For Peer Review Only Journal: BMJ Open

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Nodding Syndrome in Ugandan Children - Clinical features, Brain imaging and Complications; an observational case series

For peer review only Journal: BMJ Open

Manuscript ID: bmjopen-2012-002540

Article Type: Research

Date Submitted by the Author: 27-Dec-2012

Complete List of Authors: Idro, Richard; Mulago Hospital/Makerere University, Department of Paediatrics and Child Health; Oxford University , Nuffield Department of Medicine Opoka, Robert; Mulago Hospital/Makerere University, Department of Paediatrics and Child Health Aanyu, Hellen; Mulago Hospital/Makerere University, Department of Paediatrics and Child Health Kakooza, Angelina; Mulago Hospital/Makerere University, Department of Paediatrics and Child Health Piloya, Theresa; Mulago Hospital/Makerere University, Department of Paediatrics and Child Health Namusoke, Hanifa; Mulago Hospital/Makerere University, Department of Paediatrics and Child Health http://bmjopen.bmj.com/ Musoke, Sarah; Mulago Hospital/Makerere University, Department of Paediatrics and Child Health Nalugya, Joyce; Mulago Hospital/Makerere University, Department of Psychiatry Mwaka, Amos; Mulago Hospital/Makerere University, Department of Internal Medicine White, Steven; Great Ormond Street hospital for Children, Department of Neurophysiology

Chong, Kling; Great Ormond Street hospital for Children, Department of on September 23, 2021 by guest. Protected copyright. Neuroradiology Atai-Omoruto, Anne; Mulago Hospital/Makerere University, Department of Community Medicine and Family Health Mworozi, Edison; Mulago Hospital/Makerere University, Department of Paediatrics and Child Health Nankunda, Jolly; Mulago Hospital/Makerere University, Department of Paediatrics and Child Health Kiguli, Sarah; Mulago Hospital/Makerere University, Department of Paediatrics and Child Health Aceng, Jane; Ministry of Health, Headquarters Tumwine, James; Ministry of Health, Headquarters

Primary Subject Paediatrics Heading:

Secondary Subject Heading: Neurology

Keywords: Paediatric neurology < PAEDIATRICS, Epilepsy < NEUROLOGY,

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2 3 NODDING SYNDROME IN UGANDAN CHILDREN - CLINICAL FEATURES, BRAIN IMAGING 4 5 AND COMPLICATIONS; AN OBSERVATIONAL CASE SERIES 6 7 8 Author’s names 9 10 Richard Idro, Robert Opika Opoka, Hellen Aanyu, Angelina Kakooza-Mwesige, Theresa Piloya, 11 Hanifa Namusoke, Sarah Bonita Musoke, Joyce Nalugya, Paul Bangirana, Amos Deogratius 12 13 Mwaka, Steven White, Kling Chong, Anne D Atai-Omoruto, Edison Mworozi, Jolly Nankunda, 14 15 Sarah Kiguli, JaneFor Ruth Aceng, peer James K Tumwinereview only 16 17 18 1Department of Paediatrics, Mulago hospital/Makerere University College of Health 19 20 Sciences, Kampala, Uganda 21 2Centre for Tropical Medicine, Nuffield Department of Medicine, Oxford University 22 3 23 Department of Psychiatry, Mulago hospital/Makerere University College of Health 24 Sciences, Kampala, Uganda 25 26 4Department of Internal Medicine, Mulago hospital/Makerere University College of Health 27 28 Sciences, Kampala, Uganda 29 5Department of Neurophysiology, Great Ormond Street hospital for Children, London, UK 30 31 6Department of Neuro-Radiology, Great Ormond Street hospital for Children, London, UK 32 7 33 Department of Community Health and Family Medicine, Mulago hospital/Makerere http://bmjopen.bmj.com/ 34 University College of Health Sciences, Kampala, Uganda 35 8 36 Ministry of Health Head Quarters, Kampala, Uganda 37

38 39 Correspondence to Dr Richard Idro, Department of Paediatrics, Mulago hospital/ 40

41 Makerere University College of Health Sciences, P.O Box 7072, Kampala, Uganda on September 23, 2021 by guest. Protected copyright. 42 Email: [email protected] 43 44 45 46 Tel: +256-41-531875 47 48 49 Word count 50 51 Abstract 296 52 Text 3,546 53 54 55 56 57 58 59 60 1

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2 3 ABSTRACT 4 5 Objectives: Nodding syndrome is a devastating neurological disorder of uncertain aetiology 6 7 affecting children in Africa. There is no diagnostic test and risk factors and symptoms that would 8 allow early diagnosis are poorly documented. This study aimed to describe the clinical, 9 10 neurophysiologic and brain imaging (MRI) features and complications of nodding syndrome in 11 Ugandan children. 12 13 14 15 Design: Case seriesFor peer review only 16 Participants: 22 children with nodding syndrome brought to Mulago National Referral hospital 17 18 for assessment. 19 20 Outcome measures: Clinical features, physical and functional disabilities, electro- 21 encephalogram (EEG) and brain MRI findings and a staging system with a progressive 22 23 development of symptoms and complications. 24

25 26 Results 27 28 The median age of symptom onset was 6(range 4-10) years and median duration of symptoms 29 was 8.5(range 2-11) years. Sixteen of 22 families reported multiple affected children. Physical 30 31 manifestations and complications included stunting, wasting, lip changes and gross physical 32

33 deformities. The bone age was delayed by 2(range 1-6) years. There was peripheral muscle http://bmjopen.bmj.com/ 34 wasting and progressively, generalised wasting. Four children had nodding as the only seizure 35 36 type; 18 in addition had myoclonic, absence and generalised tonic-clonic seizures developing 1- 37 3years in the course of illness. Psychiatric manifestations included wandering, aggression, 38 39 depression and disordered perception. Cognitive assessment in 3 children demonstrated 40

41 profound impairment. The EEG was abnormal in all, suggesting symptomatic generalized on September 23, 2021 by guest. Protected copyright. 42 epilepsy. There were different degrees of cortical atrophy on brain MRI but no hippocampal 43 44 changes. Five stages with worsening physical, EEG and brain imaging features were identified: 45 46 a prodrome, development of head nodding and cognitive decline, other seizure types, multiple 47 complications, and severe debilitation. 48 49 50 Conclusions 51 52 Nodding syndrome is a neurologic disorder that may be characterised as probably symptomatic 53 54 generalized epilepsy. Clinical manifestations and complications develop in stages which might 55 be useful in defining treatment and rehabilitation. Studies of risk factors, pathogenesis, 56 57 management, and long-term outcome are urgently needed. 58 59 60 2

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2 3 ARTICLE SUMMARY 4 5 6 7 Article focus 8 • This paper offers detailed descriptions of the clinical features and complications of 9 10 nodding syndrome in Ugandan children and the neurophysiologic and brain imaging 11 12 features. 13 • It also proposes a clinical staging system for the disease. 14 15 For peer review only 16 Key messages 17 18 • Nodding syndrome is an epidemic neurologic disorder affecting children in parts of sub- 19 20 Saharan Africa that may be characterised as probably symptomatic generalized epilepsy 21 and with features of an epileptic encephalopathy. 22 23 • Patients progressively develop both physical and functional deficits including multiple 24 25 seizure types, cognitive and physical decline, malnutrition, and psychiatric features. Five 26 such stages could be identified. 27 28 • The proposed clinical stages are associated with worsening cortical atrophy on brain 29 30 imaging and more severe epileptiform and background EEG changes. These stages 31 may be useful in guiding treatment and rehabilitation. 32

33 http://bmjopen.bmj.com/ 34 35 Strengths and limitations of this study 36 • Although the sample size is small and there is no comparison group, this is the first 37 38 study to carefully document a range of co-morbidities and complications in nodding 39 40 syndrome, describe the natural history and provide a staging system, and combine these

41 with extensive neurophysiology and brain imaging data. on September 23, 2021 by guest. Protected copyright. 42 43 • The study patients however may not be representative of the population as they were 44 not randomly drawn from the community. 45 46 • The study did not investigate aetiology and the proposed staging was derived from 47 48 parental descriptions rather than prospective observations and therefore suffers from 49 recall. 50 51 • The resolution of our brain MRI images is quite low. 52 53 54 55 56 57 58 59 60 3

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2 3 BACKGROUND 4 5 Nodding syndrome is an emerging and devastating neurological disorder of uncertain aetiology 6 7 affecting children in sub-Saharan Africa. Current estimates suggest there are about 10,000 8 affected children1. The syndrome was first reported in Tanzania in 1960’s2 and subsequent 9 3 4-6 7 8 10 reports have come from Liberia , South Sudan and Uganda . The syndrome is characterized 11 by head nods, now determined as atonic seizures, often in association with feeding and 12 13 development of other seizure types and cognitive decline6 9. 14 15 For peer review only 16 In Uganda, almost all affected individuals are from the north where there are close to an 17 18 estimated 3,000 cases. This region is crossed by two rivers - Aswa and Pager; with high malaria 19 20 transmission and endemic for Onchocerca volvulus. This parasite has variously been 21 associated with the Nakalanga syndrome (short stature and malnutrition)10-12, epilepsy13 and 22 2 5 9 23 nodding syndrome . The region has also, for the past 20 years, had instability due to rebel 24 activity14. As a result, the population was internally displaced into densely populated camps. It is 25 26 only in the last 5 years that peace has returned and people returned to their homes. 27 28 29 There are only limited descriptions of nodding syndrome4 5 9 15. Initial symptoms that would allow 30 31 early recognition of the disease, the natural history and risk factors to identify any modifiable 32

33 factors are poorly understood. There is no diagnostic test and the current case definition is http://bmjopen.bmj.com/ 34 based on clinical criteria only. The objective of this study was to describe the clinical, 35 36 neurophysiologic and brain imaging features and complications of nodding syndrome in 37 Ugandan children and to propose a staging system. 38 39 40

41 on September 23, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 4

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2 3 METHODS 4 5 Design and setting 6 7 This is a case series of 22 Ugandan children with nodding syndrome. The study was conducted 8 in Mulago, the National Referral hospital in Uganda and teaching hospital for Makerere 9 10 University College of Health Sciences in Kampala. This hospital provides tertiary level care for 11 patients in a country in which most public healthcare services are paid for by the state. 12 13 14 15 Participants For peer review only 16 Participants were patients with suspected nodding syndrome brought by the Ministry of Health 17 18 from Kitgum district near the border with South Sudan, to Mulago Hospital in March 2012 for 19 20 specialist assessments to better understand the syndrome. Kitgum district is the epicentre of the 21 disease and one of the most affected districts in the country. Of the 25 patients one young adult 22 23 (a 23 year old male found to have a brain tumour) and two adolescents (an 18 year old girl with 24 a cerebellar hypoplasia syndrome and a 16 year old boy with history of cerebral malaria at the 25 26 age of 4 years and subsequent neurologic sequelae) were excluded. The remaining 22 children 27 28 had probable nodding syndrome and were included in the study. Then, a case of probable 29 nodding syndrome was defined as: 30 31 32

33 • A child older than 2 years or adolescent who previously was developing normally, http://bmjopen.bmj.com/ 34 • Presents with two or more episodes of recurrent head nodding occurring spontaneously 35 36 or consequent to the sight of food or coldness 37 38 • With or without other types of seizures, neurological signs, regression in growth or 39 mental retardation. 40

41 on September 23, 2021 by guest. Protected copyright. 42 43 This case definition was revised during the International Meeting on Nodding syndrome later. All 44 the same, all selected patients still fulfilled the revised criteria16. 45 46 47 Permission for the study was obtained from Makerere University School of Medicine Research 48 49 and Ethics Committee. However, we had no study protocol prior to the arrival of the patients and 50 51 so, patient care and assessments followed the hospital’s procedures for routine non-surgical 52 care for children. Thus, verbal parental consent was obtained for all clinical, laboratory and 53 54 imaging procedures. As is policy however, parents provided written consent for photography as 55 56 this is considered over and above routine care and for surgical procedures. Parents were 57 specifically made aware that the objective of the assessments was not cure but better 58 59 60 5

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2 3 understanding of the disease and that, results of investigations will be made available to the 4 5 wider scientific community in presentations and publications. To this effect, a submission was 6 7 then made to the Ethics Committee and permission to use results of the investigations 8 subsequently granted. 9 10 11 Study measurements and Procedures 12 13 All had detailed clinical, neurophysiologic, and brain imaging assessments and laboratory 14 15 testing. For peer review only 16 Clinical assessment 17 18 The history included an inquiry of the time from pregnancy to onset and the progressive 19 20 development of symptoms, physical and functional difficulties. The physical examination 21 included the general, nutritional, neurologic, cognitive and mental state assessment. Wasting 22 23 was defined as weight for height Z score of -<2 and stunting as height for age Z score of -<2. 24 Sexual maturity was assessed using the Tanner Sexual Maturity staging. Patients were 25 26 classified as having nodding syndrome only or nodding syndrome plus if they had complications 27 28 such as a report of other seizure types, neurologic and clinically evident cognitive decline, 29 physical and functional difficulties. X-rays of the left wrist were taken for bone age and reported 30 31 using a Greulich and Pyle Atlas by a blinded radiologist17. Bone growth was considered delayed 32

33 if it was 2 years below chronological age. http://bmjopen.bmj.com/ 34 35 36 Laboratory procedures 37 Ten millilitres of blood was drawn for full blood count, ESR, malaria parasites, electrolytes, liver 38 39 and renal function tests, and HIV testing. Cerebrospinal fluid was examined for cells, glucose, 40

41 protein, microscopy and bacteriologic culture. In addition, 10 children had a skin snip examined on September 23, 2021 by guest. Protected copyright. 42 for Onchocerca volvulus as previously described9. 43 44 45 46 Neurophysiology and imaging 47 All had a 30 minute EEG and the recording examined by a consultant neurophysiologist (SW) in 48 49 UK. Brain MRI in T1, T2 and Flair sequences were obtained without contrast in 19/22 patients 50 51 using a 0.5Tesla machine (BASDA Medical Apparatus, Guangzhou) and the images also 52 examined in the UK by a Consultant Neuro-radiologist (KC). 53 54 55 56 57 58 59 60 6

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2 3 Treatment 4 5 Patients were started on symptomatic treatment (sodium valproate for seizure control, nutritional 6 7 and physical therapy, counselling and social support) according to national guidelines 8 developed a month earlier18. In this management, all received sodium valproate starting at 9 10 10mg/kg/day. The dose was titrated in 5-10 mg/kg/day increases with seizure control. Nutritional 11 rehabilitation included Ready to Use Therapeutic Foods (Plumpy’Nut®, Nutriset, Malaunay) and 12 13 locally prepared food. Occupational and physiotherapy, family counselling and support were 14 15 provided as appropriate.For peer review only 16 17 18 Data analysis 19 20 Data was analysed using STATA version 12 (STATA Corp, TX). Results are summarised as 21 frequencies, proportions and medians as appropriate. The clinical features, complications and 22 23 disability were then used to describe treatment and rehabilitation needs. Clinical stages were 24 identified and brain imaging and EEG correlated with the clinical stages. 25 26 27 28 RESULTS 29 30 31 General features 32

33 Nine patients (40.9%) were male. The age range was 12-18 years. The median age at onset of http://bmjopen.bmj.com/ 34 symptoms was 6(range 4–10) years. The median duration of symptoms was 8.5(range 2-11) 35 36 years. Sixteen of the 22 families reported multiple cases; median 2(range 0–4), Table 1. 37

38 39 Striking features on physical examination included stunting, cognitive impairment (on KABC or 40

41 performance of basic tasks), lip changes with or without other physical deformities. Several on September 23, 2021 by guest. Protected copyright. 42 children had burns and scars from falls into fires. The skin was dry, thin and scaly. Extremities, 43 44 especially the feet, felt cold with a temperature gradient with the trunk but a normal capillary 45 46 refill time. There were striking changes of the lower lip (Figure 1). In mild cases, the lower lip 47 was enlarged with no visible or palpable localised swellings. In severe cases, the mucosa was 48 49 deep purple, with soft papular growths and increasingly large, thick bands of tissue. One child, 50 51 not exposed to sodium valproate previously, had unexplained alopecia. 52 53 54 55 56 57 58 59 60 7

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2 3 Table 1 Characteristics of 22 patients with nodding syndrome 4 5 ID Sex Age Duration of Admission Discharge Seizure Main Other EEG Seizure 6 (yrs) symptoms weight in weight in based Psychiatric prominent classification 7 in yrs Kg Kg classification morbidity complications 8 1 F 14 11 20.2 23.1 Head nodding Behaviour Severe Generalised plus other problems cognitive epileptiform 9 seizures types impairment discharges 10 Hallucinations Burns 11 Lip deformity 12 Severe stunting, with 13 severe wasting 14 Motor 15 For peer review onlydifficulties with 16 musculoskeleta l deformities 17 and 18 contractures 19 2 F 13 5 28.1 28.3 Head nodding Hallucinations Moderate Generalised plus other Aggressive wasting epileptiform 20 seizures types behaviour discharges 21 3 F 15 10 23.6 24.8 Head nodding Behaviour Severe wasting Generalised 22 plus other problems Speech epileptiform 23 seizures types Aggression difficulties discharges Pycho-social 24 disorder 25 4 F 14 9 37.1 39.0 Head nodding Severe Generalised 26 only cognitive epileptiform 27 impairment discharges Stunting 28 29 5 F 16 9 36.2 37.8 Head nodding Aggressive Severe Right temporal 30 plus other behavior cognitive discharges 31 seizures types Wandering impairment Hallucinations 32 Speech 33 difficulties http://bmjopen.bmj.com/ 34 35 Moderate wasting 36 6 F 14 5 38.4 39.9 Head nodding Generalised 37 plus other epileptiform 38 seizures types discharges 39 7 F 14 7 21.7 21.2 Head nodding Severe Generalised plus other cognitive epileptiform 40 seizures types impairment discharges

41 Lip deformity on September 23, 2021 by guest. Protected copyright. 42 Severe wasting 43 8 F 18 10 48.3 49.1 Head nodding Aggressive Severe Generalised plus other behaviour cognitive epileptiform 44 seizures types impairment discharges 45 Hallucinations 46 Speech 47 difficulties 9 F 18 8 30.1 36.3 Head nodding Psychotic Severe Left temporal 48 plus other symptoms cognitive discharges 49 seizures types impairment 50 Behavioural 51 problems Lip deformity

52 Speech 53 difficulties 54 55 Severe wasting 10 M 16 11 36 34.5 Head nodding Moderate Generalised 56 plus other wasting epileptiform 57 seizures types Burns discharges 58 Marked lip 59 60 8

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2 3 deformity 4 11 M 15 9 17.0 19.2 Head nodding Depression Hearing Generalised 5 plus other impairment epileptiform 6 seizures types Stunting discharges

7 Burns 8 9 Musculoskeleta l 10 Deformities 11 Severe 12 cognitive 13 impairment

14 Severe wasting 15 12 M 13 For 8 peer34.0 35.5review Head nodding Hallucinations only Generalised 16 plus other epileptiform 17 seizures types discharges 13 F 13 3 32.0 32.9 Head nodding Moderate Generalised 18 plus other wasting epileptiform 19 seizures types discharges 20 14 F 14 9 34.8 38.3 Head nodding Hallucinations Generalised 21 plus other epileptiform seizures types discharges 22 15 M 12 8 16.1 18.8 Head nodding Severe wasting Generalised 23 plus other Stunting epileptiform 24 seizures types Kyphosis, discharges 25 pectus deformity 26 Generalised 27 skin changes 28 16 M 12 2 17.1 18.2 Head nodding Stunting Generalised 29 alone Severe wasting epileptiform discharges 30 17 M 14 8 23.7 25.1 Head nodding Post ictal Severe Generalised 31 plus other Aggression cognitive epileptiform 32 seizures types impairment discharges

33 Wandering Stunting http://bmjopen.bmj.com/

34 Lip deformity, 35 36 Ataxia 37 Speech 38 difficulties 39 40 Motor difficulties with 41 musculoskeleta on September 23, 2021 by guest. Protected copyright. 42 l deformities 43 44 Moderate wasting 45 18 M 18 6 33.3 35.3 Head nodding Moderate Generalised 46 plus other wasting epileptiform 47 seizures types discharges 48 19 F 12 4 21 21.4 Head nodding Moderate Generalised alone wasting epileptiform 49 Stunting discharges 50 51 20 M 15 9 28.9 31.4 Head nodding Stunting Generalised 52 alone symptomatic epilepsy 53 21 M 15 9 20.5 24.1 Head nodding Severe Generalised 54 plus other cognitive epileptiform 55 seizures types impairment discharges 56 Lip deformity 57 58 59 60 9

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2 3 Speech 4 difficulties 5 Stunting Moderate 6 wasting 7 8 Motor disability 9 with severe musculoskeleta 10 l deformity, 11 wasting/dystrop 12 hy 13 22 F 15 9 27.3 32.7 Head nodding Behavioural Severe Generalised plus other problems cognitive epileptiform 14 seizures types Aggression impairment discharges 15 For peer review onlyStunting 16 Burns 17 Episodes of disorientation 18 Speech 19 difficulties 20 21 22 Growth and sexual maturity 23 Sixteen of the 22 children were wasted and nine stunted. Ten had sexual maturity assessed; 24 25 3/10 children (aged 12, 13, 14 years) scored Tanner Stage 3. All remaining 7 children (ages 12- 26 27 17 years) were either Tanner Stage 1 or 2. The bone age was delayed by a median 2(range 1- 28 6) years. 29 30 31 Musculoskeletal findings 32

33 Almost all had peripheral muscle wasting with flat feet and hands, thin cylindrical digits and http://bmjopen.bmj.com/ 34 35 progressively, more generalised wasting. Other physical changes included kyphosis and pectus 36 deformities of the chest. Flexion limb deformities were seen in severely debilitated patients 37 38 (Figure 2). 39 40

41 Neurological, cognitive and behavioural features on September 23, 2021 by guest. Protected copyright. 42 43 Seizures 44 Other than head nodding, a variety of other seizures including absence, complex partial, 45 46 myoclonic, and tonic-clonic seizures were described in 18/22 patients. 47 48 a) Head nodding 49 Nodding was precipitated by food in 16/22 children. In 4/22, it was associated with cold weather 50 51 or cold breeze while in 13/22, it developed spontaneously. Nodding episodes came in clusters 52 53 (both day and night) and were characterised by repetitive flexion and forward drop of the head 54 around the neck. It lasted several seconds to minutes. Some children became unresponsive 55 56 and stared blankly with a cluster of nodding, stopped feeding or drooled saliva. 57 58 59 60 10

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2 3 b) Other seizure types 4 5 Initially nodding was the predominant seizure type but as the disease progressed, generalised 6 7 tonic-clonic seizures gained more prominence. Myoclonic seizures were not readily reported but 8 were observed in several children in hospital. One such child had a prolonged cluster of nodding 9 10 with concurrent myoclonic jerks involving both upper limbs lasting about 10 minutes. In a 11 second child, similar myoclonic jerking was followed by a generalised tonic-clonic seizure. 12 13 Several children reported sudden falls sustaining facial and head injuries. 14 15 For peer review only 16 Four children reported paroxysmal events associated with fear, panic and visual hallucinations. 17 18 We could not obtain clear descriptions of the images seen by two. The third child would shout 19 20 and run with onset of the hallucinations and the forth reported seeing a person with knives 21 whose intention ‘was to kill her’. None of these events was captured on EEG. 22 23 24 Other neurologic complications 25 26 Focal neurological signs were uncommon exception. There were no obvious cranial nerve 27 28 palsies. However, six children were lethargic with an apathetic and expressionless face or 29 ‘myopathic facies’. Three of the six drooled saliva while two had very slow speech and repeated 30 31 epileptiform (spike and wave) discharges on EEG. The deep tendon reflexes were increased in 32

33 a minority of patients. In the majority however, the reflexes were either normal or reduced. http://bmjopen.bmj.com/ 34 Almost all these had peripheral muscle wasting manifesting with flat feet and hands and thin 35 36 cylindrical fingers and progressively, generalised wasting. 37

38 39 Vision, hearing and speech difficulties 40

41 No parent reported visual impairment and we did not test visual acuity but hearing impairment on September 23, 2021 by guest. Protected copyright. 42 was reported in one child. Speech difficulties were reported in 10/22 children. These included 43 44 immature speech for age and slow, slurred or dysarthric speech. Two children were mute but 45 46 retained gestural ability and receptive language. 47 48 49 Behaviour and psychiatric features and complications 50 51 The earliest psychiatric manifestation was wandering behaviour or running away. Because of 52 concerns about injury or getting lost, some parents tied up the patients to restrain them in the 53 54 home. Aggression, particularly towards familiar people, was reported in 6/22 manifesting 3-6 55 years after onset of nodding. In two children, the onset was concurrent with wandering 56 57 58 59 60 11

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2 3 behaviour. Five children had sleep difficulties and at least 8/22 had moderate to severe mood 4 5 problems with one clinically depressed. 6 7 8 Cognitive function 9 10 All 22 children had cognitive difficulties and were out of school. Academic performance declined 11 with symptom onset; previously well performing pupils started getting poorer grades and were 12 13 eventually withdrawn from school within 2-4 years of disease onset. Cognitive functioning, using 14 nd 15 the Kaufman AssessmentFor peer Battery for Children review 2 Edition (KABC-2),only was assessed in four 16 children ages 13-15 years two weeks after initiation of sodium valproate. This test has 17 18 previously been adapted to Uganda19. Three of the 4 children responded to the test instructions. 19 20 The fourth child did not respond at all. All 3 children had severe cognitive impairment (Table 2). 21 22 Table 2: Cognitive function in 3 children two weeks after initiation of sodium valproate 23 24 25 Cognitive Domain Patient 1 Patient 2 Patient 3 26 27 Male 13 years Male 15 years Male 15 years 28 29 Test Age Test Age Test Age 30 Score equivalent Score equivalent equivalent 31 in years in years Score in years 32 33 Working memory 8 <5 7 <5 21 =5 http://bmjopen.bmj.com/ 34 35 36 Planning 7 <8 1 <5 3 <5 37 38 Learning 28 <5 25 <5 54 =5 39 40 Visual spatial 0 <5 0 <5 31 <5

41 on September 23, 2021 by guest. Protected copyright. 42 Knowledge 11 <5 5 <5 52 <8 43 44 45 46 Laboratory findings 47 The mean haemoglobin was 12.4 (range 10.8–14.8) g/dl and the mean red cell volume was 48 49 81.4 (range 65.8-89.1)fl. Five children had iron deficiency anaemia. Total white blood cell and 50 51 platelet counts were normal but 10/22 children had eosinophilia. The ESR was high in 17/22 52 children with a median of 28.5 (range 5-90) mm in the first hour. Other than mild elevations of 53 54 gamma GGT, the liver and renal function was normal. Nine children had osteopenia on X ray 55 56 but only one had hypocalcaemia and four, hypophosphataemia. Creatine kinase levels were 57 58 59 60 12

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2 3 normal in all children and all tested HIV negative. Cerebrospinal fluid total protein, cells and 4 5 glucose were all normal. Three out of 10 patients had O.volvulus microfilaria on the skin snip. 6 7 8 EEG 9 10 The diagnostic EEG was abnormal in all cases. The background showed generalised excess of 11 slow activity. Generalised inter-ictal epileptiform activity was observed in all but two patients in 12 13 whom, they were focal temporal (unilateral in one and bilateral in the second). All patients with 14 15 generalised epileptiformFor activity peer had high review amplitude spikes oronly sharp waves, some associated 16 with slow wave activity often occurring in runs (Figure 3). The discharges had bilateral fronto- 17 18 temporal or fronto-centro-temporal emphasis but some were more generalised and increased in 19 20 frequency in light sleep. There was a clear gradation from mild to more severe background 21 abnormalities and epileptiform activity. No overnight recordings were performed. The EEG 22 23 findings suggested symptomatic generalised epilepsy in 20 and symptomatic focal epilepsy in 24 the remaining 2. 25 26 27 28 Brain imaging 29 Brain MRI without contrast was performed in 19/22 patients. The imaging showed different 30 31 degrees of cortical and some cerebellar atrophy. No focal cerebral cortical or hippocampal 32

33 changes were observed (Figure 4). http://bmjopen.bmj.com/ 34 35 36 Disease progression 37 Five stages with deteriorating seizures, neuro-cognitive and psychiatric disability were identified: 38 39 a prodrome; development of head nodding and cognitive impairment; other seizure types; 40

41 multiple complications and, severe debilitation (Panel 1). on September 23, 2021 by guest. Protected copyright. 42 Panel 1: A mum’s description of the sequential chronology of symptoms and disease progression in her 18 43 year old daughter. 44 45 “She was growing well until the age of 8 years when symptoms of nodding began. The head nodding is triggered by 46 food. When food is given, she freezes with it in her hand, stares blankly into space with a fixed gaze, and then nods 47 48 repeatedly for a time which varies with each episode but the maximum time was initially 5 minutes. The symptoms 49 got worse with time and about 6 years later, the nodding symptoms were immediately followed by or associated with 50 big seizures during which the whole body shook. She would drool saliva, foam around the mouth and loses 51 52 consciousness. After the big seizure, she would sleep and on waking is often weak and sometimes disoriented. On 53 some nights, she reports seeing a figure that holds a knife and wants to kill her. She is distressed by her illness and 54 gets embarrassed on waking if she had a seizure in public. She is very quiet but sometimes aggressive. Overtime, 55 56 her speech has become sluggish. Although she is 18 years old, she still has childish behaviour which is evident as 57 she speaks. Her father died following a febrile illness. She has six siblings two of who have similar symptoms.” 58 59 60 13

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2 3 4 5 Stage 1 The prodromal period 6 7 This poorly defined and short-lived period was reported in four patients. The earliest symptoms 8 included “dizziness” and increasing inattention. The children were excessively sleepy, lethargic 9 10 and would sometimes stare blankly during meals. 11

12 13 Stage 2 Development of head nodding 14 15 Among the fourFor patients, headpeer nodding review developed within 6 only weeks of the prodrome. In the 16 majority however, the initial feature was an abrupt onset of nodding. Subsequently, parents 17 18 reported declining cognitive abilities and behaviour difficulties. Disease progression however 19 20 appeared to arrest in these four. 21 22 23 Stage 3 Development of other seizure types 24 Other than the four children with nodding only, 18 children in addition developed other seizure 25 26 types including absence, complex partial, myoclonic and generalised tonic-clonic seizures. One 27 28 child developed generalised tonic clonic seizures almost simultaneously with the nodding. In the 29 others however, these developed 1-3 years after initial symptoms. It was around this time that 30 31 almost all school going children dropped out of school. 32

33 http://bmjopen.bmj.com/ 34 Stage 4 Development of multiple complications 35 36 Multiple complications developed 4-8 years after the initial symptoms associated with marked 37 regression in achievement. These consisted of deteriorating behaviour and psychiatric 38 39 symptoms and decline in motor, speech and other cognitive functions. Some patients developed 40

41 physical deformities including kyphosis, limb and pectus deformities (Figure 2). Some sustained on September 23, 2021 by guest. Protected copyright. 42 severe facial injuries with “drop attacks” and burns. Those who were still independently mobile 43 44 would wander about or ran away and were prone to getting lost. Changes in the architecture of 45 46 the lower lips (Figure 1) also occurred at this time. With disrupted and poor feeding, the children 47 became severely wasted. 48 49 50 Stage 5 The severely debilitated child 51 52 These children have little if any, independent mobility. The general picture was that of a 53 54 severely wasted child with apathy and depressive features including a flat affect, poor appetite 55 and limited speech. Some had contractures around the major joints. 56 57 58 59 60 14

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2 3 Patients with head nodding only had less cortical atrophy on brain MRI compared to those with 4 5 multiple complications. In addition, there was a clear gradation from milder to more severe 6 7 epileptiform and background EEG abnormalities in patients with suggested later clinical stages 8 of the disease. 9 10 11 Response of seizures to sodium valproate 12 13 The patients had previously been on mostly small doses of different anti epileptic drugs 14 15 including phenytoin,For phenbarbitone peer and carbamazepine.review In conformityonly with proposed national 16 guidelines, all were started on sodium valproate and the other anti epileptic drugs weaned off. 17 18 Prior to this, a 24 hour seizure count was obtained and this was repeated 14 days later. Overall, 19 20 there was a 57% reduction in total seizures including clusters of nodding. The median total daily 21 seizures reduced from 5 (range 2–14) on admission to 2 (range 0-8) 14 days after initiation of 22 23 sodium valpraote. Concurrent improvements were also seen on the EEG with marked 24 improvements or absent interictal discharges in 3/5 patients who had repeat recordings on the 25 26 day of assessment (Figure 3). 27 28 29 DISCUSSION 30 31 Recently, world media has highlighted reports of “a mysterious disease” baffling scientists – the 32 8 20 21 33 nodding syndrome. The main questions are: what is the cause, the pathogenesis, disease http://bmjopen.bmj.com/ 34 classification, clinical spectrum and treatment? In this paper we describe the clinical features, 35 36 complications of nodding syndrome in Ugandan children together with the brain imaging 37 features. Our results suggest that nodding syndrome is a neurologic disorder characterised as 38 39 symptomatic generalised epilepsy. 40

41 on September 23, 2021 by guest. Protected copyright. 42 Clinical features and complications 43 44 Nodding syndrome in Ugandan children manifests with head nodding, cognitive dysfunction, 45 46 psychiatric features, and/or multiple other seizure types. It may be complicated by stunted 47 growth, pubertal delay, wasting, motor decline and physical deformities. The earliest 48 49 manifestations are that of a poorly defined prodrome followed within weeks by head nodding. In 50 51 the later stages, there is cognitive dysfunction, psychiatric difficulties, severe muscle wasting 52 and musculoskeletal deformity. Delayed physical growth, bone age and sexual maturity are 53 54 common in affected children. This may partly be a result of delayed puberty since most were in 55 Tanner Stage 2. Pubertal delay may be secondary to chronic illness, poor nutrition and/or 56 57 58 59 60 15

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2 3 psychosocial deprivation. If so, improved nutrition, a caring environment and symptom control 4 5 should lead to improved growth and the initiation of puberty. 6 7 8 The progressive development of symptoms and complications appears to reflect the natural 9 10 progression of an epileptic encephalopathy. Stage 1 might be brief seizures, while the departure 11 from school in Stage 3 can be explained by uncontrolled seizures. Stage 4 can be the time 12 13 when a high seizure load contributes to regression which together with ensuing poor nutrient 14 15 intake leaves aFor severely debilitatedpeer child review in Stage 5, the sumonly effect of multiple factors on 16 functioning. 17 18 19 6 20 The clinical features in Ugandan children are as severe as in South Sudanese children but may 21 be more severe than that reported in Tanzanian patients9. Despite similar age of onset and 22 23 duration of symptoms, only 18% of Ugandan children had the milder nodding only compared to 24 45% in Tanzania; all our patients had abnormal interictal background EEG compared to 60% in 25 26 Tanzania. Ugandan children also had severer cognitive impairment and a much higher burden 27 28 and variety of seizures. These differences may suggest a variation in the presentation of the 29 disease by region. Family clustering in all three countries however suggests a common 30 31 exposure factor. 32

33 http://bmjopen.bmj.com/ 34 Aetiology and pathogenesis 35 36 The aetiology of nodding syndrome and pathogenesis of the complications remain unknown. A 37 variety of viral central nervous system infections have been screened for on PCR but no 38 39 association has been demonstrated16. The uncertain association with infestation with 40 5 9

41 Onchocerca Volvulus however remains . Others have postulated that nodding syndrome is a on September 23, 2021 by guest. Protected copyright. 42 consequence of treatment of patients with heavy Onchocerca volvulus infestation or dual 43 44 infection with other similar parasites7 15. Contrary evidence of any association with 45 22 46 onchocerciasis also exists . Other aetiologic considerations include toxic brain injury, an 47 inflammatory brain disease, a slow virus infection or prion disease, an atypical mitochondrial 48 49 disease or other genetic disorder. Repeated severe psycho-trauma has also been proposed23. 50 51 Earlier studies by the Ugandan Ministry of Health and the US Centers of Disease Control 52 demonstrated very low serum levels of vitamin B6 in cases compared to controls. Although 53 54 unlikely, the question then was whether nodding syndrome is an atypical form of pyridoxine 55 dependent epilepsy? Studies to further investigate this are awaited24. 56 57 58 59 60 16

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2 3 Children with the syndrome demonstrate some features of prion protein disease including motor 4 5 and cognitive dysfunction, epilepsy, behaviour and psychiatric morbidity. However, other 6 7 features such as extrapyramidal involvement and cortical blindness have not been reported. 8 The age of onset of symptoms is much younger and progression much slower25. The brain 9 10 imaging and EEG too are not supportive. Brain biopsy or autopsy studies would be important in 11 excluding prion disease. Future studies should also include the auto-immune encephalitides. 12 13 14 15 The brain MRI For findings maypeer suggest viralreview encephalitis, a para-infectiousonly phenomenon (an 16 antibody mediated channelopathy) or an outside chance of a neurotoxin as possible aetiologies. 17 18 Among Tanzanian patients, hippocampal gliosis, probably from inflammation, was described in 19 9 20 some patients . Although this could partly explain the cognitive difficulties, we did not observe 21 such lesions even with the more severe cognitive impairment in our patients. Instead, we think 22 23 an epileptic encephalopathy is likely. The background EEG in all 22 showed generalized excess 24 of theta and slow activity. Interictal epileptiform activity was demonstrated in all but one patient. 25 26 Prolonged EEG recording (including during sleep) with detailed neuropsychological testing and 27 28 functional brain imaging may help with understanding pathogenesis of the cognitive decline. 29 30 31 Study limitations 32

33 Our patients may not be representative sample as they were not drawn randomly from the http://bmjopen.bmj.com/ 34 community. This study did not investigate aetiology and the proposed staging was mostly 35 36 derived from parental descriptions rather than prospective observations and therefore suffers 37 from recall. Third, we only performed diagnostic EEG rather than prolonged recordings 38 39 important in investigating associations between seizures and cognitive dysfunction. The 40

41 resolution of our MRI images is also quite low. on September 23, 2021 by guest. Protected copyright. 42 43 44 CONCLUSIONS 45 46 Nodding syndrome is a neurologic disorder that is complicated by multiple physical and 47 functional disabilities and may be classified as symptomatic generalised epilepsy. Assessment 48 49 and care should be provided by a multidisciplinary team. Studies of aetiology, pathogenesis, 50 51 evidence based treatment and rehabilitation strategies are urgently needed. 52 53 54 55 56 57 58 59 60 17

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2 3 Acknowledgements 4 5 We would like to thank Drs Aggrey Dhabangi, Ruth Lanyero and Odong Ochaya who helped 6 7 with the daily clinical care, the nursing team of Acute Care Unit where the children were resident 8 and Dr Faith Ameda who reported the x rays. We also thank Prof Charles Newton and Prof 9 10 Chandy John who read through the draft manuscript and offered valuable comments to improve 11 it. 12 13 14 15 Author contributionsFor peer review only 16 Rl, ROO, AKM, HAT, TPW, PB, JN1, SBM, ADM, HN, SW, EM, JN2, SK, JRA and JKT all 17 18 participated in patient care and performed the different assessments. ROO, AKM, HAT and 19 20 SBN were in-charge of daily care, TPW and EM performed the growth and sexual staging 21 assessments, JN1 the psychiatric assessments, HN the nutrition assessment, SW reported the 22 23 EEG recordings, KC the brain MRI and Rl wrote the first draft. All provided a critical review of 24 the manuscript. 25 26 27 28 Conflict of Interest 29 The authors report no competing interests. 30 31 32

33 Funding http://bmjopen.bmj.com/ 34 This work was supported by the Government of Uganda through the Ministry of Health and by 35 36 the Waterloo Foundation through grant number 1025/1490 to Dr ldro. The funding agency had 37 no role in data collection, analysis, and interpretation of results and in the decision to submit for 38 39 publication. 40

41 on September 23, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 18

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2 3 Reference 4 5 1. Korevaar DA, Visser BJ. Reviewing the evidence on nodding syndrome, a mysterious tropical 6 disorder. International journal of infectious diseases : IJID : official publication of the 7 International Society for Infectious Diseases 2012. 8 2. Jilek LA. [Mental Diseases and Epilepsy in Tropical Africa]. Fortschritte der Neurologie, Psychiatrie, 9 10 und ihrer Grenzgebiete 1964;32:213-59. 11 3. Goudsmit J, van der Waals FW. Endemic epilepsy in an isolated region of Liberia. Lancet 12 1983;1(8323):528-9. 13 4. Lacey M. Nodding disease: mystery of southern Sudan. Lancet neurology 2003;2(12):714. 14 5. Nodding syndrome - South Sudan, 2011. MMWR. Morbidity and mortality weekly report 15 2012;61(3):52-4.For peer review only 16 6. Nyungura JL, Akim, T., Lako, A., Gordon, A., Lejeng, L., Gibson, W. Investigation into the Nodding 17 18 syndrome in Witto Payam, Western Equatoria State, 2010. Southern Sudan Medical Journal 19 2011;4. (1):3-6. 20 7. Kaiser C, Pion S, Boussinesq M. Head nodding syndrome and river blindness: a parasitologic 21 perspective. Epilepsia 2009;50(10):2325-6. 22 8. Wasswa H. Ugandan authorities deal with a mysterious ailment that leaves people nodding 23 continuously. BMJ 2012;344:e349. 24 25 9. Winkler AS, Friedrich K, Konig R, Meindl M, Helbok R, Unterberger I, et al. The head nodding 26 syndrome--clinical classification and possible causes. Epilepsia 2008;49(12):2008-15. 27 10. Leonard PJ, Stanfield JP. Some biochemical observations in the Nakalanga. East African medical 28 journal 1965;42(12):692-4. 29 11. Jelliffe DB, Jones PR, Stroud CE. Nakalanga notes on the endemic dwarfism of Uganda. Tropical 30 and geographical medicine 1962;14:97-104. 31 12. Marshall AJ, Cherry JK. Endocrine dysfunction in a Nakalanga dwarf. Transactions of the Royal 32

33 Society of Tropical Medicine and Hygiene 1961;55:188-91. http://bmjopen.bmj.com/ 34 13. Kipp W, Burnham G, Bamuhiiga J, Leichsenring M. The Nakalanga syndrome in Kabarole District, 35 Western Uganda. The American journal of tropical medicine and hygiene 1996;54(1):80-3. 36 14. Wendo C. Northern Uganda humanitarian crisis shocks UN chief. Rebels in northern districts have 37 left people trapped in hunger, disease, poverty, and fear. Lancet 2003;362(9398):1818. 38 15. Winkler AS, Friedrich K, Meindl M, Kidunda A, Nassri A, Jilek-Aall L, et al. Clinical characteristics of 39 people with head nodding in southern Tanzania. Tropical doctor 2010;40(3):173-5. 40 16. WHO. International Scientific Meeting on Nodding Syndrome, 2012:1-42. 41 on September 23, 2021 by guest. Protected copyright. 42 17. Acheson RM, Fowler G, Fry EI, Janes M, Koski K, Urbano P, et al. Studies in the Reliability of 43 Assessing Skeletal Maturity from X-Rays. I. Greulich-Pyle Atlas. Human biology 1963;35:317- 44 49. 45 18. Ministry of Health U. Nodding Syndrome; Health Workers Training Manual. Draft Edition; February 46 2012 ed. Kampala: Ministry of Health, 2012:1-107. 47 48 19. Bangirana P, Seggane M, Allebeck P, Giordani B, John CC, Opoka OR, et al. A preliminary 49 examination of the construct validity of the KABC-II in Ugandan children with a history of 50 cerebral malaria. African health sciences 2009;9(3):186-92. 51 20. Williams SC. Nodding syndrome leaves baffled scientists shaking their heads. Nature medicine 52 2012;18(3):334. 53 21. Edwards J. Nodding disease confounds clinicians. CMAJ : Canadian Medical Association journal = 54 journal de l'Association medicale canadienne 2012. 55 56 57 58 59 60 19

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2 3 22. Twum-Danso NA. Mass treatment of onchocerciasis with ivermectin: should people with epilepsy 4 and/or growth-retardation syndromes be excluded? Annals of tropical medicine and 5 6 parasitology 2004;98(2):99-114. 7 23. Nodding Disease In Northern Uganda - A Possible Relationship To Psychotrauma. 8 9 . 7th MakCHS ANNUAL SCIENTIFIC CONFERENCE, 19thUNACOHANNUAL SCIENTIFIC CONFERENCE, 10 11 10th WHO DR. MATHEW LUKWIYA MEMORIAL LECTURE; 2011; Speke Resort, Munyonyo, Kampala, 12 Uganda. Makerere University College of Health Sciences 13 14 24. Donnelly J. CDC planning trial for mysterious nodding syndrome. Lancet 2012;379(9813):299. 15 25. Wadsworth For JD, Collinge peer J. Update on review human prion disease. only Biochimica et biophysica acta 16 2007;1772(6):598-609. 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

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41 on September 23, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 20

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2 3 Figure legends 4 5 6 7 Figure 1 Lip changes 8 The figure shows changes in the lips with increasing distortion. In patients with mild 9 10 involvement, the lower lip is enlarged but with no visible or palpable swellings. With more severe 11 involvement, there is deep purple discolouration of the mucosa, soft papular growths and 12 13 increasingly larger and thicker bands of tissue. Other oral abnormalities included lacerations 14 15 and loss of teethFor from injuries. peer review only 16 17 18 Figure 2 Hand and foot muscle wasting, deformities and contractures 19 20 Figure 2 shows wasting of the muscles of the hand and foot, knee and foot flexion deformities 21 and contractures, pectus deformity of the chest and kyphosis. Such marked deformities are 22 23 seen with increasing symptom duration. 24

25 26 Figure 3 EEG recordings 27 28 Figure 3 is an EEG recording of a 12 year old girl. She had head nodding and cognitive 29 impairment. During the recording, interictal epileptiform discharges (spikes and sharp waves) 30 31 were observed in wakefulness (3a) and during light sleep when increasingly more florid 32

33 epileptiform discharges were observed. There was no clinical event with this recording (3b). http://bmjopen.bmj.com/ 34 35 36 Figure 4 Brain MRI 37 Figure 4 shows T1 and T2 brain MRI images of a 15 year old boy. He had head nodding, 38 39 myoclonic and absence seizures but no tonic clonic seizures. There is cortical brain atrophy with 40

41 widening of adjacent sulci but no focal lesions or obvious abnormalities in the hippocampi. on September 23, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 21

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11 http://bmjopen.bmj.com/ 12 13 14 15 16 17 18 19 20 on September 23, 2021 by guest. Protected copyright. 21 22 23 24 25 26 27 28 29 30 31 4d 32 33 4c 34 35 36 37 38 Figure 4c 39 40 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtmlMild cerebellar 41 42 atrophy on T2 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from Page 26 of 6-7 6-7 6-7 6-7 5-7 5-7 4 4 5-7 5-7 7 7 5 5 - 5 5

4 4

N/A N/A N/A N/A 1 1 2 2 N/A N/A N/A N/A N/A N/A Reported Reported on# page

BMJ Open http://bmjopen.bmj.com/ —Give the—Give criteria, eligibility and sourcesthe methodsand of selection of participants —Give the—Give eligibility criteria, and sourcesthe methodsand case of ascertainment and control —If —If applicable, explain of matching how cases and controls addressed was —For matched studies,matching criteria give theand number of controlsper case on September 23, 2021 by guest. Protected copyright. —Give eligibilitythe criteria, and sourcesthe methods and of selectionof participants. Describe —If applicable, howexplain loss to addressedfollow-up was —For matched matching criteriastudies, give number of exposedand unexposed and R Idro et al, Nodding Syndrome in Ugandan Children Children Ugandan in Syndrome Nodding al, et RIdro Checklist for cohort, case-control, and cross-sectional studies (combined) (combined) studies cross-sectional and case-control, for cohort, Checklist For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Cohort study Cohort study Cohort study

) Describe statistical all methods, including thosecontrol confoundingused for to ) ) Indicate)the study’scommonly design a with inused term the the ortitle abstract ) ) Describe any methods used tosubgroups examine interactionsand ) ) inProvide the abstract informativean and balanced summaryof what was done and what was found ) Explain missinghow data were addressed a a a d c b b b For eachof interest,For variable sourcesgive of data details and of methods of assessment (measurement). Describe comparability comparability of assessment isthere methods more if thanone group

criteria, if criteria, if applicable collection methods of follow-up Case-control study selection. Give the rationalethe selection. Give forthe of caseschoice and controls Cross-sectional study ( ( ( ( ( Recommendation and why and Case-control Case-control study For peer review Case-control study only 3 3 objectives, State includingspecific pre-specifiedany hypotheses 1 1 ( 5 5 Describe setting,the locations, relevantand dates, including periods exposure,of recruitment, follow-up, and data 9 9 Describe efforts to any addresssourcespotential of bias 6 6 ( 7 7 define Clearly outcomes, exposures,all potential predictors, confounders, and effect modifiers. diagnostic Give 4 4 Present key of elements study design early in paperthe 10 10 Explain studythe how size was arrived at 12 12 ( STROBE 2007 (v4) checklist of items to be included in reports of observational studies in epidemiology* epidemiology* in studies observational of reports in be included to of items checklist (v4) 2007 STROBE Item Item # Statistical Statistical methods Quantitative variables 11 Explain quantitativehow were variables handled in analyses.the If applicable, describe which groupings chosen were Study size Bias Data sources/Data measurement 8* Variables Participants Setting Study design Methods Objectives Background/rationale 2 Explain scientific the background rationale investigation the for and being reported Introduction Title andTitle abstract Section/Topic

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 7-13 7-13 16-17 17 17 15 15 N/A N/A - 12-13 Table 1 Table 4-5 4-5 - - N/A N/A 18 18

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BMJ Open http://bmjopen.bmj.com/ Report numbers eventsof outcome summary measuresor If describe applicable, analytical methods account taking of sampling strategy — Report numbers in each category,exposure summaryor measures of exposure on September 23, 2021 by guest. Protected copyright. —Summarise —Summarise follow-up(eg, time average and total amount) R Idro et al, Nodding Syndrome in Ugandan Children Children Ugandan in Syndrome Nodding al, et RIdro —Report numbers eventsof outcome or summary measures over time sectional studysectional - For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Cohort study ) Report) category boundaries when continuous variables were categorized ) Give unadjusted estimates ifapplicable, and, confounder-adjusted estimatestheir and precision95% (eg, ) Describesensitivity any analyses ) If )relevant, If considertranslating estimates of relative risk forintorisk meaningful absolute periodtime a c b a e from similar studies,from otherand relevant evidence and magnitudeand of potential any bias Cross-sectional Cross-sectional study— Case-control Case-control study— Cohort studyCohort potential confounderspotential confirmed eligible,confirmed included in thecompleting study, follow-up,analysed and confidence interval). confidence Make clear which confounders were adjustedthey wereincluded andfor why Cross ( For peer review only presentthe which article is based ( (

(c) number Indicate (b) participants of missingwith eachfor data of interest variable Consider (c) diagram use flow of a reasons Give (b) non-participationfor stage each at 18 18 Summarise resultskey to study objectivesreference with 17 17 other Report analyses done—eg analyses of subgroups interactions, and sensitivity and analyses 20 20 Give cautiousinterpretationa of overall results considering objectives, limitations, multiplicity of resultsanalyses, 16 16 ( 21 21 Discuss the (external generalisability of validity) studythe results 22 22 sourcethe Give of funding rolethethe and of funders presentthe for if studyapplicable, originaltheand, for study on 19 19 Discuss of thelimitations taking into study, sourcesaccount biasof potential or imprecision. Discussbothdirection 14* characteristics (a) Give participantsof study (eg demographic, clinical, social) and information on exposures and 15* 13* (a) numbers Report of individuals each at stage of study—eg numbers potentially eligible, examined eligibility,for An Explanation and Elaboration article discusses itemeach checklist and gives methodological backgroundand published examples of transparent reporting. The STROBE checklist is best used in thiswith conjunction (freely available article onsites the Medicine of PLoS Web http://www.plosmedicine.org/,at Annals of Internal Medicine at http://www.annals.org/, Epidemiologyhttp://www.epidem.com/). at and Information on InitiativeSTROBE the is www.strobe-statement.org.available at information*Give separately cases for and controls studiesin case-controlfor applicable, if and, exposedunexposed and groups in cohort and cross-sectional studies. Note: Funding Other information Generalisability Interpretation Limitations Key Key results Discussion Other analyses

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Nodding Syndrome in Ugandan Children - Clinical features, Brain imaging and Complications; an observational case series

For peer review only Journal: BMJ Open

Manuscript ID: bmjopen-2012-002540.R1

Article Type: Research

Date Submitted by the Author: 02-Apr-2013

Primary Subject Paediatrics Heading:

Secondary Subject Heading: Neurology

Keywords: Paediatric neurology < PAEDIATRICS, Epilepsy < NEUROLOGY,

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33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40

1 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 NODDING SYNDROME IN UGANDAN CHILDREN - CLINICAL FEATURES, BRAIN IMAGING 4 5 AND COMPLICATIONS; AN OBSERVATIONAL CASE SERIES 6 7 8 Author’s names 9 1, 2 1 1 1 10 Richard Idro , Robert Opika Opoka , Hellen Aanyu , Angelina Kakooza-Mwesige , Theresa 11 Piloya-Were1, Hanifa Namusoke1, Sarah Bonita Musoke1, Joyce Nalugya3, Paul Bangirana3, 12 13 Amos Deogratius Mwaka4, Steven White5, Kling Chong6, Anne D Atai-Omoruto7, Edison 14 1 1 1 8 1 15 Mworozi , Jolly NankundaFor , peerSarah Kiguli , reviewJane Ruth Aceng , Jamesonly K Tumwine 16 17 18 1Department of Paediatrics, Mulago Hospital/Makerere University College of Health 19 20 Sciences, Kampala, Uganda 21 2Centre for Tropical Medicine, Nuffield Department of Medicine, Oxford University, Oxford, 22 23 UK 24 3Department of Psychiatry, Mulago Hospital/Makerere University College of Health 25 26 Sciences, Kampala, Uganda 27 4 28 Department of Internal Medicine, Mulago Hospital/Makerere University College of Health 29 Sciences, Kampala, Uganda 30 31 5Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, 32

33 London, UK http://bmjopen.bmj.com/ 34 6Department of Neuroradiology, Great Ormond Street Hospital for Children, London, UK 35 7 36 Department of Community Health and Family Medicine, Mulago Hospital/Makerere 37 University College of Health Sciences, Kampala, Uganda 38 39 8Ministry of Health Head Quarters, Kampala, Uganda 40

41 on September 23, 2021 by guest. Protected copyright. 42 Correspondence to Dr Richard Idro, Department of Paediatrics, Mulago Hospital/ 43 44 Makerere University College of Health Sciences, P.O Box 7072, Kampala, Uganda 45 46 Email: [email protected] 47 48 49 Tel: +256-41-531875 50

51 52 Word count 53 54 Abstract 300 55 Text 3,926 56 57 58 59 60 1

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2 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 ABSTRACT 4 5 Objectives: Nodding syndrome is a devastating neurological disorder of uncertain aetiology 6 7 affecting children in Africa. There is no diagnostic test and risk factors and symptoms that would 8 allow early diagnosis are poorly documented. This study aimed to describe the clinical, 9 10 electrophysiologic and brain imaging (MRI) features and complications of nodding syndrome in 11 Ugandan children. 12 13 14 15 Design: Case seriesFor peer review only 16 Participants: 22 children with nodding syndrome brought to Mulago National Referral Hospital 17 18 for assessment. 19 20 Outcome measures: Clinical features, physical and functional disabilities, electro- 21 encephalogram (EEG) and brain MRI findings and a staging system with a progressive 22 23 development of symptoms and complications. 24

33 deformities. The bone age was delayed by 2(range 1-6) years. There was peripheral muscle http://bmjopen.bmj.com/ 34 wasting and progressive generalised wasting. Four children had nodding as the only seizure 35 36 type; 18 in addition had myoclonic, absence and/or generalised tonic-clonic seizures developing 37 1-3years after the onset of illness. Psychiatric manifestations included wandering, aggression, 38 39 depression and disordered perception. Cognitive assessment in 3 children demonstrated 40

41 profound impairment. The EEG was abnormal in all, suggesting symptomatic generalised on September 23, 2021 by guest. Protected copyright. 42 epilepsy in the majority. There were different degrees of cortical and cerebellar atrophy on brain 43 44 MRI but no hippocampal changes. Five stages with worsening physical, EEG and brain imaging 45 46 features were identified: a prodrome, development of head nodding and cognitive decline, other 47 seizure types, multiple complications, and severe disability. 48 49 50 Conclusions 51 52 Nodding syndrome is a neurologic disorder that may be characterised as probably symptomatic 53 54 generalised epilepsy. Clinical manifestations and complications develop in stages which might 55 be useful in defining treatment and rehabilitation. Studies of risk factors, pathogenesis, 56 57 management, and outcome are urgently needed. 58 59 60 2

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3 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 ARTICLE SUMMARY 4 5 6 7 Article focus 8 • This paper offers detailed descriptions of the clinical features and complications of 9 10 nodding syndrome in Ugandan children and the electrophysiologic and brain imaging 11 12 features. 13 • It also proposes a clinical staging system for the disease. 14 15 For peer review only 16 Key messages 17 18 • Nodding syndrome is an epidemic neurologic disorder affecting children in parts of sub- 19 20 Saharan Africa that may be characterised as a probable symptomatic generalised 21 epilepsy with features of epileptic encephalopathy. 22 23 • Patients progressively develop both physical and functional deficits including multiple 24 25 seizure types, cognitive and physical decline, malnutrition, and psychiatric features. Five 26 clinical stages could be identified. 27 28 • The proposed clinical stages are associated with worsening cortical and cerebellar 29 30 atrophy on brain imaging and more severe epileptiform and background EEG changes. 31 These stages may be useful in guiding treatment and rehabilitation. 32

33 http://bmjopen.bmj.com/ 34 35 Strengths and limitations of this study 36 • Although the sample size is small and there is no comparison group, this is one of the 37 38 few studies so far to have carefully documented the clinical features and complications 39 40 of nodding syndrome combined with extensive electrophysiology and brain imaging data,

41 describe the natural history and the first to provide a staging system.The study patients, on September 23, 2021 by guest. Protected copyright. 42 43 however, may not be representative of the population, as they were not randomly drawn 44 from the community. 45 46 • The study did not investigate aetiology and the proposed staging was mainly derived 47 48 from parental descriptions rather than prospective observations and, therefore, suffers 49 from recall bias. 50 51 • The resolution of our brain MRI images is quite low. 52 53 54 55 56 57 58 59 60 3

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4 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 BACKGROUND 4 5 Nodding syndrome is a devastating neurological disorder of uncertain aetiology described in 6 1 2 7 African children . It was first described in Tanzania in 1960s and subsequent reports have 8 come from Liberia3, South Sudan4-6 and Uganda7 8. The syndrome is characterized by head 9 8 10 nodding determined to be atonic seizures often occurring in association with feeding, a cold 11 breeze or cold weather and complicated by other seizure types, malnutrition and cognitive 12 13 decline6 9 10. 14 15 For peer review only 16 In Uganda, almost all affected individuals are from the north of the country where there are an 17 18 estimated 3,000 cases. The region has for the past 20 years, had instability from rebel 19 11 20 activity . As a result, the population was internally displaced into densely populated camps. It is 21 only in the last 5 years that peace returned and population returned to their homes. This region 22 23 is crossed by two rivers - the Aswa and Pager Rivers, has high malaria transmission and is 24 endemic for Onchocerca volvulus. This parasite has variously been associated with the 25 26 Nakalanga syndrome (a tropical syndrome characterised by short stature and malnutrition)12-15, 27 16 17 5 9 28 epilepsy and nodding syndrome . This association has, however, been indirect as no O. 29 volvulus contamination of cerebrospinal fluid has been documented18. 30 31 32 4 5 8-10 33 There are only limited descriptions of nodding syndrome . Winkler et al provided the most http://bmjopen.bmj.com/ 34 detailed account of the syndrome to date, describing clinical features in 62 Tanzanian patients 35 36 and classifying them as either head nodding only or head nodding plus, if they also had other 37 seizure types9. Initial symptoms allowing early recognition of the disease, its natural history and 38 39 potentially modifiable risk factors are poorly characterized. There is no diagnostic test and the 40

41 current case definition is based solely on clinical criteria. The objective of this study was to on September 23, 2021 by guest. Protected copyright. 42 describe the clinical, electrophysiologic and brain imaging features and complications of 43 44 nodding syndrome in Ugandan children and to propose a staging system. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 4

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5 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 METHODS 4 5 Design and setting 6 7 This is a case series of 22 Ugandan children with nodding syndrome. The study was conducted 8 in Mulago, the National Referral Hospital in Uganda and teaching hospital for Makerere 9 10 University College of Health Sciences in Kampala. This hospital provides tertiary level care for 11 patients in a country in which most public healthcare services are paid for by the state. 12 13 14 15 Participants For peer review only 16 Participants were patients with suspected nodding syndrome brought by the Ministry of Health 17 18 from Kitgum district near the border with South Sudan, to Mulago Hospital in March 2012 for 19 20 specialist assessments to better understand the syndrome. Kitgum district is the epicentre of the 21 disease and one of the most affected districts in the country. Of the 25 patients brought to 22 23 Mulago, one young adult (a 23 year old male found to have a brain tumour) and two 24 adolescents (an 18 year old girl with a cerebellar hypoplasia syndrome and a 16 year old boy 25 26 with history of cerebral malaria at the age of 4 years and subsequent neurologic sequelae) were 27 28 excluded. The remaining 22 children had probable nodding syndrome and were included in the 29 study. A case of probable nodding syndrome was defined as: 30 31 32

33 • A child older than 2 years or an adolescent who previously was developing normally http://bmjopen.bmj.com/ 34 • Two or more episodes of recurrent head nodding occurring spontaneously or 35 36 consequent to the sight of food or coldness 37 38 • With or without other types of seizures, neurological signs, regression in growth or 39 learning disability. 40

41 on September 23, 2021 by guest. Protected copyright. 42 43 This case definition was revised during the International Meeting on Nodding Syndrome later in 44 2012.However, all selected patients fulfilled the revised criteria19. 45 46 47 Permission for the study was obtained from Makerere University School of Medicine Research 48 49 and Ethics Committee. However, as we had no study protocol prior to the arrival of the patients, 50 51 clinical care and assessment followed the hospital’s standard procedures for routine non- 52 surgical care for children. Verbal parental consent was obtained for all clinical, laboratory and 53 54 imaging procedures. As is policy, however, parents gave written consent for photography, as 55 56 this is considered over and above routine care and for any surgical procedures. Parents were 57 specifically made aware that the objective of the assessments was not cure, but a better 58 59 60 5

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6 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 understanding of the disease and that the general findings from the evaluation of the group of 4 5 patients with nodding syndrome would be made available to the wider scientific community in 6 7 presentations and publications, with the specific aim of improving the care of people affected by 8 the disorder in the future. To this effect, a submission was then made to the Ethics Committee 9 10 and permission to use results of the investigations subsequently granted. 11

12 13 Study measurements and Procedures 14 15 All had detailedFor clinical, electrophysiologic,peer review and brain imaging only assessments and laboratory 16 testing. 17 18 19 20 Clinical assessment 21 The history included an inquiry about the time from pregnancy to the onset and the progressive 22 23 development of symptoms, physical and functional difficulties. The clinical examination included 24 general, nutritional, neurologic, cognitive and mental state assessments. Wasting was defined 25 26 as weight for height Z score of -<2 and stunting as height for age Z score of -<2. Sexual maturity 27 28 was assessed using the Tanner Sexual Maturity staging. Patients were classified as having 29 nodding syndrome only or nodding syndrome plus depending on whether they also had other 30 31 seizure types9. X-rays of the left wrist were taken for bone age and reported using a Greulich 32 20 33 and Pyle Atlas by a blinded radiologist . Bone growth was considered delayed if it was 2 years http://bmjopen.bmj.com/ 34 below the chronological age. Cognitive functioning was assessed in detail in four children - 35 36 median age 14.5 (range 13-15) years - two weeks after initiation of sodium valproate using the 37 Kaufman Assessment Battery for Children 2nd Edition (KABC-2). This test has previously been 38 39 adapted for use in Uganda21. All four had had symptoms for longer than five years. 40

41 on September 23, 2021 by guest. Protected copyright. 42 Laboratory procedures 43 44 Ten millilitres of blood was drawn for full blood count, ESR, malaria parasites, electrolytes, liver 45 46 and renal function tests, and HIV testing. Cerebrospinal fluid was examined for cells, glucose, 47 protein, microscopy and bacteriologic culture. In addition, 10 children had a skin snip examined 48 49 for Onchocerca volvulus as previously described9. 50

51 52 Neurophysiology and imaging 53 54 All had a 30 minute EEG recording with an XLTEK EEG system (Optima Medical Ltd, London, 55 UK) using the 10-20 electrode placement system , which was reviewed by a consultant clinical 56 57 neurophysiologist(SW) in the UK. Brain MRI in T1, T2 and Flair sequences were obtained 58 59 60 6

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7 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 without contrast in 19/22 patients using a 0.5Tesla machine (BASDA Medical Apparatus, 4 5 Guangzhou) and the images also examined in the UK by a Consultant Neuroradiologist (KC). 6 7 8 Natural history and staging 9 10 At the end of the first week after patients and carers had acclimatised to the referral hospital 11 environment, the attending clinician sat with each carer and obtained detailed histories of the 12 13 progressive development and timing of symptoms and complications of nodding syndrome to 14 15 characterize theFor natural history. peer A standardised review proforma with aonly diagrammatic representation of 16 possible events and a linear timeline was used to obtain these descriptions. Information from 17 18 each patient was plotted on the timeline and later combined with the data from other patients to 19 20 identify emerging patterns, from which the proposed stages of the disorder were derived. 21 22 23 Treatment 24 Patients were started on symptomatic treatment (sodium valproate for seizure control, nutritional 25 26 and physical therapy, counselling and social support) according to national guidelines 27 22 28 developed a month earlier . In this protocol, all received sodium valproate starting at 29 10mg/kg/day. The dose was titrated in 5-10 mg/kg/day increases according to the level of 30 31 seizure control. Nutritional rehabilitation included Ready to Use Therapeutic Foods 32

33 (Plumpy’Nut®, Nutriset, Malaunay) and locally prepared food. Occupational and physiotherapy, http://bmjopen.bmj.com/ 34 family counselling and support were provided as appropriate. 35 36 37 Data analysis 38 39 Data was analysed using STATA version 12 (STATA Corp, TX). Results are summarised as 40

41 frequencies, proportions and medians as appropriate. The clinical features, complications and on September 23, 2021 by guest. Protected copyright. 42 disability were then used to describe treatment and rehabilitation needs. Clinical stages were 43 44 identified and brain imaging and EEG correlated with the clinical stages. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 7

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8 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 RESULTS 4 5 General features 6 7 Nine patients (40.9%) were male. The age range was 12-18 years. The median age at onset of 8 symptoms was 6 (range 4–10) years and the median duration of symptoms was 8.5(range 2-11) 9 10 years (Table 1). Sixteen of the 22 families reported more than one case (median 2 (range 0–4)). 11 Prior to hospitalisation, all patients had received antiepileptic drug treatment with 12 13 phenobarbitone, phenytoin or carbamazepine with no clear documentation of benefit. Treatment 14 15 had often been intermittentFor peerand at sub-therapeutic review doses. only 16 17 18 Striking features on physical examination included stunting, cognitive impairment (on KABC or 19 20 performance of basic tasks), lip changes (Figure 1) and other physical deformities. Several 21 children had burns and scars from burns. The skin was dry, thin and scaly. Extremities, 22 23 especially the feet, felt cold with a temperature gradient with the trunk, but a normal capillary 24 refill time. Among those with mild lip changes, the lower lip was enlarged with no visible or 25 26 palpable localised swellings. In progressively more severe cases, the mucosa was deep purple, 27 28 with soft papular growths and increasingly large, thick bands of tissue. One child, not exposed 29 to sodium valproate previously, had unexplained alopecia. 30 31 32

33 Table 1 Characteristics of 22 patients with nodding syndrome http://bmjopen.bmj.com/ 34 ID Age Duration of Seizure based Main Psychiatric Other prominent EEG Seizure 35 (years) symptoms in classification morbidity complications classification 36 yrs 37 1 14 11 Head nodding plus Behaviour problems Severe cognitive Generalised 38 other seizures types impairment epileptiform Hallucinations Burns discharges 39 Lip deformity 40 Severe stunting, with

41 severe wasting on September 23, 2021 by guest. Protected copyright. 42 Spasticity and contractures with 43 musculoskeletal 44 deformities 45 2 13 5 Head nodding plus Hallucinations Moderate wasting Generalised 46 other seizures types Aggressive epileptiform behaviour discharges 47 3 15 10 Head nodding plus Behaviour problems Severe wasting Generalised 48 other seizures types Aggression Speech difficulties epileptiform 49 Pychosocial discharges 50 disorder 4 14 9 Head nodding only Severe cognitive Generalised 51 impairment epileptiform 52 Stunting discharges 53 54 5 16 9 Head nodding plus Aggressive Severe cognitive Right temporal other seizures types behaviour impairment discharges 55 Wandering 56 Hallucinations Speech difficulties 57 58 Moderate wasting 59 60 8

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9 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 6 14 5 Head nodding plus Generalised 4 other seizures types epileptiform 5 discharges 6 7 14 7 Head nodding plus Severe cognitive Generalised other seizures types impairment epileptiform 7 Lip deformity discharges 8 Severe wasting 9 8 18 10 Head nodding plus Aggressive Severe cognitive Generalised other seizures types behaviour impairment epileptiform 10 discharges 11 Hallucinations Speech difficulties 12 9 18 8 Head nodding plus Psychotic Severe cognitive Left temporal 13 other seizures types symptoms impairment discharges

14 Behavioural Lip deformity 15 For peer reviewproblems only 16 Speech difficulties 17 Severe wasting 18 10 16 11 Head nodding plus Moderate wasting Generalised 19 other seizures types Burns epileptiform 20 Marked lip deformity discharges 21 11 15 9 Head nodding plus Depression Hearing impairment Generalised other seizures types Stunting epileptiform 22 discharges 23 Burns 24 25 Musculoskeletal Deformities 26 Severe cognitive 27 impairment 28 29 Severe wasting 12 13 8 Head nodding plus Hallucinations Generalised 30 other seizures types epileptiform 31 discharges 32 13 13 3 Head nodding plus Moderate wasting Generalised

33 other seizures types epileptiform http://bmjopen.bmj.com/ discharges 34 14 14 9 Head nodding plus Hallucinations Generalised 35 other seizures types epileptiform 36 discharges 37 15 12 8 Head nodding plus Severe wasting Generalised other seizures types Stunting epileptiform 38 Kyphosis, pectus discharges 39 deformity 40 Generalised skin changes 41 on September 23, 2021 by guest. Protected copyright. 16 12 2 Head nodding only Stunting Generalised 42 Severe wasting epileptiform 43 discharges 44 17 14 8 Head nodding plus Post- ictal Severe cognitive Generalised 45 other seizures types aggression impairment epileptiform Stunting discharges 46 Wandering 47 Lip deformity, 48 49 Ataxia

50 Speech difficulties 51 52 Spasticity and contractures with 53 musculoskeletal 54 deformities 55 56 Moderate wasting 18 18 6 Head nodding plus Moderate wasting Generalised 57 other seizures types epileptiform 58 59 60 9

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10 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 discharges 4 19 12 4 Head nodding only Moderate wasting Generalised 5 Stunting epileptiform 6 discharges 20 15 9 Head nodding only Stunting Generalised 7 epileptiform 8 discharges 9 21 15 9 Head nodding plus Severe cognitive Generalised 10 other seizures types impairment epileptiform discharges 11 Lip deformity 12 13 Speech difficulties Stunting 14 Moderate wasting 15 For peer review only 16 Spasticity with 17 contractures and severe 18 musculoskeletal 19 deformity, 20 wasting/dystrophy 21 22 15 9 Head nodding plus Behavioural Severe cognitive Generalised other seizures types problems impairment epileptiform 22 Aggression Stunting discharges 23 Burns 24 Episodes of 25 disorientation Speech difficulties 26

27 28 Growth and sexual maturity 29 30 Sixteen of the 22 children were wasted and nine stunted. Increasingly more severe wasting was 31 observed with a longer duration of symptoms. Thus, patients with moderate wasting had 32

33 symptoms lasting 3-6 years, while severe wasting was more common among those with http://bmjopen.bmj.com/ 34 35 symptoms lasting longer than 7 years. Ten had sexual maturity assessed; 3/10 children (aged 36 12, 13, 14 years) scored Tanner Stage 3. All remaining 7 children (ages 12-17 years) were 37 38 either Tanner Stage 1 or 2. The bone age was delayed by a median 2(range 1-6) years. 39

41 Musculoskeletal findings on September 23, 2021 by guest. Protected copyright. 42 43 Almost all had peripheral muscle wasting with progressively flat feet and hands, thin cylindrical 44 digits and increasing generalised wasting. Other physical changes included kyphosis and 45 46 pectus deformities of the chest. Flexion limb deformities were seen in patients with severe 47 48 disability (Figure 2). 49 50 51 Neurological, cognitive and behavioural features 52 Seizures 53 54 Other than head nodding, a variety of other seizure types were described in 18/22 patients - 55 56 including absence, complex partial, myoclonic, and tonic-clonic seizures. Head nodding 57 58 59 60 10

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11 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 Nodding was precipitated by food in 16/22 children. In 4/22, it was associated with cold weather 4 5 or a cold breeze, while in 13/22 it developed spontaneously. Nodding episodes came in clusters 6 7 occurring during both the day and the night and were characterised by repetitive flexion and 8 forward drop of the head. The clusters of head nodding lasted several seconds to minutes. 9 10 Some children became unresponsive and stared blankly with each cluster of nodding, stopped 11 feeding or drooled saliva. 12 13 14 15 Initially head noddingFor was peer the predominant review seizure type butonly as the disease progressed, 16 generalised tonic-clonic seizures became more prominent. Myoclonic seizures were not often 17 18 reported, but were observed in several children while in hospital. One such child had a 19 20 prolonged cluster of nodding with concurrent myoclonic jerks involving both upper limbs, lasting 21 about 10 minutes. In a second child, similar myoclonic jerking was followed by a generalised 22 23 tonic-clonic seizure. Several children had sudden falls, sustaining facial and head injuries. 24

25 26 Four children experienced paroxysmal events associated with fear, panic and visual 27 28 hallucinations. We could not obtain clear descriptions of the images seen by two. The third child 29 would shout and run with onset of the hallucinations and the forth reported seeing a person with 30 31 knives whose intention ‘was to kill her’. None of these events was captured on EEG. 32

33 http://bmjopen.bmj.com/ 34 Other neurologic complications 35 36 Focal neurological signs were uncommon. There were no obvious cranial nerve palsies. 37 However, six children were lethargic with an apathetic and expressionless face or ‘myopathic 38 39 facies’. Three of the six drooled saliva while two had very slow speech and repeated 40

41 epileptiform (spike and wave) discharges on EEG. The deep tendon reflexes were increased in on September 23, 2021 by guest. Protected copyright. 42 a minority of patients. In the majority, however, the reflexes were either normal or reduced. 43 44 45 46 Vision, hearing and speech difficulties 47 No parent reported visual impairment and we did not test visual acuity but hearing impairment 48 49 was reported in one child. Speech difficulties were reported in 10/22 children. These included 50 51 immature speech for age and slow, slurred or dysarthric speech. Two children were mute but 52 retained gestural ability and receptive language. 53 54 55 56 57 58 59 60 11

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12 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 Behaviour and psychiatric features and complications 4 5 The earliest psychiatric manifestation was wandering behaviour or running away. Because of 6 7 concerns about injury or getting lost, some parents tied up the patients to restrain them in the 8 home. Aggression, particularly towards familiar people, was reported in 6/22 cases, manifesting 9 10 3-6 years after onset of nodding. In two children, the onset was concurrent with wandering 11 behaviour. Five children had sleep difficulties and at least 8/22 had moderate to severe mood 12 13 problems with one clinically depressed. 14 15 For peer review only 16 Cognitive function 17 18 All 22 children had cognitive difficulties and were out of school. Academic performance declined 19 20 with symptom onset; as symptoms increased, pupils started getting poorer grades and were 21 eventually withdrawn from school within 2-4 years of disease onset. Three of the 4 children who 22 23 had cognitive functioning assessed using the KABC-2 responded to the test instructions. The 24 fourth child did not respond at all. All 3 children had severe cognitive impairment (Table 2). 25 26 27 Table 2: Cognitive function on the KABC 2nd Edition in 3 children two weeks after 28 initiation of sodium valproate 29 30 Cognitive Domain Patient 1 Patient 2 Patient 3 31 32

33 Male 13 years Male 15 years Male 15 years http://bmjopen.bmj.com/ 34 35 Test Age Test Age Test Age 36 Score equivalent Score equivalent equivalent 37 in years in years Score in years 38 39 Working memory 8 <5 7 <5 21 =5 40

41 on September 23, 2021 by guest. Protected copyright. 42 Planning 7 <8 1 <5 3 <5 43 44 Learning 28 <5 25 <5 54 =5 45 46 Visual spatial 0 <5 0 <5 31 <5 47 48 Knowledge 11 <5 5 <5 52 <8 49 50 51 52 53 54 55 56 57 58 59 60 12

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13 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 Laboratory findings 4 5 The mean haemoglobin was 12.4 (range 10.8–14.8) g/dl and the mean red cell volume was 6 7 81.4 (range 65.8-89.1) fl. Five children had iron deficiency anaemia. The total white blood cell 8 and platelet counts were normal but 10/22 children had eosinophilia, median eosinophil count 9 9 10 0.4 (range 0.1 – 1.9) x 10 /L. The ESR was high in 17/22 children with a median of 28.5 (range 11 5-90) mm in the first hour. Other than mild elevations of gamma GT, the liver and renal function 12 13 was normal. All tested negative for malaria on admission to Mulago, although one subsequently 14 15 developed malariaFor in the third peer week of hospitalisation. review Nine children only had osteopenia on x ray but 16 only one had hypocalcaemia and four hypophosphataemia. Creatine kinase levels were normal 17 18 in all children and all tested HIV negative. Cerebrospinal fluid total protein, cells and glucose 19 20 were all normal and all bacteriologic cultures had no growth. Three out of 10 patients had 21 O.volvulus microfilaria on the skin snip. Microfilaria density was, however, not reported. 22 23 24 EEG 25 26 The routine diagnostic EEG was abnormal in all cases. The background activity showed a 27 28 generalised excess of slow activity mainly in the conventional theta and delta frequency ranges. 29 Generalised inter-ictal epileptiform activity was observed in all but two patients, in whom there 30 31 were focal temporal discharges (unilateral in one and bilateral in the second). All patients with 32

33 generalised epileptiform activity had high amplitude spikes or sharp waves, some associated http://bmjopen.bmj.com/ 34 with slow wave activity and often occurring in irregular bursts rather than runs (Figure 3). There 35 36 was no consistent frequency to this. The discharges had bilateral fronto-temporal or fronto- 37 centro-temporal emphasis, but some were more generalised and increased in frequency in light 38 39 sleep. There was a clear gradation from mild to more severe background abnormalities and 40

41 epileptiform activity. No overnight recordings were performed. The EEG findings suggested on September 23, 2021 by guest. Protected copyright. 42 symptomatic generalised epilepsy in 20 and symptomatic focal epilepsy in the remaining 2. 43 44 45 46 Brain imaging 47 Brain MRI without contrast was performed in 19/22 patients. The imaging showed different 48 49 degrees of cortical and cerebellar atrophy. No focal cerebral cortical or hippocampal changes 50 were observed (Figure 4). Cerebellar disease was evident in the majority of cases, but among 51 52 patients with especially generalised cortical atrophy, there was a suggestion of more atrophy in 53 54 the occipital lobes or the parieto-occipital regions than anteriorly. 55 56 57 58 59 60 13

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14 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 Disease progression 4 5 Five stages with deteriorating seizures, neuro-cognitive and psychiatric disability were identified: 6 7 a prodrome; development of head nodding and cognitive impairment; other seizure types; 8 multiple complications and severe debilitation (Panel 1). 9 10 11 Panel 1: A mum’s description of the sequential chronology of symptoms and disease progression in her 18 12 year old daughter. 13 14 “She was growing well until the age of 8 years when symptoms of nodding began. The head nodding is triggered by 15 food. When food is Forgiven, she freezes peer with it in her reviewhand, stares blankly into onlyspace with a fixed gaze, and then nods 16 17 repeatedly for a time which varies with each episode but the maximum time was initially 5 minutes. The symptoms 18 got worse with time and about 6 years later, the nodding symptoms were immediately followed by or associated with 19 big seizures during which the whole body shook. She would drool saliva, foam around the mouth and loses 20 21 consciousness. After the big seizure, she would sleep and on waking is often weak and sometimes disoriented. On 22 some nights, she reports seeing a figure that holds a knife and wants to kill her. She is distressed by her illness and 23 gets embarrassed on waking if she had a seizure in public. She is very quiet but sometimes aggressive. Overtime, 24 25 her speech has become sluggish. Although she is 18 years old, she still has childish behaviour which is evident as 26 she speaks. Her father died following a febrile illness. She has six siblings two of who have similar symptoms.” 27 28 29 Stage 1 The prodromal period 30 31 This poorly defined and short-lived period was reported in four patients. The earliest symptoms 32

33 included “dizziness” and increasing inattention. The children were excessively sleepy, lethargic http://bmjopen.bmj.com/ 34 and would sometimes stare blankly during meals. 35 36 37 Stage 2 Development of head nodding 38 39 Among the four patients reporting prodromal symptoms, head nodding developed within 6 40 weeks of the prodrome. In the majority, however, the initial feature was an abrupt onset of 41 on September 23, 2021 by guest. Protected copyright. 42 nodding. Subsequently, parents reported declining cognitive abilities and behaviour difficulties. 43 44 Disease progression however appeared to arrest in these four. 45 46 47 Stage 3 Development of other seizure types 48 49 Apart from the four children with nodding only, 18 children developed other seizure types 50 including absence, complex partial, myoclonic and generalised tonic-clonic seizures. One child 51 52 developed generalised tonic clonic seizures almost simultaneously with the nodding. In the 53 54 others, however, additional seizure types developed 1-3 years after initial symptoms. It was 55 around this time that almost all school going children dropped out of school. 56 57 58 59 60 14

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15 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 Stage 4 Development of multiple complications 4 5 Multiple complications developed 4-8 years after the initial symptoms, associated with marked 6 7 regression in achievement. These consisted of deteriorating behaviour and psychiatric 8 symptoms and a decline in motor, speech and other cognitive functions. Some patients 9 10 developed physical deformities including kyphosis, limb and pectus deformities (Figure 2). 11 Some sustained severe facial injuries with “drop attacks” and burns. Those who were still 12 13 independently mobile would wander about or run away and were prone to getting lost. Changes 14 15 in the architectureFor of the lowerpeer lips (Figure review 1) also occurred only at this time. With disrupted and 16 poor feeding, the children became severely wasted. 17 18 19 20 Stage 5 Severe disability 21 These children have little, if any, independent mobility. The general picture is that of a severely 22 23 wasted child with apathy and depressive features including a flat affect, poor appetite and 24 limited speech. Some had contractures around the major joints. 25 26 27 28 Patients with head nodding only had less cortical and cerebellar atrophy on brain MRI compared 29 to those with multiple complications. In addition, there was a clear gradation from milder to more 30 31 severe epileptiform and background EEG abnormalities in patients with the later clinical stages 32

33 of the disease. http://bmjopen.bmj.com/ 34 35 36 Response of seizures to sodium valproate 37 The patients had previously been on mostly low doses of various anti-epileptic drugs including 38 39 phenytoin, phenbarbitone and carbamazepine. In conformity with proposed national guidelines, 40

41 all were started on sodium valproate and the other anti-epileptic drugs weaned off. Prior to this, on September 23, 2021 by guest. Protected copyright. 42 a 24 hour seizure count was obtained and this was repeated 14 days later. Overall, there was a 43 44 57% reduction in total seizures including clusters of nodding. The median total daily number of 45 46 seizures reduced from 5 (range 2–14) on admission to 2 (range 0-8) 14 days after initiation of 47 sodiumvalproate. Concurrent improvements were also seen on the EEG with substantially 48 49 reduced or absent interictal discharges in 3/5 patients who had repeat recordings on the day of 50 assessment (Figure 3). 51 52 53 54 55 56 57 58 59 60 15

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16 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 DISCUSSION 4 5 Recently, there have been media reports of “a mysterious disease” baffling scientists – the 6 7 23 24 7 nodding syndrome. There are many uncertainties about this newly recognized disorder: 8 what is the cause, the pathogenesis, disease classification, clinical spectrum and treatment? In 9 10 this paper, we describe the clinical features and complications of nodding syndrome in Ugandan 11 children, together with the EEG and brain imagingappearances. Our findings suggest that 12 13 nodding syndrome is a neurologic disorder characterised by a symptomatic generalised 14 15 epilepsy. For peer review only 16 17 18 Clinical features and complications 19 20 Nodding syndrome in Ugandan children manifests with head nodding, cognitive dysfunction, 21 psychiatric features, and/or multiple seizure types. It may be complicated by stunted growth, 22 23 pubertal delay, wasting, motor decline and physical deformities. The earliest manifestation is a 24 poorly defined prodrome followed within weeks by head nodding. In the later stages, there is 25 26 cognitive dysfunction, psychiatric disturbance, and severe muscle wasting and musculoskeletal 27 28 deformity. Delayed physical growth, bone age and sexual maturity are common in affected 29 children. This may partly be a result of delayed puberty, since most were in Tanner Stage 2. 30 31 Pubertal delay may be secondary to chronic illness, poor nutrition and/or psychosocial 32

33 deprivation. If so, improved nutrition, a supportive environment and symptom control should http://bmjopen.bmj.com/ 34 lead to improved growth and the initiation of puberty. 35 36 37 The progressive stages of the disorder appear to reflect the natural progression of an epileptic 38 39 encephalopathy. In Stage 1, there are brief seizures, while by Stage 3 uncontrolled seizures 40

41 prevent the child from continuing in school. In Stage 4 a high seizure burden contributes to on September 23, 2021 by guest. Protected copyright. 42 regression, which together with ensuing poor nutrient intake leaves a severely disabled child by 43 44 Stage 5, when multiple factors impair functioning. 45 46 47 The clinical features in Ugandan children are as severe as in South Sudanese children,6 but 48 49 may be more severe than in Tanzanian patients9. Despite similar age of onset and duration of 50 51 symptoms, only 18% of Ugandan children had the milder nodding only variant, compared to 52 45% in Tanzania; all our patients had abnormal interictal background EEG compared to 60% in 53 54 Tanzania. Ugandan children also had more severe cognitive impairment and a much greater 55 burden and variety of seizures. These differences may suggest a variation in the presentation of 56 57 58 59 60 16

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17 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 the disease by region. Family clustering in all three countries, however, suggests a common 4 5 exposure factor. 6 7 8 Aetiology and pathogenesis 9 10 The aetiology of nodding syndrome and pathogenesis of the complications remain unknown. A 11 variety of viral central nervous system infections have been screened for on PCR but no 12 13 association has been demonstrated19. An association with infestation with Onchocerca Volvulus 14 5 9 18 25 15 has been reportedFor in some peer series, but review has not been evident only in other studies. . Other 16 aetiologic considerations have included toxic brain injury, inflammatory brain disease, a slow 17 18 virus infection or prion disease, an atypical mitochondrial disease or other genetic disorder. 19 26 20 Repeated severe psychological trauma has also been proposed as a mechanism . Earlier 21 studies by the Ugandan Ministry of Health and the US Centers of Disease Control found a 22 23 higher proportion of cases with low serum vitamin B6 compared to controls. Although unlikely, 24 the possibility was raised that nodding syndrome could be an atypical form of pyridoxine 25 26 dependent epilepsy. Studies to explore this hypothesis further are awaited27. 27 28 29 Children with the syndrome show some features reminiscent of prion protein disease, including 30 31 motor and cognitive dysfunction, epilepsy, behaviour and psychiatric morbidity. However, other 32

33 features commonly seen in prion disease - such as extrapyramidal involvement and cortical http://bmjopen.bmj.com/ 34 blindness - have not been reported. The age of onset of symptoms is also much younger and 35 28 36 progression much slower . The brain imaging and EEG findings too are not suggestive of prion 37 disease. Nevertheless, brain biopsy or autopsy studies would be important in excluding prion 38 39 disease. 40

41 on September 23, 2021 by guest. Protected copyright. 42 The brain MRI findings might suggest viral encephalitis, a para-infectious phenomenon (such as 43 44 an antibody- mediated channelopathy) or even a neurotoxin as possible aetiologies. A genetic 45 46 disorder or metabolic disease is also possible. Future studies should also consider the recently 47 described auto-immune encephalitides. Among Tanzanian patients, hippocampal gliosis, 48 49 probably from inflammation, was described in some patients9. Although this could partly explain 50 51 the cognitive difficulties, we did not observe such lesions, even in the sub-group with more 52 severe cognitive impairment.. We consider that an epileptic encephalopathy is more likely. The 53 54 background EEG in all 22 cases showed a generalized excess of theta and slow activity. 55 Prolonged EEG recording (including during sleep) with detailed neuropsychological testing and 56 57 functional brain imaging may help with understanding the pathogenesis of cognitive decline. 58 59 60 17

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18 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 Study limitations 4 5 Our patients may not be a representative sample, as they were not drawn randomly from the 6 7 community. The study did not investigate aetiology and the proposed staging was derived 8 primarily from parental descriptions rather than prospective observations and so may be 9 10 influenced by recall bias. We only performed routine diagnostic EEGs, rather than prolonged 11 recordings which are important in investigating associations between seizures and cognitive 12 13 dysfunction. The resolution of our MRI images is also quite low. 14 15 For peer review only 16 CONCLUSIONS 17 18 Nodding syndrome is a neurologic disorder that is complicated by multiple physical and 19 20 functional disabilities and may be considered as symptomatic generalised epilepsy. Assessment 21 and care should be provided by a multidisciplinary team. Studies of aetiology, pathogenesis, 22 23 evidence- based treatment and rehabilitation strategies are urgently needed. 24

25 26 27 28 29 30 31 32

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41 on September 23, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 18

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19 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 Acknowledgements 4 5 We would like to thank Drs Aggrey Dhabangi, Ruth Lanyero, Betty Lanyero and Odong Ochaya 6 7 who helped with the daily clinical care, the nursing team of Acute Care Unit where the children 8 were resident and Dr Faith Ameda who reported the x rays. We also thank Prof Charles Newton 9 10 and Prof Chandy John, who read through the draft manuscript and offered valuable comments 11 to improve it. 12 13 14 15 Author contributionsFor peer review only 16 Rl, ROO, AKM, HAT, TPW, PB, JN1, SBM, ADM, HN, , EM, JN2, SK, JRA and JKT all 17 18 participated in patient care and performed the different assessments. ROO, AKM, HAT and 19 20 SBN were in-charge of daily care, TPW and EM performed the growth and sexual staging 21 assessments, JN1 the psychiatric assessments, HN the nutrition assessment, SW reported the 22 23 EEG recordings, KC the brain MRI and Rl wrote the first draft. All provided a critical review of 24 the manuscript. 25 26 27 28 Conflict of Interest 29 The authors report no competing interests. 30 31 32

41 on September 23, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 19

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20 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 Reference 4 5 1. Korevaar DA, Visser BJ. Reviewing the evidence on nodding syndrome, a mysterious tropical 6 disorder. International journal of infectious diseases : IJID : official publication of the 7 International Society for Infectious Diseases 2013;17(3):e149-52. 8 2. Aall L. Epilepsy in Tanganyika. Review and Newsletter- Transcultural Research in Mental Health 9 10 Problems 1962;13:54–7. 11 3. Goudsmit J, van der Waals FW. Endemic epilepsy in an isolated region of Liberia. Lancet 12 1983;1(8323):528-9. 13 4. Lacey M. Nodding disease: mystery of southern Sudan. Lancet neurology 2003;2(12):714. 14 5. Nodding syndrome - South Sudan, 2011. MMWR. Morbidity and mortality weekly report 15 2012;61(3):52-4.For peer review only 16 6. Nyungura JL, Akim, T., Lako, A., Gordon, A., Lejeng, L., Gibson, W. Investigation into the Nodding 17 18 syndrome in Witto Payam, Western Equatoria State, 2010. Southern Sudan Medical Journal 19 2011;4. (1):3-6. 20 7. Wasswa H. Ugandan authorities deal with a mysterious ailment that leaves people nodding 21 continuously. BMJ 2012;344:e349. 22 8. Sejvar JJ, Kakooza AM, Foltz JL, Makumbi I, Atai-Omoruto AD, Malimbo M, et al. Clinical, 23 neurological, and electrophysiological features of nodding syndrome in Kitgum, Uganda: an 24 25 observational case series. Lancet neurology 2013;12(2):166-74. 26 9. Winkler AS, Friedrich K, Konig R, Meindl M, Helbok R, Unterberger I, et al. The head nodding 27 syndrome--clinical classification and possible causes. Epilepsia 2008;49(12):2008-15. 28 10. Winkler AS, Friedrich K, Meindl M, Kidunda A, Nassri A, Jilek-Aall L, et al. Clinical characteristics of 29 people with head nodding in southern Tanzania. Tropical doctor 2010;40(3):173-5. 30 11. Wendo C. Northern Uganda humanitarian crisis shocks UN chief. Rebels in northern districts have 31 left people trapped in hunger, disease, poverty, and fear. Lancet 2003;362(9398):1818. 32

33 12. Leonard PJ, Stanfield JP. Some biochemical observations in the Nakalanga. East African medical http://bmjopen.bmj.com/ 34 journal 1965;42(12):692-4. 35 13. Jelliffe DB, Jones PR, Stroud CE. Nakalanga notes on the endemic dwarfism of Uganda. Tropical 36 and geographical medicine 1962;14:97-104. 37 14. Marshall AJ, Cherry JK. Endocrine dysfunction in a Nakalanga dwarf. Transactions of the Royal 38 Society of Tropical Medicine and Hygiene 1961;55:188-91. 39 15. Kipp W, Burnham G, Bamuhiiga J, Leichsenring M. The Nakalanga syndrome in Kabarole District, 40 Western Uganda. The American journal of tropical medicine and hygiene 1996;54(1):80-3. 41 on September 23, 2021 by guest. Protected copyright. 42 16. Kipp W, Kasoro S, Burnham G. Onchocerciasis and epilepsy in Uganda. Lancet 1994;343(8890):183- 43 4. 44 17. Pion SD, Kaiser C, Boutros-Toni F, Cournil A, Taylor MM, Meredith SE, et al. Epilepsy in 45 onchocerciasis endemic areas: systematic review and meta-analysis of population-based 46 surveys. PLoS neglected tropical diseases 2009;3(6):e461. 47 48 18. Konig R, Nassri A, Meindl M, Matuja W, Kidunda AR, Siegmund V, et al. The role of Onchocerca 49 volvulus in the development of epilepsy in a rural area of Tanzania. Parasitology 50 2010;137(10):1559-68. 51 19. WHO. International Scientific Meeting on Nodding Syndrome. Geneva: World Health Organization, 52 2012:1-42. 53 20. Acheson RM, Fowler G, Fry EI, Janes M, Koski K, Urbano P, et al. Studies in the Reliability of 54 Assessing Skeletal Maturity from X-Rays. I. Greulich-Pyle Atlas. Human biology 1963;35:317- 55 56 49. 57 58 59 60 20

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21 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 21. Bangirana P, Seggane M, Allebeck P, Giordani B, John CC, Opoka OR, et al. A preliminary 4 examination of the construct validity of the KABC-II in Ugandan children with a history of 5 6 cerebral malaria. African health sciences 2009;9(3):186-92. 7 22. Ministry of Health U. Nodding Syndrome; Health Workers Training Manual. Draft Edition; February 8 2012 ed. Kampala: Ministry of Health, 2012:1-107. 9 23. Williams SC. Nodding syndrome leaves baffled scientists shaking their heads. Nature medicine 10 2012;18(3):334. 11 24. Edwards J. Nodding disease confounds clinicians. CMAJ : Canadian Medical Association journal = 12 13 journal de l'Association medicale canadienne 2012. 14 25. Twum-Danso NA. Mass treatment of onchocerciasis with ivermectin: should people with epilepsy 15 and/or growth-retardationFor peer syndromes review be excluded? Annalsonly of tropical medicine and 16 parasitology 2004;98(2):99-114. 17 26. Nodding Disease In Northern Uganda - A Possible Relationship To Psychotrauma. 7th MakCHS 18 ANNUAL SCIENTIFIC CONFERENCE, 19thUNACOHANNUAL SCIENTIFIC CONFERENCE, 10th WHO 19 DR. MATHEW LUKWIYA MEMORIAL LECTURE; 2011; Speke Resort, Munyonyo, Kampala, 20 21 Uganda. Makerere University College of Health Sciences 22 23 27. Donnelly J. CDC planning trial for mysterious nodding syndrome. Lancet 2012;379(9813):299. 24 28. Wadsworth JD, Collinge J. Update on human prion disease. Biochimica et biophysica acta 25 2007;1772(6):598-609. 26 27 28 29 30 31 32

33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40

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22 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 Figure legends 4 5 6 7 Figure 1 Lip changes 8 The figure shows changes in the lips with increasing distortion. In patients with mild 9 10 involvement, the lower lip is enlarged but with no visible or palpable swellings. With more severe 11 involvement, there is deep purple discolouration of the mucosa, soft papular growths and 12 13 increasingly larger and thicker bands of tissue. Other oral abnormalities included lacerations 14 15 and loss of teethFor from injuries. peer review only 16 17 18 Figure 2 Muscle wasting, deformities and contractures 19 20 Figure 2 shows wasting of the muscles of the foot, knee and foot flexion deformities and 21 contractures, pectus deformity of the chest and kyphosis. Such marked deformities were seen 22 23 with increasing symptom duration. 24

33 discharges were evident. There was no apparent clinical change with these discharges (3b). http://bmjopen.bmj.com/ 34 35 36 Figure 4 Brain MRI 37 Figure 4 shows T2-weighted brain MRI images in the axial (Fig 4a, 4b) and sagittal (Fig 4c, 4d) 38 39 plane showing marked cerebellar atrophy and generalised cerebral atrophy. 40

41 on September 23, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 22

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 24 of 49 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 1 7 8 9 NODDING SYNDROME IN UGANDAN CHILDREN - CLINICAL FEATURES, BRAIN IMAGING 10 AND COMPLICATIONS; AN OBSERVATIONAL CASE SERIES 11

12 13 Author’s names 14 Richard Idro1, 2, Robert Opika Opoka1, Hellen Aanyu1, Angelina Kakooza-Mwesige1, Theresa 15 Piloya-Were1, Hanifa NamusokeFor1, Sarahpeer Bonita Musoke review1, Joyce Nalugya3, Paul only Bangirana3, 16 4 5 6 7 17 Amos Deogratius Mwaka , Steven White , Kling Chong , Anne D Atai-Omoruto , Edison 18 Mworozi1, Jolly Nankunda1, Sarah Kiguli1, Jane Ruth Aceng8, James K Tumwine1 19 20 1Department of Paediatrics, Mulago hHospital/Makerere University College of Health 21 22 Sciences, Kampala, Uganda 23 2Centre for Tropical Medicine, Nuffield Department of Medicine, Oxford University, UK 24 3Department of Psychiatry, Mulago hHospital/Makerere University College of Health 25 26 Sciences, Kampala, Uganda 27 4Department of Internal Medicine, Mulago hHospital/Makerere University College of 28 Health Sciences, Kampala, Uganda 29 5 30 Department of Clinical Neurophysiology, Great Ormond Street hHospital for Children, 31 London, UK 32 6Department of Neuro-RadiologyNeuroradiology, Great Ormond Street hHospital for 33 http://bmjopen.bmj.com/ Children, London, UK 34 35 7Department of Community Health and Family Medicine, Mulago hHospital/Makerere 36 University College of Health Sciences, Kampala, Uganda 37 8 Ministry of Health Head Quarters, Kampala, Uganda 38 39 40 Correspondence to Dr Richard Idro, Department of Paediatrics, Mulago hHospital/

41 Makerere University College of Health Sciences, P.O Box 7072, Kampala, Uganda on September 23, 2021 by guest. Protected copyright. 42 43 Email: [email protected] 44 45 Tel: +256-41-531875 46

47 48 Word count 49 Abstract 296300 50 Text 3,5463,925 51 52 53 54 1 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 25 of 49 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 2 7 8 9 ABSTRACT 10 Objectives: Nodding syndrome is a devastating neurological disorder of uncertain aetiology 11 affecting children in Africa. There is no diagnostic test and risk factors and symptoms that would 12 13 allow early diagnosis are poorly documented. This study aimed to describe the clinical, 14 neurophysiologicelectrophysiologic and brain imaging (MRI) features and complications of 15 nodding syndrome in UgandanFor children. peer review only 16 17 Design: Case series 18 Participants: 22 children with nodding syndrome brought to Mulago National Referral hHospital 19 for assessment. 20 Outcome measures: Clinical features, physical and functional disabilities, electro- 21 22 encephalogram (EEG) and brain MRI findings and a staging system with a progressive 23 development of symptoms and complications. 24 Results 25 26 The median age of symptom onset was 6(range 4-10) years and median duration of symptoms 27 was 8.5(range 2-11) years. Sixteen of 22 families reported multiple affected children. Physical 28 manifestations and complications included stunting, wasting, lip changes and gross physical 29 30 deformities. The bone age was delayed by 2(range 1-6) years. There was peripheral muscle 31 wasting and progressively, generalised wasting. Four children had nodding as the only seizure 32 type; 18 in addition had myoclonic, absence and/or generalised tonic-clonic seizures developing 33 http://bmjopen.bmj.com/ 1-3years in during the course after the onset of illness. Psychiatric manifestations included 34 35 wandering, aggression, depression and disordered perception. Cognitive assessment in 3 36 children demonstrated profound impairment. The EEG was abnormal in all, suggesting 37 symptomatic generalized generalised epilepsy in the majority. There were different degrees of 38 39 cortical and cerebellar atrophy on brain MRI but no hippocampal changes. Five stages with 40 worsening physical, EEG and brain imaging features were identified: a prodrome, development

41 of head nodding and cognitive decline, other seizure types, multiple complications, and severe on September 23, 2021 by guest. Protected copyright. 42 43 debilitationdisability. 44 Conclusions 45 Nodding syndrome is a neurologic disorder that may be characterised as probably symptomatic 46 generaliszed epilepsy. Clinical manifestations and complications develop in stages which might 47 48 be useful in defining treatment and rehabilitation. Studies of risk factors, pathogenesis, 49 management, and long-term outcome are urgently needed. 50 51 52 53 54 2 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 26 of 49 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 3 7 8 9 ARTICLE SUMMARY 10 11 Article focus 12 13 • This paper offers detailed descriptions of the clinical features and complications of 14 nodding syndrome in Ugandan children and the neurophysiologicelectrophysiologic and 15 brain imaging features.For peer review only 16 17 • It also proposes a clinical staging system for the disease. 18 19 Key messages 20 21 • Nodding syndrome is an epidemic neurologic disorder affecting children in parts of sub- 22 Saharan Africa that may be characterised as a probably probable symptomatic 23 generalized generalised epilepsy and with features of an epileptic encephalopathy. 24 25 • Patients progressively develop both physical and functional deficits including multiple 26 seizure types, cognitive and physical decline, malnutrition, and psychiatric features. Five 27 such clinical stages could be identified. 28 29 • The proposed clinical stages are associated with worsening cortical and cerebellar 30 atrophy on brain imaging and more severe epileptiform and background EEG changes. 31 These stages may be useful in guiding treatment and rehabilitation. 32

33 http://bmjopen.bmj.com/ 34 Strengths and limitations of this study 35 • Although the sample size is small and there is no comparison group, this is one of the 36 few the first study studies so far to have carefully documented a the clinical features 37 38 range of co-morbidities and complications in of nodding syndrome combined with 39 extensive electroneurophysiology and brain imaging data, describe the natural history 40 and the first to provide a staging system, and combine these with extensive

41 on September 23, 2021 by guest. Protected copyright. 42 neurophysiology and brain imaging data. 43 • The study patients, however, may not be representative of the population, as they were 44 not randomly drawn from the community. 45 46 • The study did not investigate aetiology and the proposed staging was majorly mainly 47 derived from parental descriptions rather than prospective observations and, therefore,

48 suffers from recall bias. Formatted: Font color: Black 49 50 • The resolution of our brain MRI images is quite low. Formatted: Font color: Black 51 52 53 54 3 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 27 of 49 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 4 7 8 9 BACKGROUND 10 Nodding syndrome is an emerging and devastating neurological disorder of uncertain aetiology Formatted: Font: Bold 11 affecting described in African children1 in sub-Saharan Africa . Current estimates suggest there 12 13 are about 10,000 affected children. The syndrome It was first reporteddescribed in Tanzania in 14 1960’s2 and subsequent reports have come from Liberia3, South Sudan4-6 and Uganda7 8. It The 15 syndrome is characterizedFor by head nodpeerdings, now determined review to be as atonic seizuresonly8, often 16 17 occurring in association with feeding, a cold breeze or cold weather and development of 18 othercomplicated by other seizure types, malnutrition and cognitive decline6 9 10. 19 20 In Uganda, almost all affected individuals are from the north of the country where there are Formatted: Add space between paragraphs of 21 the same style, Don't adjust space between 22 close to an estimated 3,000 cases. The region has for the past 20 years, had instability from Latin and Asian text, Don't adjust space between Asian text and numbers 23 rebel activity11. As a result, the population was internally displaced into densely populated 24 camps. It is only in the last 5 years that peace returned and population returned to their homes. 25 26 This region is crossed by two rivers - the Aswa and Pager Rivers;, with has high malaria Formatted: Font: Italic 27 transmission and is endemic for Onchocerca volvulus. This parasite has variously been Formatted: Font: Italic 28 associated with the Nakalanga syndrome (a tropical syndrome characterised by short stature 29 12-15 16 17 5 9 30 and malnutrition) , epilepsy and nodding syndrome . This association has, however, Field Code Changed 31 been indirect as no O. volvulus contamination of cerebrospinal fluid has been documented18. Field Code Changed Field Code Changed 32 The region has also, for the past 20 years, had instability due to rebel activity(Wendo 2003). As 33 Field Code Changed http://bmjopen.bmj.com/ a result, the population was internally displaced into densely populated camps. It is only in the 34 Formatted: Font: (Default) Arial, 11 pt 35 last 5 years that peace has returned and people returned to their homes. Formatted: Font: (Default) Arial, 11 pt 36 Formatted: Font color: Black, English (U.S.) 37 4 5 8-10 There are only limited descriptions of nodding syndrome . Winkler et al provided the most 38 39 detailed description account of the syndrome to date, describing clinical features in 62 40 Tanzanian patients and classifying them as either head nodding only or head nodding plus, if

41 they in addition also had other seizure types9. Initial symptoms that would allowing early on September 23, 2021 by guest. Protected copyright. 42 43 recognition of the disease, theits natural history and potentially modifiable risk factors to identify 44 any modifiable factors are however only poorly understooddescribedcharacterized. There is no Formatted: Font: Italic 45 diagnostic test and the current case definition is based solely on clinical criteria only. The 46 objective of this study was to describe the clinical, neurophysiologic electrophysiologic and brain 47 48 imaging features and complications of nodding syndrome in Ugandan children and to propose a 49 staging system. 50 51 52 53 54 4 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 28 of 49 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 5 7 8 9 METHODS 10 Design and setting 11 This is a case series of 22 Ugandan children with nodding syndrome. The study was conducted 12 13 in Mulago, the National Referral hHospital in Uganda and teaching hospital for Makerere 14 University College of Health Sciences in Kampala. This hospital provides tertiary level care for 15 patients in a country in whichFor most public peer healthcare services review are paid for by the state.only 16 17 18 Participants 19 Participants were patients with suspected nodding syndrome brought by the Ministry of Health 20 from Kitgum district near the border with South Sudan, to Mulago Hospital in March 2012 for 21 22 specialist assessments to better understand the syndrome. Kitgum district is the epicentre of the 23 disease and one of the most affected districts in the country. Of the 25 patients brought to 24 Mulago, one young adult (a 23 year old male found to have a brain tumour) and two 25 26 adolescents (an 18 year old girl with a cerebellar hypoplasia syndrome and a 16 year old boy 27 with history of cerebral malaria at the age of 4 years and subsequent neurologic sequelae) were 28 excluded. The remaining 22 children had probable nodding syndrome and were included in the 29 30 study. Then, a A case of probable nodding syndrome was defined as: 31 32 • A child older than 2 years or an adolescent who previously was developing normally, 33 http://bmjopen.bmj.com/ 34 • Presents with two Two or more episodes of recurrent head nodding occurring 35 spontaneously or consequent to the sight of food or coldness 36 • With or without other types of seizures, neurological signs, regression in growth or 37 38 mental retardation learning disability. 39 40 This case definition was revised during the International Meeting on Nodding sSyndrome later in

41 on September 23, 2021 by guest. Protected copyright. 2012. All the sameHowever, all selected patients still fulfilled the revised criteria19. 42 43 44 Permission for the study was obtained from Makerere University School of Medicine Research 45 and Ethics Committee. However, as we had no study protocol prior to the arrival of the patients 46 47 and so, clinicalpatient care and assessments followed the hospital’s standard procedures for 48 routine non-surgical care for children. Thus, verbal Verbal parental consent was obtained for all 49 clinical, laboratory and imaging procedures. As is policy, however, parents provided gave 50 51 written consent for photography, as this is considered over and above routine care and for any 52 surgical procedures. Parents were specifically made aware that the objective of the 53 54 5 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 29 of 49 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 6 7 8 9 assessments was not cure, but a better understanding of the disease and that the general 10 findings from the evaluation of the group of patients with nodding syndrome , results of 11 investigations will would be made available to the wider scientific community in presentations 12 13 and publications, with the specific aim of improving the care of people affected by the disorder in 14 the future. To this effect, a submission was then made to the Ethics Committee and permission 15 to use results of the investigationsFor subsequently peer granted. review only 16 17 18 Study measurements and Procedures 19 All had detailed clinical, neurophysiologicelectrophysiologic, and brain imaging assessments 20 and laboratory testing. 21 22 Clinical assessment 23 The history included an inquiry of about the time from pregnancy to the onset and the Formatted: Tab stops: 5.06", Left 24 progressive development of symptoms, physical and functional difficulties. The physical clinical 25 9 26 examination included the general, nutritional , neurologic, cognitive and mental state 27 assessments. Wasting was defined as weight for height Z score of -<2 and stunting as height 28 for age Z score of -<2. Sexual maturity was assessed using the Tanner Sexual Maturity staging. 29 30 Patients were classified as having nodding syndrome only or nodding syndrome plus depending 31 on whether theyif they in addition also had complications such as a report of other seizure 32 types , neurologic and clinically evident cognitive decline, physical and functional difficulties. X- 33 http://bmjopen.bmj.com/ rays of the left wrist were taken for bone age and reported using a Greulich and Pyle Atlas by a 34 35 blinded radiologist20. Bone growth was considered delayed if it was 2 years below the 36 chronological age. Cognitive functioning was assessed in detail in four children - median age 37 14.5 (range 13-15) years - two weeks after initiation of sodium valproate using the Kaufman 38 nd 39 Assessment Battery for Children 2 Edition (KABC-2). This test has previously been adapted to 40 for use in Uganda21. All four had had symptoms for longer than five years.

41 on September 23, 2021 by guest. Protected copyright. 42 43 Laboratory procedures 44 Ten millilitres of blood was drawn for full blood count, ESR, malaria parasites, electrolytes, liver 45 and renal function tests, and HIV testing. Cerebrospinal fluid was examined for cells, glucose, 46 protein, microscopy and bacteriologic culture. In addition, 10 children had a skin snip examined 47 9 48 for Onchocerca volvulus as previously described . 49 50 51 52 Neurophysiology and imaging 53 54 6 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 30 of 49 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 7 7 8 9 All had a 30 minute EEG recording with an XLTECK EEG system (Optima Medical Ltd, London, 10 UK) using the 10-20 electrode placement system and the recording , which was examined 11 reviewed by a consultant neurophysiologist electrophysiologist clinical neurophysiologist(SW) in 12 13 the UK. Brain MRI in T1, T2 and Flair sequences were obtained without contrast in 19/22 14 patients using a 0.5Tesla machine (BASDA Medical Apparatus, Guangzhou) and the images 15 also examined in the UKFor by a Consultant peer Neuro-radiologist review (KC). only 16 17 18 Natural history and staging 19 At the end of the first week after patients and carers had acclimatised to the referral hospital 20 environment, the attending clinician sat with each carer and obtained detailed histories of the 21 22 progressive development and timing of symptoms and complications of nodding syndrome to 23 describe characterize the natural history. A standardised proforma with a diagrammatic 24 representation of possible events and a linear timeline was used to obtain these descriptions. 25 26 Information from each patient was plotted on the timeline and these later combined with that of 27 the data from other patients to identify emerging patterns, from which the proposed stages of 28 the disorder were then derived. 29 30 31 Treatment 32 Patients were started on symptomatic treatment (sodium valproate for seizure control, nutritional 33 http://bmjopen.bmj.com/ and physical therapy, counselling and social support) according to national guidelines 34 35 developed a month earlier22. In this management protocol, all received sodium valproate starting 36 at 10mg/kg/day. The dose was titrated in 5-10 mg/kg/day increases with according to the level 37 of seizure control. Nutritional rehabilitation included Ready to Use Therapeutic Foods 38 39 (Plumpy’Nut®, Nutriset, Malaunay) and locally prepared food. Occupational and physiotherapy, 40 family counselling and support were provided as appropriate.

41 on September 23, 2021 by guest. Protected copyright. 42 43 Data analysis 44 Data was analysed using STATA version 12 (STATA Corp, TX). Results are summarised as 45 frequencies, proportions and medians as appropriate. The clinical features, complications and 46 disability were then used to describe treatment and rehabilitation needs. Clinical stages were 47 48 identified and brain imaging and EEG correlated with the clinical stages. 49 50 51 52 53 54 7 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 31 of 49 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 8 7 8 9 RESULTS 10 11 General features 12 13 Nine patients (40.9%) were male. The age range was 12-18 years. The median age at onset of 14 symptoms was 6 (range 4–10) years and t. The the median duration of symptoms was 15 8.5(range 2-11) years (,For Table 1). Sixteen peer of the 22 families review reported multiple casesmore only than 16 17 one case; (median 2 (range 0–4), Table 1). Prior to hospitalisation, all patients had received 18 varying but mostly sub-therapeutic and intermittent antiepileptic drug treatment with 19 phenobarbitone, phenytoin or carbamazepine with no clear documentation of benefit. Treatment 20 had often been intermittent and at sub-therapeutic doses. 21 22 23 Striking features on physical examination included stunting, cognitive impairment (on KABC or 24 performance of basic tasks), lip changes (Figure 1) and with or without other physical 25 26 deformities. Several children had burns and scars from falls into fireburns. The skin was dry, 27 thin and scaly. Extremities, especially the feet, felt cold with a temperature gradient with the 28 trunk, but a normal capillary refill time. There were striking changes of the lower lip (Figure 1). 29 30 Among those with In mild lip changases, the lower lip was enlarged with no visible or palpable 31 localised swellings. In progressively more severe cases, the mucosa was deep purple, with soft 32 papular growths and increasingly large, thick bands of tissue. One child, not exposed to sodium 33 http://bmjopen.bmj.com/ valproate previously, had unexplained alopecia. 34 35 36 Table 1 Characteristics of 22 patients with nodding syndrome 37 ID Age Duration of Seizure based Main Psychiatric Other prominent EEG Seizure 38 (years) symptoms in classification morbidity complications classification 39 yrs 1 14 11 Head nodding plus Behaviour problems Severe cognitive Generalised 40 other seizures types impairment epileptiform Hallucinations Burns discharges 41 on September 23, 2021 by guest. Protected copyright. Lip deformity 42 Severe stunting, with severe wasting 43 Motor 44 difficultiesSpasticity and contractures with 45 musculoskeletal 46 deformities and contractures 47 2 13 5 Head nodding plus Hallucinations Moderate wasting Generalised 48 other seizures types Aggressive epileptiform behaviour discharges 49 3 15 10 Head nodding plus Behaviour problems Severe wasting Generalised other seizures types Aggression Speech difficulties epileptiform 50 Pycho-social discharges 51 disorder 4 14 9 Head nodding only Severe cognitive Generalised 52 impairment epileptiform 53 54 8 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 32 of 49 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 9 7 8 Stunting discharges 9 10 5 16 9 Head nodding plus Aggressive Severe cognitive Right temporal other seizures types behaviour impairment discharges 11 Wandering 12 Hallucinations Speech difficulties

13 Moderate wasting 14 6 14 5 Head nodding plus Generalised other seizures types epileptiform 15 For peer review onlydischarges 16 7 14 7 Head nodding plus Severe cognitive Generalised other seizures types impairment epileptiform 17 Lip deformity discharges Severe wasting 18 8 18 10 Head nodding plus Aggressive Severe cognitive Generalised 19 other seizures types behaviour impairment epileptiform discharges 20 Hallucinations Speech difficulties 21 9 18 8 Head nodding plus Psychotic Severe cognitive Left temporal other seizures types symptoms impairment discharges 22 Behavioural Lip deformity 23 problems 24 Speech difficulties

25 Severe wasting 26 10 16 11 Head nodding plus Moderate wasting Generalised other seizures types Burns epileptiform 27 Marked lip deformity discharges 28 11 15 9 Head nodding plus Depression Hearing impairment Generalised other seizures types Stunting epileptiform 29 discharges Burns 30 31 Musculoskeletal Deformities 32 Severe cognitive 33 impairment http://bmjopen.bmj.com/

34 Severe wasting 35 12 13 8 Head nodding plus Hallucinations Generalised other seizures types epileptiform 36 discharges 13 13 3 Head nodding plus Moderate wasting Generalised 37 other seizures types epileptiform 38 discharges 14 14 9 Head nodding plus Hallucinations Generalised 39 other seizures types epileptiform 40 discharges 15 12 8 Head nodding plus Severe wasting Generalised

41 other seizures types Stunting epileptiform on September 23, 2021 by guest. Protected copyright. 42 Kyphosis, pectus discharges deformity 43 Generalised skin 44 changes 16 12 2 Head nodding Stunting Generalised 45 aloneonly Severe wasting epileptiform discharges 46 17 14 8 Head nodding plus Post- ictal Severe cognitive Generalised 47 other seizures types Aaggression impairment epileptiform Stunting discharges 48 Wandering 49 Lip deformity,

50 Ataxia

51 Speech difficulties 52 53 54 9 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 33 of 49 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 10 7 8 Motor 9 difficultiesSpasticity 10 and contractures with musculoskeletal 11 deformities 12 Moderate wasting 13 18 18 6 Head nodding plus Moderate wasting Generalised 14 other seizures types epileptiform discharges 15 19 12 For4 Head peer nodding reviewModerate wasting onlyGeneralised onlyalone Stunting epileptiform 16 discharges 17 20 15 9 Head nodding Stunting Generalised onlyalone symptomatic 18 epileptiform 19 epilepsydischarges 21 15 9 Head nodding plus Severe cognitive Generalised 20 other seizures types impairment epileptiform 21 discharges Lip deformity 22 Speech difficulties 23 Stunting 24 Moderate wasting

25 Motor 26 disabilitySpasticity with contractures and 27 severe musculoskeletal 28 deformity, 29 wasting/dystrophy 22 15 9 Head nodding plus Behavioural Severe cognitive Generalised 30 other seizures types problems impairment epileptiform 31 Aggression Stunting discharges Burns 32 Episodes of

33 disorientation http://bmjopen.bmj.com/ Speech difficulties 34 35 36 Growth and sexual maturity 37 Sixteen of the 22 children were wasted and nine stunted. Increasingly more severe wasting was 38 observed with a longer duration of symptoms. Thus, patients with moderate wasting had 39 symptoms lasting 3-6 years, while severe wasting was more common among those with 40 symptoms lasting longer than 7 years. Ten had sexual maturity assessed; 3/10 children (aged 41 on September 23, 2021 by guest. Protected copyright. 42 12, 13, 14 years) scored Tanner Stage 3. All remaining 7 children (ages 12-17 years) were 43 either Tanner Stage 1 or 2. The bone age was delayed by a median 2(range 1-6) years. 44 45 46 Musculoskeletal findings 47 Almost all had peripheral muscle wasting with progressively flat feet and hands, thin cylindrical 48 49 digits and increasingprogressively, more generalised wasting. Other physical changes included 50 kyphosis and pectus deformities of the chest. Flexion limb deformities were seen in patients with 51 severe disability debilitated patients (Figure 2). 52 53 54 10 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 34 of 49 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 11 7 8 9 Neurological, cognitive and behavioural features 10 Seizures 11 Other than head nodding, a variety of other seizures types were described in 18/22 patients - 12 13 including absence, complex partial, myoclonic, and tonic-clonic seizures. were described in 14 18/22 patients. 15 a) Head nodding For peer review only Formatted: Normal, No bullets or numbering 16 17 Nodding was precipitated by food in 16/22 children. In 4/22, it was associated with cold weather 18 or a cold breeze, while in 13/22, it developed spontaneously. Nodding episodes came in 19 clusters occurring during (both the day and the night) and were characterised by repetitive 20 flexion and forward drop of the head. around the neck. The clusters of head nodding It lasted 21 22 several seconds to minutes. Some children became unresponsive and stared blankly with each 23 cluster of nodding, stopped feeding or drooled saliva. 24

25 26 b)a) Other seizure types 27 Initially head nodding was the predominant seizure type but as the disease progressed, 28 generalised tonic-clonic seizures gained became more prominentce. Myoclonic seizures were 29 30 not readily often reported, but were observed in several children while in hospital. One such 31 child had a prolonged cluster of nodding with concurrent myoclonic jerks involving both upper 32 limbs, lasting about 10 minutes. In a second child, similar myoclonic jerking was followed by a 33 http://bmjopen.bmj.com/ generalised tonic-clonic seizure. Several children reported had sudden falls, sustaining facial 34 35 and head injuries. 36 37 Four children reported experienced paroxysmal events associated with fear, panic and visual 38 39 hallucinations. We could not obtain clear descriptions of the images seen by two. The third child 40 would shout and run with onset of the hallucinations and the forth reported seeing a person with

41 knives whose intention ‘was to kill her’. None of these events was captured on EEG. on September 23, 2021 by guest. Protected copyright. 42 43 44 Other neurologic complications 45 Focal neurological signs were uncommon exception. There were no obvious cranial nerve 46 palsies. However, six children were lethargic with an apathetic and expressionless face or 47 48 ‘myopathic facies’. Three of the six drooled saliva while two had very slow speech and repeated 49 epileptiform (spike and wave) discharges on EEG. The deep tendon reflexes were increased in 50 a minority of patients. In the majority, however, the reflexes were either normal or reduced. 51 52 53 54 11 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 35 of 49 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 12 7 8 9 Almost all these had peripheral muscle wasting manifesting with flat feet and hands and thin 10 cylindrical fingers and progressively, generalised wasting. 11

12 13 Vision, hearing and speech difficulties 14 No parent reported visual impairment and we did not test visual acuity but hearing impairment 15 was reported in one child.For Speech difficultiespeer were reported review in 10/22 children. Theseonly included 16 17 immature speech for age and slow, slurred or dysarthric speech. Two children were mute but 18 retained gestural ability and receptive language. 19 20 Behaviour and psychiatric features and complications 21 22 The earliest psychiatric manifestation was wandering behaviour or running away. Because of 23 concerns about injury or getting lost, some parents tied up the patients to restrain them in the 24 home. Aggression, particularly towards familiar people, was reported in 6/22 cases, manifesting 25 26 3-6 years after onset of nodding. In two children, the onset was concurrent with wandering 27 behaviour. Five children had sleep difficulties and at least 8/22 had moderate to severe mood 28 problems with one clinically depressed. 29 30 31 Cognitive function 32 All 22 children had cognitive difficulties and were out of school. Academic performance declined 33 http://bmjopen.bmj.com/ with symptom onset; previously well performing with increasing as symptoms increased, pupils 34 35 started getting poorer grades and were eventually withdrawn from school within 2-4 years of 36 disease onset. Cognitive functioning, using the Kaufman Assessment Battery for Children 2nd 37 Edition (KABC-2), was assessed in four children ages 13-15 years two weeks after initiation of 38 39 sodium valproate. This test has previously been adapted to Uganda(Bangirana, Seggane et al. 40 2009). Three of the 4 children who had cognitive functioning assessed using the KABC-2

41 responded to the test instructions. The fourth child did not respond at all. All 3 children had on September 23, 2021 by guest. Protected copyright. 42 43 severe cognitive impairment (Table 2). 44 45 46 47 48 49 50 51 52 53 54 12 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 36 of 49 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 13 7 8 nd 9 Table 2: Cognitive function on the KABC 2 Edition in 3 children two weeks after Formatted: Superscript 10 initiation of sodium valproate 11 Cognitive Domain Patient 1 Patient 2 Patient 3 12 13 Male 13 years Male 15 years Male 15 years 14 15 ForTest Age peer Test reviewAge Test Ageonly 16 Score equivalent Score equivalent equivalent 17 in years in years Score in years 18 19 Working memory 8 <5 7 <5 21 =5 20 Planning 7 <8 1 <5 3 <5 21 22 Learning 28 <5 25 <5 54 =5 23 24 Visual spatial 0 <5 0 <5 31 <5 25 Knowledge 11 <5 5 <5 52 <8 26 27 28 Laboratory findings 29 30 The mean haemoglobin was 12.4 (range 10.8–14.8) g/dl and the mean red cell volume was 31 81.4 (range 65.8-89.1) fl. Five children had iron deficiency anaemia. The total white blood cell 32 and platelet counts were normal but 10/22 children had eosinophilia, median eosinophil count http://bmjopen.bmj.com/ 33 9 34 0.4 (range 0.1 – 1.9) x 10 /L. The ESR was high in 17/22 children with a median of 28.5 (range 35 5-90) mm in the first hour. Other than mild elevations of gamma GGT, the liver and renal 36 function was normal. All tested negative for malaria on admission to Mulago, althoughbut one 37 eventually subsequently developed malaria in the third week of hospitalisation. Nine children 38 39 had osteopenia on x ray but only one had hypocalcaemia and four, hypophosphataemia. 40 Creatine kinase levels were normal in all children and all tested HIV negative. Cerebrospinal

41 on September 23, 2021 by guest. Protected copyright. fluid total protein, cells and glucose were all normal and all bacteriologic cultures had no growth. 42 43 Three out of 10 patients had O.volvulus microfilaria on the skin snip. Microfilaria density was, 44 however, not reported. 45 46 47 EEG 48 The routine diagnostic EEG was abnormal in all cases. The background activity showed a 49 generalised excess of slow activity mainly in the conventional theta and delta frequency ranges. 50 Generalised inter-ictal epileptiform activity was observed in all but two patients, in whom, therey 51 52 were focal temporal discharges (unilateral in one and bilateral in the second). All patients with 53 54 13 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 37 of 49 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 14 7 8 9 generalised epileptiform activity had high amplitude spikes or sharp waves, some associated 10 with slow wave activity and often occurring in irregular bursts rather than runs (Figure 3). There 11 was no consistent frequency to this. The discharges had bilateral fronto-temporal or fronto- 12 13 centro-temporal emphasis, but some were more generalised and increased in frequency in light 14 sleep. There was a clear gradation from mild to more severe background abnormalities and 15 epileptiform activity. NoFor overnight recordingspeer were performed. review The EEG findings only suggested 16 17 symptomatic generalised epilepsy in 20 and symptomatic focal epilepsy in the remaining 2. 18 19 Brain imaging 20 Brain MRI without contrast was performed in 19/22 patients. The imaging showed different 21 22 degrees of cortical and cerebellar atrophy. No focal cerebral cortical or hippocampal changes 23 were observed (Figure 4). Cerebellar disease was evident in the majority of cases, but among 24 patients with especially generalised cortical atrophy, there was a suggestion of more atrophy in 25 26 the occipital lobes or the parieto-occipital regions than anteriorly. 27 28 Disease progression 29 30 Five stages with deteriorating seizures, neuro-cognitive and psychiatric disability were identified: 31 a prodrome; development of head nodding and cognitive impairment; other seizure types; 32 multiple complications and, severe debilitation (Panel 1). 33 http://bmjopen.bmj.com/

34 35 Panel 1: A mum’s description of the sequential chronology of symptoms and disease progression in her 18 year old daughter. 36 37 “She was growing well until the age of 8 years when symptoms of nodding began. The head nodding is triggered by 38 food. When food is given, she freezes with it in her hand, stares blankly into space with a fixed gaze, and then nods 39 repeatedly for a time which varies with each episode but the maximum time was initially 5 minutes. The symptoms 40 got worse with time and about 6 years later, the nodding symptoms were immediately followed by or associated with

41 big seizures during which the whole body shook. She would drool saliva, foam around the mouth and loses on September 23, 2021 by guest. Protected copyright. 42 consciousness. After the big seizure, she would sleep and on waking is often weak and sometimes disoriented. On 43 some nights, she reports seeing a figure that holds a knife and wants to kill her. She is distressed by her illness and 44 gets embarrassed on waking if she had a seizure in public. She is very quiet but sometimes aggressive. Overtime, 45 her speech has become sluggish. Although she is 18 years old, she still has childish behaviour which is evident as 46 she speaks. Her father died following a febrile illness. She has six siblings two of who have similar symptoms.” 47 48 49 50 51 52 53 54 14 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 38 of 49 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 15 7 8 9 Stage 1 The prodromal period 10 This poorly defined and short-lived period was reported in four patients. The earliest symptoms 11 included “dizziness” and increasing inattention. The children were excessively sleepy, lethargic 12 13 and would sometimes stare blankly during meals. 14 15 Stage 2 DevelopmentFor of head peernodding review only 16 17 Among the four patients reporting prodromal symptoms, head nodding developed within 6 18 weeks of the prodrome. In the majority, however, the initial feature was an abrupt onset of 19 nodding. Subsequently, parents reported declining cognitive abilities and behaviour difficulties. 20 Disease progression however appeared to arrest in these four. 21 22 23 Stage 3 Development of other seizure types 24 Other than Apart from the four children with nodding only, 18 children in addition developed 25 26 other seizure types including absence, complex partial, myoclonic and generalised tonic-clonic 27 seizures. One child developed generalised tonic clonic seizures almost simultaneously with the 28 nodding. In the others, however, additional seizure types these developed 1-3 years after initial 29 30 symptoms. It was around this time that almost all school going children dropped out of school. 31 32 Stage 4 Development of multiple complications 33 http://bmjopen.bmj.com/ Multiple complications developed 4-8 years after the initial symptoms, associated with marked 34 35 regression in achievement. These consisted of deteriorating behaviour and psychiatric 36 symptoms and a decline in motor, speech and other cognitive functions. Some patients 37 developed physical deformities including kyphosis, limb and pectus deformities (Figure 2). 38 39 Some sustained severe facial injuries with “drop attacks” and burns. Those who were still 40 independently mobile would wander about or ran run away and were prone to getting lost.

41 Changes in the architecture of the lower lips (Figure 1) also occurred at this time. With on September 23, 2021 by guest. Protected copyright. 42 43 disrupted and poor feeding, the children became severely wasted. 44 45 Stage 5 The sSeverely disabilityebilitated child 46 These children have little, if any, independent mobility. The general picture wais that of a 47 48 severely wasted child with apathy and depressive features including a flat affect, poor appetite 49 and limited speech. Some had contractures around the major joints. 50 51 52 53 54 15 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 39 of 49 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 16 7 8 9 Patients with head nodding only had less cortical and cerebellar atrophy on brain MRI compared 10 to those with multiple complications. In addition, there was a clear gradation from milder to more 11 severe epileptiform and background EEG abnormalities in patients with thesuggested later 12 13 clinical stages of the disease. 14 15 For peer review only 16 17 Response of seizures to sodium valproate 18 The patients had previously been on mostly small low doses of different various antiepileptic 19 drugs including phenytoin, phenbarbitone and carbamazepine. In conformity with proposed 20 national guidelines, all were started on sodium valproate and the other antiepileptic drugs 21 22 weaned off. Prior to this, a 24 hour seizure count was obtained and this was repeated 14 days 23 later. Overall, there was a 57% reduction in total seizures including clusters of nodding. The 24 median total daily number of seizures reduced from 5 (range 2–14) on admission to 2 (range 0- 25 26 8) 14 days after initiation of sodium valpraotevalproate. Concurrent improvements were also 27 seen on the EEG with substantially reduced marked improvements or absent interictal 28 discharges in 3/5 patients who had repeat recordings on the day of assessment (Figure 3). 29 30 31 DISCUSSION 32 Recently, world media has highlighted there have been media reports of “a mysterious disease” 33 http://bmjopen.bmj.com/ baffling scientists – the nodding syndrome.7 23 24 There are many uncertainties about this newly 34 35 recognized disorder: main questions are: what is the cause, the pathogenesis, disease 36 classification, clinical spectrum and treatment? In this paper, we describe the clinical features 37 and, complications of nodding syndrome in Ugandan children, together with the EEG and brain 38 39 imaging featuresappearances. Our results findings suggest that nodding syndrome is a 40 neurologic disorder characterised as by a symptomatic generalised epilepsy.

41 on September 23, 2021 by guest. Protected copyright. 42 43 Clinical features and complications 44 Nodding syndrome in Ugandan children manifests with head nodding, cognitive dysfunction, 45 psychiatric features, and/or multiple other seizure types. It may be complicated by stunted 46 growth, pubertal delay, wasting, motor decline and physical deformities. The earliest 47 48 manifestations are that of is a poorly defined prodrome followed within weeks by head nodding. 49 In the later stages, there is cognitive dysfunction, psychiatric difficulties disturbance, severe 50 muscle wasting and musculoskeletal deformity. Delayed physical growth, bone age and sexual 51 52 maturity are common in affected children. This may partly be a result of delayed puberty, since 53 54 16 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 40 of 49 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 17 7 8 9 most were in Tanner Stage 2. Pubertal delay may be secondary to chronic illness, poor nutrition 10 and/or psychosocial deprivation. If so, improved nutrition, a caring supportive environment and 11 symptom control should lead to improved growth and the initiation of puberty. 12 13 14 The progressive development of symptoms and complications stages of the disorder appears to 15 reflect the natural progressionFor of an epilepticpeer encephalopathy. review In Stage 1, there only are might be 16 17 brief seizures, while the departure from school in by Stage 3 can be explained by uncontrolled 18 seizures prevent the child from continuing in school. In Stage 4 can be the time when a high 19 seizure load burden contributes to regression, which together with ensuing poor nutrient intake 20 leaves a severely disabled ebilitated child in by Stage 5, when the sum effect of multiple factors 21 22 on impair functioning. 23 24 The clinical features in Ugandan children are as severe as in South Sudanese children,6 but 25 9 26 may be more severe than that reported in Tanzanian patients . Despite similar age of onset and 27 duration of symptoms, only 18% of Ugandan children had the milder nodding only variant, 28 compared to 45% in Tanzania; all our patients had abnormal interictal background EEG 29 30 compared to 60% in Tanzania. Ugandan children also had severer more severe cognitive 31 impairment and a much higher greater burden and variety of seizures. These differences may 32 suggest a variation in the presentation of the disease by region. Family clustering in all three 33 http://bmjopen.bmj.com/ countries, however, suggests a common exposure factor. 34 35 36 Aetiology and pathogenesis 37 The aetiology of nodding syndrome and pathogenesis of the complications remain unknown. A 38 39 variety of viral central nervous system infections have been screened for on PCR but no 40 association has been demonstrated19. There is uncertain An association with infestation with

41 Onchocerca Volvulus however remains has been reported in some series,5 9 but . Others have on September 23, 2021 by guest. Protected copyright. 42 43 postulated that nodding syndrome is a consequence of treatment of patients with heavy 44 Onchocerca volvulus infestation or dual infection with other similar parasites. Ccontrary 45 evidence of any association with onchocerciasis also exists has not been evident in other 46 studies.18 25. Other aetiologic considerations have included toxic brain injury, an inflammatory 47 48 brain disease, a slow virus infection or prion disease, an atypical mitochondrial disease or other 49 genetic disorder. Repeated severe psycho- psychological trauma has also been proposed as a 50 mechanism26. Earlier studies by the Ugandan Ministry of Health and the US Centers of Disease 51 52 Control found demonstrated a higher proportion of cases with very low serum levels of vitamin 53 54 17 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 41 of 49 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 18 7 8 9 B6 in cases compared to controls. Although unlikely, the question then was the possibility was 10 raised that whether nodding syndrome could be is an atypical form of pyridoxine dependent 11 epilepsy.? Studies to further investigate explore this hypothesis further this are awaited27. 12 13 14 Children with the syndrome demonstrate show some features reminiscent of prion protein 15 disease, including motorFor and cognitive peer dysfunction, review epilepsy, behaviour and only psychiatric 16 17 morbidity. However, other features commonly seen in prion disease - such as extrapyramidal 18 involvement and cortical blindness - have not been reported. The age of onset of symptoms is 19 also much younger and progression much slower28. The brain imaging and EEG findings too 20 are not suggestive of prion disease.supportive. Nevertheless, B brain biopsy or autopsy studies 21 22 would be important in excluding prion disease. Future studies should also include consider the 23 recently described the auto-immune encephalitides. 24

25 26 The brain MRI findings may might suggest viral encephalitis, a para-infectious phenomenon 27 (such as an antibody- mediated channelopathy) or an outside chance of even a neurotoxin as 28 possible aetiologies. A genetic disorder or metabolic disease is also possible. Future studies 29 30 should also consider the recently described auto-immune encephalitides. Some cases however 31 did not exhibit these finding and therefore further evaluation is needed. Among Tanzanian 32 patients, hippocampal gliosis, probably from inflammation, was described in some patients9. 33 http://bmjopen.bmj.com/ Although this could partly explain the cognitive difficulties, we did not observe such lesions, 34 35 even in the sub-group with with the more severe cognitive impairment. in our patients. Instead, 36 we We consider that think an epileptic encephalopathy is more likely. The background EEG in 37 all 22 cases showed a generalized excess of theta and slow activity. Interictal epileptiform 38 39 activity was demonstrated in all but one patient. Prolonged EEG recording (including during 40 sleep) with detailed neuropsychological testing and functional brain imaging may help with

41 understanding the pathogenesis of the cognitive decline. on September 23, 2021 by guest. Protected copyright. 42 43 44 Study limitations 45 Our patients may not be a representative sample, as they were not drawn randomly from the 46 community. This The study did not investigate aetiology and the proposed staging was mostly 47 48 derived primarily from parental descriptions rather than prospective observations and so 49 therefore may be influenced by recall bias.suffers from recall. Third, we We only performed 50 routine diagnostic EEGs, rather than prolonged recordings which are important in investigating 51 52 53 54 18 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 42 of 49 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 19 7 8 9 associations between seizures and cognitive dysfunction. The resolution of our MRI images is 10 also quite low. 11

12 13 CONCLUSIONS 14 Nodding syndrome is a neurologic disorder that is complicated by multiple physical and 15 functional disabilities andFor may be classified peer considered asreview a symptomatic generalised only epilepsy. 16 17 Assessment and care should be provided by a multidisciplinary team. Studies of aetiology, 18 pathogenesis, evidence- based treatment and rehabilitation strategies are urgently needed. 19 20

21 22 Acknowledgements 23 We would like to thank Drs Aggrey Dhabangi, Ruth Lanyero, Betty Lanyero and Odong Ochaya 24 who helped with the daily clinical care, the nursing team of Acute Care Unit where the children 25 26 were resident and Dr Faith Ameda who reported the x rays. We also thank Prof Charles Newton 27 and Prof Chandy John, who read through the draft manuscript and offered valuable comments 28 to improve it. 29 30 31 Author contributions 32 Rl, ROO, AKM, HAT, TPW, PB, JN1, SBM, ADM, HN, SW, EM, JN2, SK, JRA and JKT all 33 http://bmjopen.bmj.com/ participated in patient care and performed the different assessments. ROO, AKM, HAT and 34 35 SBN were in-charge of daily care, TPW and EM performed the growth and sexual staging 36 assessments, JN1 the psychiatric assessments, HN the nutrition assessment, SW reported the 37 EEG recordings, KC the brain MRI and Rl wrote the first draft. All provided a critical review of 38 39 the manuscript. 40

41 Conflict of Interest on September 23, 2021 by guest. Protected copyright. 42 43 The authors report no competing interests. 44 45 Funding 46 This work was supported by the Government of Uganda through the Ministry of Health and by 47 48 the Waterloo Foundation through grant number 1025/1490 to Dr ldro. The funding agency had 49 no role in data collection, analysis, and interpretation of results and in the decision to submit for 50 publication. 51 52 53 54 19 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 43 of 49 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 20 7 8 9 Reference 10 1. Korevaar DA, Visser BJ. Reviewing the evidence on nodding syndrome, a mysterious tropical 11 disorder. International journal of infectious diseases : IJID : official publication of the 12 International Society for Infectious Diseases 2013;17(3):e149-52. 13 2. Aall L. Epilepsy in Tanganyika. Review and Newsletter- Transcultural Research in Mental Health 14 Problems 1962;13:54–7. 15 3. Goudsmit J, van derFor Waals FW. Endemicpeer epilepsy inreview an isolated region of Liberia.only Lancet 16 1983;1(8323):528-9. 17 4. Lacey M. Nodding disease: mystery of southern Sudan. Lancet neurology 2003;2(12):714. 5. Nodding syndrome - South Sudan, 2011. MMWR. Morbidity and mortality weekly report 18 2012;61(3):52-4. 19 6. Nyungura JL, Akim, T., Lako, A., Gordon, A., Lejeng, L., Gibson, W. Investigation into the Nodding 20 syndrome in Witto Payam, Western Equatoria State, 2010. Southern Sudan Medical Journal 21 2011;4. (1):3-6. 22 7. Wasswa H. Ugandan authorities deal with a mysterious ailment that leaves people nodding 23 continuously. BMJ 2012;344:e349. 24 8. Sejvar JJ, Kakooza AM, Foltz JL, Makumbi I, Atai-Omoruto AD, Malimbo M, et al. Clinical, 25 neurological, and electrophysiological features of nodding syndrome in Kitgum, Uganda: an 26 observational case series. Lancet neurology 2013;12(2):166-74. 27 9. Winkler AS, Friedrich K, Konig R, Meindl M, Helbok R, Unterberger I, et al. The head nodding 28 syndrome--clinical classification and possible causes. Epilepsia 2008;49(12):2008-15. 10. Winkler AS, Friedrich K, Meindl M, Kidunda A, Nassri A, Jilek-Aall L, et al. Clinical characteristics of 29 people with head nodding in southern Tanzania. Tropical doctor 2010;40(3):173-5. 30 11. Wendo C. Northern Uganda humanitarian crisis shocks UN chief. Rebels in northern districts have 31 left people trapped in hunger, disease, poverty, and fear. Lancet 2003;362(9398):1818. 32 12. Leonard PJ, Stanfield JP. Some biochemical observations in the Nakalanga. East African medical 33 journal 1965;42(12):692-4. http://bmjopen.bmj.com/ 34 13. Jelliffe DB, Jones PR, Stroud CE. Nakalanga notes on the endemic dwarfism of Uganda. Tropical 35 and geographical medicine 1962;14:97-104. 36 14. Marshall AJ, Cherry JK. Endocrine dysfunction in a Nakalanga dwarf. Transactions of the Royal 37 Society of Tropical Medicine and Hygiene 1961;55:188-91. 38 15. Kipp W, Burnham G, Bamuhiiga J, Leichsenring M. The Nakalanga syndrome in Kabarole District, 39 Western Uganda. The American journal of tropical medicine and hygiene 1996;54(1):80-3. 40 16. Kipp W, Kasoro S, Burnham G. Onchocerciasis and epilepsy in Uganda. Lancet 1994;343(8890):183- 4. 41 17. Pion SD, Kaiser C, Boutros-Toni F, Cournil A, Taylor MM, Meredith SE, et al. Epilepsy in on September 23, 2021 by guest. Protected copyright. 42 onchocerciasis endemic areas: systematic review and meta-analysis of population-based 43 surveys. PLoS neglected tropical diseases 2009;3(6):e461. 44 18. Konig R, Nassri A, Meindl M, Matuja W, Kidunda AR, Siegmund V, et al. The role of Onchocerca 45 volvulus in the development of epilepsy in a rural area of Tanzania. Parasitology 46 2010;137(10):1559-68. 47 19. WHO. International Scientific Meeting on Nodding Syndrome. Geneva: World Health Organization, 48 2012:1-42. 49 20. Acheson RM, Fowler G, Fry EI, Janes M, Koski K, Urbano P, et al. Studies in the Reliability of 50 Assessing Skeletal Maturity from X-Rays. I. Greulich-Pyle Atlas. Human biology 1963;35:317- 51 49. 52 53 54 20 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 44 of 49 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 21 7 8 9 21. Bangirana P, Seggane M, Allebeck P, Giordani B, John CC, Opoka OR, et al. A preliminary 10 examination of the construct validity of the KABC-II in Ugandan children with a history of 11 cerebral malaria. African health sciences 2009;9(3):186-92. 12 22. Ministry of Health U. Nodding Syndrome; Health Workers Training Manual. Draft Edition; February 2012 ed. Kampala: Ministry of Health, 2012:1-107. 13 23. Williams SC. Nodding syndrome leaves baffled scientists shaking their heads. Nature medicine 14 2012;18(3):334. 15 24. Edwards J. Nodding diseaseFor confounds peer clinicians. CMAJ review: Canadian Medical Association only journal = 16 journal de l'Association medicale canadienne 2012. 17 25. Twum-Danso NA. Mass treatment of onchocerciasis with ivermectin: should people with epilepsy 18 and/or growth-retardation syndromes be excluded? Annals of tropical medicine and 19 parasitology 2004;98(2):99-114. 20 26. Nodding Disease In Northern Uganda - A Possible Relationship To Psychotrauma. . 7th MakCHS 21 ANNUAL SCIENTIFIC CONFERENCE, 19thUNACOHANNUAL SCIENTIFIC CONFERENCE, 10th WHO 22 DR. MATHEW LUKWIYA MEMORIAL LECTURE; 2011; Speke Resort, Munyonyo, Kampala, 23 Uganda. Makerere University College of Health Sciences 24 25 27. Donnelly J. CDC planning trial for mysterious nodding syndrome. Lancet 2012;379(9813):299. 26 28. Wadsworth JD, Collinge J. Update on human prion disease. Biochimica et biophysica acta 27 2007;1772(6):598-609. 28 29 30 31 32

33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40

41 on September 23, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 21 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 45 of 49 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 1 2 3 4 5 6 22 7 8 9 Figure legends 10 11 Figure 1 Lip changes 12 13 The figure shows changes in the lips with increasing distortion. In patients with mild 14 involvement, the lower lip is enlarged but with no visible or palpable swellings. With more severe 15 involvement, there is deepFor purple discolourationpeer of thereview mucosa, soft papular only growths and 16 17 increasingly larger and thicker bands of tissue. Other oral abnormalities included lacerations 18 and loss of teeth from injuries. 19 20 Figure 2 Hand and foot mMuscle wasting, deformities and contractures 21 22 Figure 2 shows wasting of the muscles of the hand and foot, knee and foot flexion deformities 23 and contractures, pectus deformity of the chest and kyphosis. Such marked deformities weare 24 seen with increasing symptom duration. 25 26 27 Figure 3 EEG recordings 28 Figure 3 is an EEG recording of a 12 year old girl. She had head nodding and cognitive 29 30 impairment. During the recording, interictal epileptiform discharges (spikes and sharp waves) 31 were observed in wakefulness (3a) and during light sleep, when increasingly more florid 32 prominent epileptiform discharges were evident.observed. There was no apparent clinical event 33 http://bmjopen.bmj.com/ with this recording change with these discharges (3b). 34 35 36 Figure 4 Brain MRI 37 Figure 4 shows T2-weighted brain MRI images in the axial (Fig 4a, 4b) and sagittal (Fig 4c, 4d) 38 39 plane showing marked cerebellar atrophy and generalised cerebral atrophy. 40 Figure 4 shows T1 and T2 brain MRI images of a 15 year old boy. He had head nodding,

41 myoclonic and absence seizures but no tonic clonic seizures. There is cortical brain atrophy with on September 23, 2021 by guest. Protected copyright. 42 43 widening of adjacent sulci, but no focal lesions or obvious abnormalities in the hippocampi. 44 45 46 47 48 49 50 51 52 53 54 22 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from

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11 http://bmjopen.bmj.com/ 12 13 14 15 16 17 18 19 20 on September 23, 2021 by guest. Protected copyright. 21 22 23 24 25 26 27 28 29 30 31 4d 32 33 4c 34 35 36 37 38 39 40 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from 6-7 6-7 6-7 6-7 5-7 5-7 4 4 5-7 5-7 7 7 5 5 - 5 5

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Main resultsMain

Outcome Outcome data

Descriptive data

Participants Results

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Nodding Syndrome in Ugandan Children - Clinical features, Brain imaging and Complications; an observational case series

For peer review only Journal: BMJ Open

Manuscript ID: bmjopen-2012-002540.R2

Article Type: Research

Date Submitted by the Author: 05-Apr-2013