Antiseizure medication reduction and withdrawal in children with drug-resistant epilepsy after starting the ketogenic diet

AIM

To investigate the rate of successful withdrawal of antiseizure medication (ASM) after starting the ketogenic diet in children and identify predictive factors.

METHOD

We retrospectively reviewed data of children with epilepsy, who were treated with the ketogenic diet for 6 months or longer at our institution, over a 5-year period. We defined successful withdrawal of one or more medications as a time period of 3 months or more off this medication without restarting it or starting a new agent. Predictive clinical factors were investigated using binary multivariable logistic regression.

RESULTS

Seventy-one children were included (28 females, 43 males; median age at seizure onset 5 months, median age at diet initiation 58.5 months, median duration of ketogenic diet 27.7 months). Reduction of one or more ASMs was attempted in 54 out of 71 (76%) children and was successful in 34 out of 54 (63%), including discontinuation of all ASMs in 13. Younger age at the start of the ketogenic diet was associated with higher odds of successful ASM withdrawal. ASM withdrawal was successful in 11 out of 19 children with less than 50% seizure reduction at 3 months.

INTERPRETATION

Reduction of ASM was achieved in two-thirds of patients after the start of the ketogenic diet, where attempted, and can be successful even with little or unchanged seizure frequency while on the diet.

Cohort Study of Autoimmune Encephalitis (AIE) in Pediatric and Adult Population from India-A Single Tertiary Centre Experience

Objective

Study and compare clinico-epidemiological data and long-term outcomes in pediatric (<18 yrs) and adult AIE patients based on serostatus.

Background

India is a burgeoning hub for autoimmune diseases. Studies on AIE comparing seropositive and seronegative outcomes in pediatric and adult population are lacking. We highlight age and serostatus specific approach in low resource country settings.

Design/Methods

Retro-prospective study from Narayana Institute of Neurosciences, Bangalore (2016-2021) included AIE patients as per Autoimmune Encephalitis International Working Group and Autoimmune Encephalitis Alliance Clinicians Network. Serum and CSF autoimmune encephalitis panels, CSF meningitis panel was incorporated to exclude infections and other demyelinating disorders. With phone calls and outpatient follow ups (1-4 yrs), results were statistically analyzed and compared based on age and serostatus.

Results

Adult AIE was commoner than pediatric (75% vs 25%,n = 60) and seronegative than seropositive (56.7% vs43.3%) with overall male preponderance. NMDAR (11.7%), MOG (8.3%), LGI1 and GAD65 (5% each) were common antibodies (MOG commoner than NMDAR in children; NMDAR, LGI1 and GAD 65 equally predominant in adults). Common presentations included seizures (75%) and memory disturbances (66.7%) independent of serostatus. There were no differences in MRI and EEG parameters based on age or serostatus. Methylprednisolone mono-therapy (46.6%) was multitude than add on rescue immunosuppressants [IVIG (28.3%),rituximab (10%), PLEX & cyclophosphamide (3.3% each)]. Pediatric age, specific antibodies, status epilepticus and dysautonomia were markers requiring aggressive immunotherapy. Oral steroids (61.7%),mycophenolate (8.3%)and azathioprine (6.7%) were maintenance immunosuppressants. 10% patients (mostly seropositive) had poor outcome with Modified Rankin Scale (MRS) >3. Deaths (all adults) though rare was slightly preponderant in seronegative type owing to lack of consent for aggressive immunosuppression. Clinical relapse was noted in 10% (mostly seropositive). 86% patients were weaned off maintenance immunosuppression (earlier in seronegative).

Conclusions

Seronegative and pediatric AIE had better long term outcomes. Methylprednisolone mono-therapy is efficacious in majority of the cases when started early. Early recognition and aggressive management in high risk groups has pivotal role. Further multi-centric studies are needed to confirm these findings.

A Rare Neurological Presentation of Familial Hemophagocytic Lymphohistiocytosis

In this case report, we described a 15-year-old boy who presented with intermittent episodes of ataxia and diplopia since 6.5 years of age. Extensive workup done over several years was negative. Brain biopsy showed a neuroinflammatory disorder, and hence, differential diagnosis of chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids, central nervous system (CNS) lymphoma, and small vessel CNS vasculitis were considered. A final diagnosis of familial hemophagocytic lymphohistiocytosis was made when the patient developed episodes of prolonged fever with pancytopenia much later in the course of illness and genetic workup revealed pathogenic mutations in the PRF1 gene.

Biotin–Thiamine Responsive Basal Ganglia Disease: A Treatable Metabolic Encephalopathy—Not to Be Missed!

Biotin–thiamine responsive basal ganglia disease (BTBGD) is an autosomal recessive neurometabolic disorder, characterized by encephalopathy, extrapyramidal signs following mild infection, trauma or surgery and is potentially reversible with treatment. We describe a 15-month-old female child of Indian-Muslim origin with characteristic clinical and radiological features of BTBGD that showed complete resolution with treatment. A comparison with previously reported cases reveals a different mutation (exon 2 vs. exon 5 in middle east cases) in the SLC19A3 gene that could be specific for the Indian subcontinent. We also emphasize the importance of a trial of vitamins in patients with acute metabolic encephalopathy.

KIF1A-related disorders in children: A wide spectrum of central and peripheral nervous system involvement

KIF1A-related disorders (KRD) were first described in 2011 and the phenotypic spectrum has subsequently expanded to encompass a range of central and peripheral nervous system involvement. Here we present a case series demonstrating the range of clinical, neurophysiological, and radiological features which may occur in childhood-onset KRD. We report on all the children and young people seen at a single large tertiary centre. Data were collected through a retrospective case-notes review. Twelve individuals from 10 families were identified. Eight different mutations were present, including four novel mutations. Two patients displayed a very severe phenotype including congenital contractures, severe spasticity and/or dystonia, dysautonomia, severe sensorimotor polyneuropathy and optic atrophy, significant white matter changes on brain MRI, respiratory insufficiency, and complete lack of neurodevelopmental progress. The remaining 10 patients represented a spectrum of severity with common features including a movement disorder with spasticity and/or dystonia, subtle features of dysautonomia, sensory axonal neuropathy, varying degrees of optic atrophy and of learning and/or behavioural difficulties, and subtle or absent-but sometimes progressive-changes in white matter on MRI. Epilepsy was common among the more severely affected children. This case series demonstrates that KRD comprise a range of neurological disorders, with both the milder and the more severe forms combining central and peripheral (including autonomic) nervous system deficits.

CLIPPERS Spectrum Disorder: A Rare Pediatric Neuroinflammatory Condition

CLIPPERS (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids) is a recently described, rare neuroinflammatory disorder diagnosed by clinical symptoms involving the brain stem with a distinct pattern on neuroimaging and a perivascular T-lymphocyte infiltrate on brain biopsy. It is a condition usually described in adults in the fourth to fifth decade. We report a case of 13-year-old Indian boy who presented with recurrent episodes of ataxia and diplopia with onset at 7 years of age. He was investigated extensively to rule out infective, neoplastic, autoimmune, and demyelinating conditions over a span of 6 years. The diagnosis of CLIPPERS was entertained on the basis of clinico-radio-pathological correlation. Treatment with steroids and steroid-sparing agents, particularly methotrexate, seems to provide a promising outcome. With very few cases in literature so far, reporting of a larger case series with pediatric onset may expand it to CLIPPERS spectrum disorder.