FM SEPTEMBER 2018 ISSUE - digital edition

case reports
HEART RHYTHM DISORDERS
MIMICKING EPILEPSY
Cardiac evaluation to rule out arrythmias shall be considered for children
having doubtful epilepsy, show case studies
Typical epileptic seizures can vary from brief to long
periods of vigorous shaking. However, epileptic seizures
may also be associated with sudden unconsciousness
and/or rolling of the eyes. Here is the story of a young girl who
suffered from on-and-off headaches and had fainting spells
associated with rolled up eyes and bladder incontinence. Her
EEG and MRI were normal, and she was initially diagnosed
with generalized idiopathic and probably myoclonic epilepsy.
However, anti-epileptic drugs were not effective for her
and even after several different treatment regimens, she
continued to have identical episodes every 5-6 months. She
was eventually brought to a senior paediatric neurologist, Dr.
K. N. Shah, at Lilawati Hospital & Research Centre in Mumbai.
Upon probing into her family history, her parents talked
about another child who also had similar episodes from the
age of 5 years. This child had been similarly diagnosed with
idiopathic and myoclonic epilepsy, and was on anti-epileptic
drugs without benefit. Unfortunately, she died at 11 years of
age during one such episode. Her parents
were desperate to not lose another child, “We
don’t want this daughter to die too. Please do
something. We are not interested in whether
this is epilepsy or not.”
Based on the history of the sudden
death of her sister, and failure to control
her episodes with anti-epileptic drugs, the
neurologist speculated whether it could be
due to cardiac arrhythmia. In children, cardiac
arrhythmia can lead to neurocardiogenic
syncope that resembles epilepsy. She was then
referred to a cardiologist, Dr. Amit Vora, for a
cardiac evaluation where ECG, 2D echo, head
tilt test, stress test, and 48-h Holter monitoring
was done. While ECG, 2D echo, head tilt and
stress tests were normal, the Holter monitoring
showed multiple, rapid polymorphic ventricular
tachycardia episodes, suggestive of cardiac
arrhythmia. In order to prevent sudden death
like her brother, a cardiac pacemaker was put
in and for the last 7 years, the child has had
no repeat episodes. In cases of a family history
of juvenile sudden death, cardiac arrhythmias
may be caused due to mutations in the genes
for cellular transmembrane ion channels.
Genetic diagnosis can be made with nextgeneration
sequencing (NGS). However, in this
case, the patient could not afford the test and
the mutations were not verified.
More recently, Dr. Shah encountered
another similar case. Eleven-year old Geeta
(name changed) in Sholapur had similar
episodes of fainting. Her twin sister, Seema,
had also been having such episodes and
had been diagnosed with epilepsy. However,
during one such episode, Seema dropped
dead while playing in front of her family
members. Now, Geeta also started having
the same episodes. MRI and EEG were done
68 / FUTURE MEDICINE / SEPTEMBER 2018