65%). Among the 68 (25.37%) patients with complex FS, 11 were 6-12 month-old, accounting for 45.83% of all the infants with FS in the younger age group. No therapy has been administered at home in 76.12% patients; 23.51% of them received endorectal diazepam and only 1 patient received buccal midazolam. At arrival at ED, no therapy was necessary for 70.52% patients; 50.63% received endorectal diazepam and 17.72% an i.v. bolus of midazolam. Blood tests and acid-base balanced were performed respectively in 82.09% of cases. An electroencephalogram at ED was performed in 21.64% of patients. Neuroimagings were done in 3.73% of cases. A neurologic consultation was asked for 36 patients (13.43%).

CONCLUSION

this is the first study assessing epidemiologic characteristics of FS in the Italian pediatric population, evidencing a higher prevalence of CFSs in children younger than 12 months of age and opening a new research scenario on the blood brain barrier vulnerability. On a national level, our study showed the need for a diagnostic standardized work-up to improve the cost/benefit ratio on CFS management.

The Gut-brain Axis: A New Pathogenic View of Neurologic Symptoms - Description of a Pediatric Case

Recent literature data have given emphasis to the relationship between gastrointestinal (GI) disorders and neurologic diseases, underlying a new pathogenic pathway: The so-called "gut-brain axis." Herein, authors report a case of a 10-month-old male infant, admitted for drug-resistant epilepsy, associated with irritable behavior and GI discomfort, secondary to cow's milk protein allergy. Seizures were described by parents as upward eye movements that were mostly deviated to the right and were associated with slight extension of his neck. They were infrequent at first, but had increased gradually during the course of 3 days (up to 15-20 times/day). No anticonvulsant therapy was effective. Only a cow's milk protein-free diet, accidentally started during a gastroenteritis episode, was effective in stopping seizures. Our case underlines the peculiar vulnerability of the blood-brain barrier under 1 year of age, for which children of this age group experience neurologic manifestations during episodes of systemic inflammation.

Levetiracetam in Neonatal Seizures as First-line Treatment: A Prospective Study

AIM OF THE STUDY

The aim of this study is to evaluate the efficacy and safety of levetiracetam (LEV) as first-line treatment of neonatal seizures.

MATERIALS AND METHODS

This study was conducted in patients of Neonatal Intensive Care Unit of Santo Bambino Hospital, University of Catania, Italy, from January to August 2016. A total of 16 neonates with convulsions not associated with major syndromes, which required anticonvulsant therapy, were included and underwent IV LEV at standard doses.

RESULTS

All patients responded to treatment, with a variety range of seizure resolution period (from 24 h to 15 days; mean hours: 96 ± 110.95). No patient required a second anticonvulsant therapy. Regarding safety of LEV, no major side-effects were observed.

CONCLUSIONS

To our knowledge, it is one of the few studies confirming the efficiency of LEV as first-line treatment in seizures of this age group. LEV was effective in resolving seizures and was safely administered in the current study.

Nervous system involvement in clinical peripheral inflammation: A description of three pediatric cases

Latest research data have emphasized the interaction between the nervous and the immune systems. In this regard, it has been demonstrated that the disruption of the blood-brain barrier (BBB) secondary to peripheral inflammation may play a key role in this relationship. This assumption is linked to recent findings according to which units that constitute the BBB are not only simply neurologic but have also been reconsidered as "neurovascular" elements, through which immune system molecules are vehiculated within the central nervous system (CNS). Herein, we report two cases of food allergy (FA) and one case of infective gastroenteritis, associated with a spectrum of neurologic disorders involving both the CNS and the peripheral nervous system (PNS), postulating some etiopathogenic hypotheses to explain the link between peripheral inflammation and diseases of the nervous system (NS). Three pediatric cases of secondary NS involvement after gastrointestinal (GI) inflammation of different nature have been reported. The first case highlights the link between FA and CNS; the second one is based on a description of a link between GI infection and CNS involvement while the third one describes the relationship between FA and PNS. The importance of these reports relies on the clinical demonstration of a link between the immune system and the NS. The relationship between immune system and NS seems to have pleiotropic aspects, involving different areas of the NS, such as CNS and PNS, which also seem to be in some way interconnected.

Epilepsy and innate immune system: A possible immunogenic predisposition and related therapeutic implications

Recent experimental studies and pathological analyses of patient brain tissue samples with refractory epilepsy suggest that inflammatory processes and neuroinflammation plays a key-role in the etiopathology of epilepsy and convulsive disorders. These inflammatory processes lead to the secretion of pro-inflammatory cytokines responsible for blood-brain-barrier disruption and involvement of resident immune cells in the inflammation pathway, occurring within the Central Nervous System (CNS). These elements are produced through activation of Toll-Like Receptors (TLRs) by exogenous and endogenous ligands thereby increasing expression of cytokines and co-stimulatory molecules through the activation of TLRs 2, 3, 4, and 9 as reported in murine studies.It has been demonstrated that IL-1β intracellular signaling and cascade is able to alter the neuronal excitability without cell loss. The activation of the IL-1β/ IL-1β R axis is strictly linked to the secretion of the intracellular protein MyD88, which interacts with other cell surface receptors, such as TLR4 during pathogenic recognition. Furthermore, TLR-signaling pathways are able to recognize molecules released from damaged tissues, such as damage-associated molecular patterns/proteins (DAMPs). Among these molecules, High-mobility group box-1 (HMGB1) is a component of chromatin that is passively released from necrotic cells and actively released by cells that are subject to profound stress. Moreover, recent studies have described models of epilepsy induced by the administration of bicuculline and kainic acid that highlight the nature of HMGB1-TLR4 interactions, their intracellular signaling pathway as well as their role in ictiogenesis and epileptic recurrence.The aim of our review is to focus on different branches of innate immunity and their role in epilepsy, emphasizing the role of immune related molecules in epileptogenesis and highlighting the research implications for novel therapeutic strategies.