Lamotrigine-induced rash--worth a rechallenge.

OBJECTIVES: The only serious adverse event associated with lamotrigine (LTG) treatment is a hypersensitivity reaction primarily presenting as a rash. Despite this concern, LTG is an antiepileptic drug (AED) with one of the most favorable efficacy/tolerability ratio compared with the new as well as the old AEDs. Thus, this study aimed to evaluate the results of rechallenge with LTG after the initial rash. MATERIAL AND METHODS: A total of 688 patients (350 as monotherapy, and 338 as add-on therapy) with either idiopathic generalized epilepsy or focal epilepsy were treated with LTG. The patients with LTG-induced rash were rechallenged to LTG. The dosage schedule was: 5 mg every day or every second day for 14 days, increased by 5 mg every 14th day to 25 mg a day. After achieving the daily dosage of 25 mg/day, the up-titration was completed following the current guidelines. RESULTS: A total of 52 patients developed a rash. The LTG-induced rash occurred in 6%, where 12 (1.8%) developed a rash shown to be coincidentally associated with the initiation of LTG therapy. In their cases LTG was continued with success without intermission. Nineteen (38%) of the initial cohort were rechallenged with LTG, with a success rate of 84%. CONCLUSION: This study is the first one to provide a successful recipe verified in time for the rechallenge with LTG after the initial drug-induced rash. Importantly, the concurrent use of valproate (VPA) was not found in this study to represent an additional risk factor for the occurrence of the rash during rechallenge with LTG. Our results agree with previous findings that women are more likely to develop the rash (P < 0.009).

Cardiac troponin levels following monitored epileptic seizures.

Cardiac arrhythmia associated with myocardial injury is a proposed mechanism for sudden unexplained death in epilepsy. The authors measured serial cardiac troponin levels in 11 patients after monitored seizures. Using highly sensitive assays and criteria, no troponin elevations were seen, indicating that myocardial injury does not occur during uncomplicated seizures. An elevation in postictal troponin elevations should suggest the presence of cardiac injury secondary to neurocardiogenic mechanisms or primary cardiac factors, prompting further evaluation.

Evidence of cardiac ischemia during seizures in drug refractory epilepsy patients.

The authors investigated whether patients with drug refractory epilepsy have cardiovascular abnormalities that might be related to a high frequency of sudden death. Twenty-three subjects underwent comprehensive cardiovascular evaluations before and during video-EEG monitoring. ST-segment depression occurred in 40% and was associated with a higher maximum heart rate during seizures. These data suggest that cardiac ischemia may occur in these patients.

Atrio-ventricular block: a possible explanation of sudden unexpected death in epilepsy.

INTRODUCTION: This is the third case report describing the occurrence of total atrio-ventricular (AV)-block as a life threatening cardiac arrhythmia complicating epileptic seizures. CASE REPORT: A 56-year-old right-handed man was admitted to our hospital for surgical assessment of his medically intractable epilepsy. During the hospitalization he was enrolled in a study investigating cardiac complication of epileptic seizures as the possible cause of sudden unexplained death among epileptics. DISCUSSION: To the best of our knowledge, we are the first to employ simultaneous video-electroencephalogram-, Holter- and pulse oximetry-recordings of our patients in the description of this complication. These recordings allowed us to discuss the evidence and consequences of this particular cardiac abnormality as an explanation of sudden unexplained death in epileptic seizures, especially those of temporal origin.

Advances in neuroimaging: non-substrate-directed partial epilepsy.

Contemporary neuroimaging studies using structural and functional techniques are critical in the evaluation of patients with localization-related epilepsy. Imaging procedures may be used to localize the epileptic brain tissue or determine the likely pathologic findings underlying the epileptogenic zone, or both. The diagnostic yield of magnetic resonance imaging (MRI) has been demonstrated in patients with partial epilepsy. The identification of an MRI epileptogenic lesion is almost invariably a reliable indicator of the site of seizure onset. Peri-ictal single photon emission computed tomography (SPECT) may be of particular benefit in patients with normal MRI studies. The use of neuroimaging in the care and management of patients with partial epilepsy is discussed here.

Fracture risk is increased in epilepsy.

OBJECTIVES: To study fracture rates and risk factors for fractures in non-institutionalized patients with epilepsy. MATERIAL AND METHODS: Historical follow-up. Self-administered questionnaires were issued to 755 patients with epilepsy (ICD 10: G40.0 to G40.9) and 1000 randomly selected controls from the background population. RESULTS: A total of 345 patients (median age: 45, range 17-80 years) and 654 control subjects (median age: 43, range 19-93 years) returned the questionnaire. Before epilepsy was diagnosed there was no difference in overall fracture rate between patients and controls (RR = 1.0, 95% CI: 0.8-1.3). After the diagnosis the overall fracture rate was significantly higher in the patients (RR = 2.0, 95% CI: 1.6-2.5). Fractures of the spine, forearms, femurs, lower legs, and feet and toes were significantly increased. Fractures related to seizures accounted for 33.9% (95% CI: 25.3-43.5%) of all fractures. After elimination of seizure related fractures the increase in fracture frequency was only borderline significant: RR = 1.3 (95% CI: 1.0-1.7, P = 0.042). No difference in fracture energy between patients and controls was observed (low energy fractures: 1.7/1.4%, medium energy fractures: 59.8/52.0%, and high energy fractures: 38.3/46.6%). Use of phenytoin (OR = 2.4, 95% CI: 1.1-5.4) and a family fracture history (OR = 2.4, 95% CI: 1.3-4.6) was associated with an increased fracture risk. CONCLUSIONS: Fractures were more common in epileptics than in controls especially among users of phenytoin. Most of the increase in fracture frequency was related to seizures and not to low bone biomechanical competence.

ECG changes in epilepsy patients.

OBJECTIVES: To investigate the frequency of ECG abnormalities suggestive of myocardial ischaemia in patients with severe drug resistant epilepsy and without any indication of previous cardiac disease, assuming that these changes may be of significance for the group of epileptic patients with sudden unexpected death. MATERIAL AND METHODS: Twelve patients with medically intractable epilepsy were investigated with simultaneous long ECG and EEG recordings while attending either epilepsy surgery investigational procedures or the investigational programme for diagnostic purposes, and one while having an episode of status epilepticus. RESULTS: The ECG recording failed in 1 patient. This patient had chest pain and minor yet morphologically conspicuous changes in the ECG, suggestive of myocardial infarction. He died in heart arrest. Eight epilepsy patients had episodes of ST segment depression in the ECG, many of which coincided with video- and EEG documented epileptic seizures. Two patients experiencing simple partial seizures and 1 patient experiencing absence seizures had no ST segment depressions in the ECG. One patient had an episode of status epilepticus secondary to brain damage and no ST segment deviation was seen during the ECG recording which continued until 3 h before the patient died. CONCLUSION: Patients with severe drug resistant epilepsy have episodes of ST segment changes, some of which are closely related to epileptic seizures. Further studies are needed to confirm the present results and to investigate the nature of these changes and document the effect of prophylactic treatment with cardioactive drugs to reduce the risk of sudden death.

A 15-year follow-up of phenytoin-induced unilateral gingival hyperplasia: a case report.

INTRODUCTION-The aim of this case report is to present a 15-year follow-up of a patient with phenytoin (PHT) intoxication with unilateral gingival hyperplasia (GH). MATERIAL AND METHODS-A 50-year-old woman was followed-up for 15 years clinically and paraclinically after a heavy PHT intoxication. Her immunoglobulins in serum were checked on PHT and after 15 years treatment with carbamazepine. RESULTS-A gross mass of hyperplasia tissue found primarily in the left side of her mouth had disappeared and serum IgA which was subnormal at the first visit had normalized. CONCLUSION-It is possible to prevent GH from PHT treatment by intensive dental care, correct mouth hygiene and by change of treatment of carbamazepine.