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Free PDF Download European Review for Medical and Pharmacological Sciences 2019; 23: 2188-2193 Paroxysmal non-epileptic events in the pediatric emergency department D. BUONSENSO1, M. PLOSNIC2, G. BERSANI1, S. MONACO1, P. FERRARA3, A. CHIARETTI1,3 1Department of Pediatrics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy 2University of Split, School of Medicine, Split, Croatia 3Department of Pediatrics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy Abstract. – Paroxysmal non-epileptic events In most cases, PS are referred to the Emer- (PNEs), or pseudoseizures (PS) resemble ep- gency Department (ED) because of the patient’s ileptic seizures. They are considered part of poor response to conventional antiepileptic drugs a personality disorder and have a higher inci- and compromising hemodynamic and respiratory dence among adolescents. Patients describe episodes (lasting up to 20 minutes) of loss of parameters. The apparently critical condition of consciousness, twitching or jerking and unusu- these patients during the clinical evaluation is the al emotional states. Unlike epileptic seizures, main cause of their Pediatric Intensive Care Unit they are not associated with electroencepha- (PICU) admission and may justify an extensive lographic abnormalities. Distinguishing epilep- workup in order to exclude anatomical disease. tic seizures from PNEs is not easy. 20% of pa- We describe two cases of adolescents who expe- tients with seizures have a final PNEs diagno- rienced a long and difficult course in our PICU sis but recognizing them on the first examina- tion is difficult. before the diagnosis of PS was set. Due to the severe initial clinical presenta- tion, these patients are often admitted in the Pediatric Intensive Care Unit (PICU) and may Case Reports be over-treated. We report two cases admitted to our PICU for apparent status epilepticus, in Case 1 which the final diagnosis was PNEs. A 13-year-old female was admitted to the ED for an episode of gradually decreasing respon- Key Words: siveness to verbal stimuli and seizures charac- Children, Emergency room, Pseudoseizures. terized by uncoordinated clonic movements. The patient was at home with her parents when the event occurred. Intravenous (IV) lorazepam and Introduction phenytoin were administered and seizure control was achieved 15 minutes after the infusions. Nei- Paroxysmal non-epileptic events (PNEs), or ther urinary nor fecal incontinence was observed. Pseudoseizures (PS), are considered to be behav- A cranial computerized tomography (CT) scan, ioral disorders with clinical manifestations that an electroencephalogram (EEG) and cerebrospi- mimic seizures and status epilepticus1. Several cas- nal fluid (CSF) cultures were normal. es are described in adults but there is limited data Her family history was positive for Guil- in the pediatric population. However, compared to lain-Barre` syndrome which occurred in the fa- adults, the prognosis in the pediatric population is ther at the age of 28. Her personal history was better2,3. The medical history often includes sexual unremarkable, except for a weight gain of 10 kg or physical abuse, personality disorders, alcohol- in the last two months. For this reason, the patient ism and psychiatric diseases4. Psychotherapy is the was on a dietetic regimen. only treatment available, even though recovery is Due to the persistence of a decreased level of not always achieved. Treatment of the underlying consciousness, the patient was referred to our behavioral disorder is the main goal of therapy and PICU. On admission the patient was drowsy. Ar- may require an interdisciplinary approach. terial oxygen saturation was 99% on the room air. 2188 Corresponding Author: Danilo Buonsenso, MD; e-mail: [email protected] Paroxysmal non-epileptic events in the pediatric emergency department Neurological examination showed a decreased cultures were negative, while an interictal EEG response to verbal and painful stimuli and loss showed a diffuse slowing pattern. Due to the per- of right hand sensation with “glove” distribution. sistence of these symptoms, he was hospitalized Neither rigor, nuchal nor cervical motility abnor- in our PICU. On admission, a similar episode was malities were observed. No autonomic changes, treated with intravenous lorazepam (0.1 mg/kg), such as sweating, salivation and altered pupillary without response. A bolus of intravenous pheno- responses occurred. A few hours after admission barbital was administered (10 mg/kg) with good in our PICU, the clinical condition of the patient control of the event. Suspecting an epileptic sei- got worse. An episode of loss of conscious- zure, an interictal EEG was performed. Results ness occurred, associated with bilateral clonic were normal. Shaking movements persisted over movements, which was treated with intravenous the following days, which did not respond to an- lorazepam 0.1 mg/kg. Because of persisting clin- tiepileptic drugs (lorazepam and phenobarbital). ical symptoms, intravenous steroids (dexametha- None of the events was followed with postictal sone 0.5 mg/kg/day) were initiated. A peripheral stupor. All laboratory and radiological investi- neuropathy of unknown origin was suspected. gations (blood tests, inflammatory markers, cer- During the following five days the patient grad- vical and cranial CT scan, MRI, transcranial ually improved; she remembered her seizures Doppler sonography, cerebral angiography, and describing them as “gradual loss of conscious- somatosensory evoked potentials) were negative. ness” and “vertigo”. On day 7, another loss of An ictal EEG performed during one prolonged consciousness episode occurred, associated with episode was normal. For this reason, a neuropsy- bilateral clonic and hypertonic movements. A chiatric consultation was requested. Their diag- bolus of intravenous lorazepam was administered nosis was psychogenic non-epileptic crisis due (0.1 mg/kg) without efficacy. A bolus of intra- to bipolar disorder. Psychotherapy was started, venous phenobarbital (10 mg/kg) followed. The and at one-year follow-up period, the general episode stopped 25 minutes after the infusion. condition of the child was good with no further Further diagnostics included cranial and cervical episodes of PS. magnetic resonance imaging (MRI), interictal EEG, electromyography, evoked motor poten- tials, echocardiography, blood and CSF cultures, Discussion serologic examinations for Poliovirus, Echovirus, Coxsackie, Borrelia, immunoglobulin and com- PNEs are clinical events that resemble epilep- plement levels. All results came out negative. tic seizures but without abnormal electrical dis- Lacking any abnormal results and having organic charges on EEG. The prevalence of PNEs in the disease excluded, a neuropsychiatric consultation general population is believed to be in the range was requested one week after admission. The of 1/3000 to 1/50,000, although it is recognized patient was diagnosed with bipolar disorder and that this may be a low estimate resulting from underwent psychotherapy for 2 years. She is underreporting and diagnosis5. The prevalence currently in good clinical condition and during a varies with the population studied. Health care three-year follow-up has experienced no further resources expended on people with PNEs consti- episodes of PS. tute 10-40% of admissions to inpatient adult and pediatric epilepsy monitoring units and 5%-20% Case 2 of referrals for intractable epilepsy6-10. A 13-year-old male was admitted to an out- These events may occur as a somatoform dis- lying hospital for gradual loss of consciousness, order with underlying psychiatric disease (bipolar which progressed, into a comatose state, follow- disorder, depression, anxiety) and tend to happen ing a prolonged (30 minutes) seizure-like event. more frequently during adolescence, although His past history was unremarkable, except for they have been reported in all pediatric age one episode of loss of consciousness during a groups3,4. One recent study implied that PNE may football match. The family history was positive be associated with psychosocial stressors in med- for epilepsy in the paternal line. During hospital- ical history, such as parental divorce, a move to ization, several episodes of tonic clonic seizures another city, loss of a close family member, school with bilateral shaking movements were observed failure and sexual (21%) or physical (6%) abuse11. but without autonomic changes, altered pupillary PNEs are not usually followed by these psycho- responses or amnesia. Cranial CT scan and CSF logical stressors immediately. Instead, they occur 2189 D. Buonsenso, M. Plosnic, G. Bersani, S. Monaco, P. Ferrara, A. Chiaretti months or years after the stressor indicating that PNEs may occur with a bizarre motor activity the occurrence of trauma may be more important which is not typical in known types of epileptic than how recently it has occurred12. Other risk seizures, including generalized arrhythmic flail- factors associated with a higher incidence of PS ing of extremities, uncoordinated movements, are a history of head trauma and a positive family arching in hyperextension, flailing or thrashing history of epilepsy. It is common for these chil- of body and swooning10,20-22. dren to try to imitate the clinical features of epi- As was evident in our cases, autonomic chang- leptic seizures noticed in their families, in order es such as sweating, salivation and altered pupil- to avoid
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