Clinical Reasoning: Pediatric Seizures of Unknown Cause.

Neurology

From the Department of Pediatrics (L.A.T., E.M.M.H.v.K., C.D.M.v.K.), Emma Children's Hospital, Amsterdam University Medical Center; On behalf of United for Metabolic Diseases (L.A.T., E.M.M.H.v.K., C.D.M.v.K.), The Netherlands; Division of Medical Genetics (N.L., A.A.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Gastroenterology and Hepatology (A.v.W.), Dietetics and Intestinal Failure, Radboud University Medical Center; Translational Metabolic Laboratory (K.L.M.C.), Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Section of Clinical Genetics and Metabolism (C.R.C.), Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora; and Department of Pediatrics (C.D.M.v.K.), Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands.

Published: June 2022

We describe a neonate and a 14-month-old child presenting with seizures that were not (completely) controlled with antiepileptic medications. There were no signs of infection, and electrolytes and neuroimaging were normal. In the neonate, pyridoxine was administered followed by cessation of seizures, and a diagnosis of pyridoxine-dependent epilepsy (PDE-ALDH7A1, a neurometabolic disorder of lysine metabolism) was genetically confirmed. The 14-month-old child received a genetic diagnosis of PDE-ALDH7A1 after abnormalities in the metabolic investigations. Both children were treated with pyridoxine and adjunct lysine reduction therapy (LRT). Seizures were controlled completely, but both children are developmentally delayed. During her second pregnancy, the mother of the neonate was started on pyridoxine treatment because of the risk of PDE-ALDH7A1. After delivery, pyridoxine treatment was continued in the neonate, who did not show any clinical symptoms. Molecular analysis identified the familial variants consistent with the diagnosis of PDE-ALDH7A1. Adjunct LRT was initiated. This child has never experienced seizures, and development has been completely normal thus far (age 2.9 years), despite the shared genotype with their sibling with developmental delays (DDs). In conclusion, in neonates, infants, and children presenting with seizures of unknown origin with partial or no response to common antiepileptic medications, the diagnosis of PDE-ALDH7A1 or other pyridoxine-responsive genetic epilepsies should be considered, prompting a trial of pyridoxine as "diagnostic therapeuticum." The digital application (treatable-id.org) can support clinicians in the early diagnosis of treatable conditions in patients presenting with DD/intellectual disability of unknown cause.

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Source
http://dx.doi.org/10.1212/WNL.0000000000200711DOI Listing

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