Intravenous immunoglobulins for epilepsy

Further delineation of primary B cell immunodeficiency caused by novel variants of the BLNK gene in two Chinese patients

Biallelic variants in BLNK cause primary B-cell immunodeficiency that usually results in absence of B cells and immunoglobulin. Here, we identified disease-causing variant(s) in two unrelated Chinese patients with agammaglobulinemia. Patient 1 showed a moderate reduction in total B-cell count but demonstrated both extremely low levels of memory B-cells and lower levels of memory T cells relative to those in healthy controls. Whole-exome sequencing (WES) revealed a novel heterozygous splice variant (c.676+1G>A), and suggested exon 9 deletion from BLNK, which was subsequently validated by quantitative polymerase chain reaction. For Patient 2, WES revealed novel compound heterozygous of a frameshift variant (p.T152Pfs*6) and a synonymous variant (c.525G>A) that resulted in exon 6 skipping, according to cDNA sequencing. These findings represent the first report of a BLNK-deficient patient presenting with impaired memory B-cell and memory T-cell development. Furthermore, this study is the first reporting a pathogenic synonymous splice variant in BLNK.

Intravenous Immunoglobulin as a Treatment for Intractable Epilepsy Secondary to Focal Cortical Dysplasia: A Meta-analysis

BACKGROUND

The observation of a dramatic response to intravenous immunoglobulin (IVIG) by a child from our center with intractable epilepsy due to focal cortical dysplasia prompted us to perform a meta-analysis on the efficiency of IVIG in this condition. Focal cortical dysplasia is a common cause of intractable epilepsy. Microglial activation and upregulation of neuroinflammatory pathways have been documented in brain specimen from surgically treated patients with intractable epilepsy and focal cortical dysplasia. IVIG has been used for decades to treat patients with intractable epilepsy; however, there is little evidence regarding its efficacy, possibly because of the pathophysiological heterogeneity of patients included in most of the published studies.

METHODS

A search for studies in patients from 0 to 18 years was performed in databases. We found four observational studies-prospective or retrospective-including patients with focal cortical dysplasia with intractable epilepsy treated with IVIG. The primary outcome was a reduction of seizure frequency by more than 50%.

RESULTS

A total of eight patients were included in this meta-analysis. The intravenous immunoglobulin doses ranged from 0.2 to 1 g/kg/day, repeated three to six times over one to 14 months (median: five months). Intravenous immunoglobulin was associated with reduced seizure frequency in six out of eight patients (P < 0.05). Among these six patients, the reduction of seizure frequency lasted for nine months to nine years (median: 3.7 years). There were either no or mild adverse effects of IVIG infusion including postinfusion paresthesia (n = 1) and a transient increase in temperature (n = 1).

CONCLUSIONS

Despite obvious limitations, mainly because of the small number of patients, and the selection biases, this study suggests that, based on the available data, IVIG might be effective in the treatment of intractable epilepsy secondary to focal cortical dysplasia. Further therapeutic trials are mandatory to further clarify the efficacy of IVIG in this condition.

Intravenous immunoglobulins for epilepsy

BACKGROUND

Epilepsy is a common neurological condition, with an estimated incidence of 50 per 100,000 persons. People with epilepsy may present with various types of immunological abnormalities, such as low serum immunoglobulin A (IgA) levels, lack of the immunoglobulin G (IgG) subclass and identification of certain types of antibodies. Intravenous immunoglobulin (IVIg) treatment may represent a valuable approach and its efficacy has important implications for epilepsy management. This is an updated version of the original Cochrane review published in Issue 1, 2011.

OBJECTIVES

To examine the effects of IVIg on the frequency and duration of seizures, quality of life and adverse effects when used as monotherapy or as add-on treatment for people with epilepsy.

SEARCH METHODS

For the latest update, we searched the Cochrane Epilepsy Group Specialized Register (2 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (2 February 2017), MEDLINE (Ovid, 1946 to 2 February 2017), Web of Science (1898 to 2 February 2017), ISRCTN registry (2 February 2017), WHO International Clinical Trials Registry Platform (ICTRP, 2 February 2017), the US National Institutes of Health ClinicalTrials.gov (2 February 2017), and reference lists of articles.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials of IVIg as monotherapy or add-on treatment in people with epilepsy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the trials for inclusion and extracted data. We contacted study authors for additional information. Outcomes included percentage of people rendered seizure-free, 50% or greater reduction in seizure frequency, adverse effects, treatment withdrawal and quality of life.

MAIN RESULTS

We included one study (61 participants). The included study was a randomized, double-blind, placebo-controlled, multi-centre trial which compared the treatment efficacy of IVIg as an add-on with a placebo add-on in patients with refractory epilepsy. There was no significant difference between IVIg and placebo in 50% or greater reduction in seizure frequency. The study reported a statistically significant effect for global assessment in favour of IVIg. No adverse effects were demonstrated. We found no randomized controlled trials that investigated the effects of IVIg monotherapy for epilepsy. Overall, the included study was rated as low/unclear risk of bias. Using GRADE methodology, the quality of the evidence was rated as low.

AUTHORS' CONCLUSIONS

We cannot draw any reliable conclusions regarding the efficacy of IVIg as a treatment for epilepsy. Further randomized controlled trials are needed.

Intractable childhood epilepsy: choosing between the treatments

Intractable epilepsy is a significant problem affecting approximately 1 in 10 children with seizures. This is traditionally defined as a failure to respond to at least 2 anticonvulsant drugs tried at reasonable doses for several weeks. Although involving a minority of those with epilepsy, these children typically have significant morbidity, detrimental effects on quality of life, and often require hours of time from a child neurologist in their care. In this review and special issue, a practical approach to management options for children who have refractory epilepsy will be presented from experts in the field.