Determining the prognosis of childhood epilepsies by establishing immune abnormalities

Epilepsy and chronic obstructive pulmonary disease among U.S. adults: National Health Interview Survey 2013, 2015, and 2017

BACKGROUND

Among U.S. adults, over 4 million report a history of epilepsy, and more than 15 million report a history of chronic obstructive pulmonary disease (COPD); Chronic obstructive pulmonary disease, which includes chronic bronchitis and emphysema, is a common somatic comorbidity of epilepsy. This study assessed the relationship between self-reported physician-diagnosed epilepsy and COPD in a large representative sample of the U.S. adult population and explored possible mechanisms.

METHODS

Cross-sectional National Health Interview Surveys for 2013, 2015, and 2017 were aggregated to compare the prevalence of COPD between U.S. respondents aged ≥18 years with a history of physician-diagnosed epilepsy (n = 1783) and without epilepsy (n = 93,126). We calculated prevalence of COPD by age-standardized adjustment and prevalence ratios of COPD overall adjusted for sociodemographic and risk factors, by using multivariable logistic regression analyses. A Z-test was conducted to compare the prevalence between people with and without epilepsy at the statistical significance level of 0.05. Prevalence ratios whose 95% confidence intervals did not overlap 1.00 were considered statistically significant.

RESULTS

The overall age-standardized prevalence was 5.7% for COPD and 1.8% for epilepsy. Age-standardized prevalence of COPD among respondents with epilepsy (15.4%) exceeded that among those without epilepsy (5.5%). The association remained significantly different among all sociodemographic and risk factor subgroups (p < .05). In the adjusted analyses, epilepsy was also significantly associated with COPD, overall (adjusted prevalence ratio = 1.8, 95% confidence interval = 1.6-2.1) and in nearly all subgroups defined by selected characteristics.

CONCLUSIONS

Epilepsy is associated with a higher prevalence of COPD in U.S. adults. Public health interventions targeting modifiable behavioral and socioeconomic risk factors among people with epilepsy may help prevent COPD and related premature death.

Intravenous immunoglobulin as adjunctive therapy for juvenile spasms

Intravenous immunoglobulin has been reported to be an effective treatment for infantile spasms. Juvenile spasms are electrically and clinically similar to infantile spasms but occur in a later age group. We retrospectively reviewed the charts of five children (aged 4.5-11.5 years) at our institution. Their primary seizure type was juvenile spasms and they were treated with a single inpatient course of intravenous immunoglobulin (400 mg/kg/day intravenously for 5 consecutive days) on an adjunctive basis. Seizure frequency was determined from parental reports. By 3 months after treatment, improvement (a 50-92% reduction in seizure frequency) was noted in four patients; sustained benefit was seen in three patients for up to 12 months. One patient showed no response at 3 and 6 months and had an increase in seizure frequency at 1 year. We conclude that single-course intravenous immunoglobulin can be effective as adjunctive therapy for juvenile spasms and that benefit can persist for many months. However, larger controlled, prospective clinical trials are needed to validate this unconventional treatment modality for specific seizure types such as juvenile spasms.

Serum cytokine levels are altered in patients with West syndrome

The objective of this study is to explore the neuroimmunomodulator effect of interleukin (IL)-2, tumor necrosis factor (TNF)-alpha and interferon (IFN)-alpha in West syndrome (WS). Twenty-three cases of WS (13 males and 10 females, aged 4-14 months old) who first visited and consisted from 10 cryptogenic and 13 symptomatic, were enrolled in this study. Double-antibody sandwich enzyme-linked immunosorbent assay was used to measure serum IL-2, TNF-alpha and IFN-alpha levels in 23 patients with WS and the data were compared to those of 15 healthy infants who were matched with regard to age and sex. Levels of all three cytokines were significantly higher in both cryptogenic and symptomatic WS groups than the control group. Serum IL-2 levels in symptomatic WS were significantly higher than that in cryptogenic WS. There was a positive correlation between IL-2 and TNF-alpha in both cryptogenic and symptomatic WS groups. The immune systems of patients with WS are in an activated state. An imbalance in cytokine levels may be involved in the immunopathology of WS.

High prevalence of antiphospholipid antibodies in children with epilepsy: a controlled study of 50 cases

Evidence of immune system aberrations in patients with epilepsy includes antiphospholipid antibody positivity in adult patients with epilepsy with a prevalence of 19-26% and in 13% of children with partial epilepsy. Also immunoglobulin A deficiency has been reported to exist in up to 25% of epilepsy patients. The possible role of immune mechanisms in the pathogenesis of childhood epilepsy is clinically supported by the effectiveness of immunomodulatory treatments in cases with catastrophic childhood epilepsies. We analyzed a set of various autoantibodies in 50 consecutive children with epilepsy and in 20 healthy control subjects. None of the children had any clinical signs of immune system disorders. The main result was a significantly (P=0.011) higher prevalence of antiphospholipid antibodies in the study group (44%) compared with controls (10%). These antibodies were unexpectedly common (71-80%) in children with multiple seizure types associated often with symptomatic etiology, early onset and high frequency of seizures. There was no evidence of the antiphospholipid positivity being induced by certain AEDs (e.g. phenytoin or carbamazepine). Even though the significance of these autoantibodies remains unknown, their increased prevalence indicates that immune system mediated mechanisms may have a role in the manifestation of epilepsy in some children.

Immunoglobulin subgroups in children with febrile seizures

BACKGROUND

The aim of the present study was to determine whether or not there was a role for immunoglobulin (Ig) or IgG subgroups in the pathogenesis of febrile seizures (FS).

METHODS

Serum levels of IgA, total IgG, IgM, IgE, IgGI, IgG2, IgG3 and IgG4 were measured in 34 children with FS and in 37 healthy children used as a control group. Both patients and controls were divided into two groups according to age (group I, 6-24 months; group II, 25-72 months).

RESULTS

Compared with controls, mean IgG4 levels in patients were found to be decreased in both groups I and II (group I: 95 +/- 14 vs 57 +/- 5, respectively, P = 0.01; group II: 178.5 +/- 38.5 vs 65.1 +/- 24.5, respectively, P < 0.01), while mean IgG2 levels were found to be decreased only in group II patients (170 +/- 16 vs 103 +/- 22; P < 0.05).

CONCLUSIONS

The results of the present study suggest that Ig subclass deficiencies may be responsible for the infections connected with FS or that they may be related to the pathogenesis of FS in some children.

Effects of single cyclosporin A pretreatment on pentylenetetrazol-induced convulsion and on TRE-binding activity in the rat brain

Using electrophoretic mobility-shift assay (EMSA), we examined changes in DNA-binding activities of transcriptional factor-activated protein-1 (AP-1), which is a Fos-Jun protein complex, onto its responsive element TRE in the hippocampus and amygdaloid nucleus of rats stimulated with pentylenetetrazol (PTZ) injection, and also investigated the effects of a single administration of the immunosuppressant cyclosporin A (CsA). In EMSA with nuclear extracts from the rat brain, the TRE-binding activity of AP-1 in the hippocampus and amygdaloid nucleus markedly increased 2 h after the PTZ injection (75 mg/kg, i.p.). These PTZ-induced increases of the TRE-binding protein in these regions were completely suppressed, by pretreatment with CsA (5 mg/kg, s.c.) 1 h before the PTZ injection. In addition, the administration of CsA significantly ameliorated PTZ-induced convulsion. This therapeutic effect of single CsA pretreatment may be based, in part, on the effects on the TRE-binding activity of AP-1 in the brain. Since single pretreatment of CsA in the present study had no effect on the PTZ-induced induction of c-fos mRNA, c-jun mRNA, Fos protein nor Jun protein, the inhibitory effects of single CsA administration on PTZ-induced TRE-binding activity in the brain may be related to the effects of CsA on AP-1 itself. These results suggest that an immune response via activation of transcriptional factor in the brain tissue is involved in the convulsion.

Effects of repeated injection of cyclosporin A on pentylenetetrazol-induced convulsion and cyclophilin mRNA levels in rat brain

To investigate the relationship between the immune system and convulsions in an animal model, we examined the effects of repeated administration with the immunosuppressant cyclosporin A on pentylenetetrazol (PTZ)-induced convulsions and the changes in the mRNA expression of its binding protein cyclophilin in the rat brain. The consecutive administration of cyclosporin A (5 mg/kg, s.c., 14 days) significantly aggravated the severity of convulsions induced with PTZ 75 mg/kg, i.p. Furthermore, it down-regulated the levels of cyclophilin mRNA in several brain regions and inhibited the PTZ-induced increase of hippocampal cyclophilin mRNA. Compared with the group without PTZ pretreatment or the group treated with chronic vehicle administration after the PTZ-preinjection, chronic cyclosporin A administration after the initial injection of PTZ apparently aggravated convulsions after the second PTZ injection. Interestingly, the increase in hippocampal cyclophilin mRNA observed after a single PTZ injection was not found after the second PTZ injection in the group with PTZ pretreatment. Therefore, these findings suggest that cyclosporin A administered peripherally can affect the central nervous system, and that an immune response associated with the first convulsive episode plays a key role in severity during subsequent attacks.

Immunoglobulin treatment in epilepsy, a review of the literature

The purpose of this study is to ascertain possible efficacy and to understand possible mechanisms of action of intramuscular or intravenous immunoglobulin (IVIg) in the treatment of intractable epilepsy, through a review of all identifiable articles on this topic. In 24 studies, none with a placebo controlled design, 368 patients with epilepsy receiving IVIg were identified. Patients' ages ranged from < 1 to 35 years, mean 7.3 years. Female/male ratio was 0.6. All patients were reported to suffer from intractable epilepsy. The average percentage of patients with an IgG2 deficiency was 25%. The total dose of IVIg varied between 0.3 and 6.8 g/kg for a period of 0.15 to 12 months. Whenever reported, adverse effects of IVIg were minimal. None of the studies reported the need of cessation of IVIg administration due to adverse effects. On the average, the mean clinical seizure reduction and the mean EEG improvement were 52% and 45%, respectively. On the average the percentage of patients with complete seizure remission and the percentage of patients with behavioral improvement were 23% and 63%, respectively. Cumulative meta-analysis of the identified articles is not possible due to the lack of controlled studies, the heterogeneity of the available studies, and the possible publication bias of unpublished negative data. Given these pitfalls, this literature study nevertheless allows some conclusions: (i) There is no formal proof of efficacy of IVIg treatment in epilepsy, and the present review underscores the need of controlled clinical trials before firm conclusions concerning efficacy can be drawn. The uncontrolled clinical observations discussed in this 'state-of-the-art' review generate suggestive evidence at best. They suggest that IVIg might be effective in some patients with intractable epilepsy, and may be considered as a safe add-on medication in various types of idiopathic and symptomatic intractable epilepsy. (ii) Review of the literature did not help in explaining intractable epilepsy or the mechanism of action of IVIg, but did permit some inferences that could serve to design future clinical and experimental approaches to IVIg administration in epilepsy.

Therapeutic drug monitoring in pediatrics: a need for improvement

Therapeutic drug monitoring (TDM) is practiced for a number of frequently used drugs in infants and children. It is believed that monitoring drug levels will increase the probability of a therapeutic response and minimize the probability of adverse drug sequelae. Dose adjustments are based on measured drug levels interpreted relative to published therapeutic ranges which may or may not reflect the true relationship with either therapeutic or adverse effects. Potential errors derive from many sources, some amenable to solutions based on current knowledge, others awaiting improved understanding of the causes and consequences of unreliable therapeutic ranges.