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Balaji A, Mohanlal S, Pachat D, Babu SS, Kumar EKS, Mamukoya N, Das S. Genome-Based Therapeutics: Era of Precision Medicine in Genetic Epilepsies and Epileptic Encephalopathies. Ann Indian Acad Neurol 2023; 26:723-727. [PMID: 38022486 PMCID: PMC10666847 DOI: 10.4103/aian.aian_314_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 08/20/2023] [Accepted: 08/24/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction The recent evolution of genomics has led to the development of targeted therapeutics, revolutionizing medical approaches. This study aimed to assess the impact of genetic testing on the current epilepsy management paradigm with a specific focus on the variability of outcomes subsequent to genetic diagnoses. Methodology Data were collected retrospectively from a cohort of children aged 1-18 years, diagnosed with refractory epilepsy of confirmed genetic origin. The participants received care at a quaternary care center's pediatric neurology clinic from August 2019 to June 2021. The collected information included demographic characteristics, seizure types, EEG findings, imaging abnormalities, genetic diagnoses, attempted treatments, and seizure outcomes. Results Among the 210 children with confirmed genetic diagnoses, 74 were included in the study. The gender distribution comprised 45 males and 29 females. Within the cohort, 68/74 exhibited single gene variations, with 23 cases associated with sodium/potassium/calcium channelopathies. Precision medicine could be applied to 25/74 cases. 17/74 children (22.97%) experienced a reduction of up to 50% in seizure frequency due to precision medicine implementation. Conclusion While our study indicates the significance of genetic insights in adapting treatment approaches for pediatric epilepsy, it is important to temper our conclusions. The retrospective nature of our study confines our ability to definitively gauge the extent of precision medicine's utility. Our findings suggest the potential of genetic information to enhance epilepsy management, but the true impact of precision medicine can only be established through prospective investigations.
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Affiliation(s)
- Aarthi Balaji
- Department of Pediatric Neurology, Aster Malabar Institute of Medical Sciences, Kozhikode, Kerala, India
| | - Smilu Mohanlal
- Department of Pediatric Neurology, Aster Malabar Institute of Medical Sciences, Kozhikode, Kerala, India
| | - Divya Pachat
- Department of Medical Genetics, Aster Malabar Institute of Medical Sciences, Kozhikode, Kerala, India
| | | | - EK Suresh Kumar
- Department of Pediatrics, Aster Malabar Institute of Medical Sciences, Kozhikode, Kerala, India
| | - Najiya Mamukoya
- Department of Pediatrics, Aster Malabar Institute of Medical Sciences, Kozhikode, Kerala, India
| | - Syama Das
- Department of Pediatrics, Aster Malabar Institute of Medical Sciences, Kozhikode, Kerala, India
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Mastrangelo M, Gasparri V, Bernardi K, Foglietta S, Ramantani G, Pisani F. Epilepsy Phenotypes of Vitamin B6-Dependent Diseases: An Updated Systematic Review. CHILDREN 2023; 10:children10030553. [PMID: 36980111 PMCID: PMC10047402 DOI: 10.3390/children10030553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/12/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023]
Abstract
Background: Vitamin B6-dependent epilepsies include treatable diseases responding to pyridoxine or pyridoxal-5Iphosphate (ALDH7A1 deficiency, PNPO deficiency, PLP binding protein deficiency, hyperprolinemia type II and hypophosphatasia and glycosylphosphatidylinositol anchor synthesis defects). Patients and methods: We conducted a systematic review of published pediatric cases with a confirmed molecular genetic diagnosis of vitamin B6-dependent epilepsy according to PRISMA guidelines. Data on demographic features, seizure semiology, EEG patterns, neuroimaging, treatment, and developmental outcomes were collected. Results: 497 published patients fulfilled the inclusion criteria. Seizure onset manifested at 59.8 ± 291.6 days (67.8% of cases in the first month of life). Clonic, tonic-clonic, and myoclonic seizures accounted for two-thirds of the cases, while epileptic spasms were observed in 7.6%. Burst-suppression/suppression-burst represented the most frequently reported specific EEG pattern (14.4%), mainly in PLPB, ALDH7A1, and PNPO deficiency. Pyridoxine was administered to 312 patients (18.5% intravenously, 76.9% orally, 4.6% not specified), and 180 also received antiseizure medications. Pyridoxine dosage ranged between 1 and 55 mg/kg/die. Complete seizure freedom was achieved in 160 patients, while a significant seizure reduction occurred in 38. PLP, lysine-restricted diet, and arginine supplementation were used in a small proportion of patients with variable efficacy. Global developmental delay was established in 30.5% of a few patients in whom neurocognitive tests were performed. Conclusions: Despite the wide variability, the most frequent hallmarks of the epilepsy phenotype in patients with vitamin B6-dependent seizures include generalized or focal motor seizure semiology and a burst suppression/suppression burst pattern in EEG.
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Affiliation(s)
- Mario Mastrangelo
- Child Neurology and Psychiatry Unit, Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
- Department of Neuroscience/Mental Health, Azienda Ospedaliero-Universitaria Policlinico Umberto I, 00161 Rome, Italy
- Correspondence:
| | - Valentina Gasparri
- Child Neurology and Psychiatry Unit, Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Katerina Bernardi
- Child Neurology and Psychiatry Unit, Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Silvia Foglietta
- Child Neurology and Psychiatry Unit, Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Georgia Ramantani
- Department of Neuropediatrics, University Children’s Hospital Zurich and University of Zurich, 8032 Zurich, Switzerland
| | - Francesco Pisani
- Child Neurology and Psychiatry Unit, Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
- Department of Neuroscience/Mental Health, Azienda Ospedaliero-Universitaria Policlinico Umberto I, 00161 Rome, Italy
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Jiao X, Gong P, Niu Y, Zhang Y, Yang Z. A Rare Presentation Characterized by Epileptic Spasms in ALDH7A1, Pyridox(am)ine-5′-Phosphate Oxidase, and PLPBP Deficiency. Front Genet 2022; 13:804461. [PMID: 35495162 PMCID: PMC9039010 DOI: 10.3389/fgene.2022.804461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/07/2022] [Indexed: 11/25/2022] Open
Abstract
Objective: To analyze the clinical feature, treatment, and prognosis of epileptic spasms (ES) in vitamin B6–dependent epilepsy, including patients with pyridoxine-dependent epilepsy (PDE) caused by ALDH7A1 mutation, pyridox(am)ine-5′-phosphate oxidase (PNPO) deficiency, and PLPBP deficiency. Methods: We analyzed data from a cohort of 54 cases with PDE, 13 cases with PNPO deficiency, and 2 cases with PLPBP deficiency and looked for the presentation of ES among them. Results: A total of 11 patients with the seizure presentation of ES have been collected. Among them, four patients carried mutations in ALDH7A1, six carried mutations in PNPO, and the remaining one carried mutation in PLPBP. The analysis of this cohort identified nine cases presenting as infantile spasms distributed in the three diseases and two cases presenting as Ohtahara syndrome diagnosed with PDE and PNPO deficiency, respectively. In the PDE and PLPBP deficiency groups, seizures were controlled by pyridoxine monotherapy, and the remaining one had refractory seizures due to secondary brain atrophy. In the groups with PNPO deficiency, one patient showed seizure-free when treated by PLP combined with valproic acid, three still had infrequent seizures treated by PLP monotherapy or pyridoxine or PLP combined with other antiseizure medications, and two died. In two cases presenting as Ohtahara syndrome, after regular treatment, one showed seizure-free, the others showed a marked decrease in seizure frequency, and they both showed an improvement in EEG. Significance: ES might be a common form of seizures in PNPO deficiency, and EEG presented as hypsarrhythmia or a burst suppression pattern. It is difficult for pyridoxine to control frequent seizures caused by secondary brain injury. In our PNPO deficiency cohort, patients with infantile spasms did not respond better to PLP than pyridoxine. Timely and correct treatment could prevent the transformation of the child’s disease from Ohtahara syndrome and infantile spasms to subsequent epileptic encephalopathy or refractory epilepsy.
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Farmania R, Gupta A, Ankur K, Chetry S, Sharma S. Complexities of pyridoxine response in PNPO deficiency. Epilepsy Behav Rep 2021; 16:100443. [PMID: 33981986 PMCID: PMC8082192 DOI: 10.1016/j.ebr.2021.100443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 02/27/2021] [Accepted: 03/04/2021] [Indexed: 11/11/2022] Open
Abstract
Pyridox(am)ine- 5- phosphate Oxidase deficiency (PNPO) is a rare cause of neonatal metabolic encephalopathy associated with refractory status epilepticus. We report a case of a premature neonate presenting with drug-resistant seizures beginning at 2 hours of life. The baby showed initial transient response to pyridoxine followed by recurrence. Genetic report confirmed the diagnosis of PNPO deficiency. A literature review on phenotypic variants in terms of response to pyridoxine is also presented along with a proposed algorithm to manage a case of suspected vitamin responsive epilepsy. This case highlights our limited understanding of why variation in response to treatment exists in children with PNPO deficiency.
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Affiliation(s)
- Rajni Farmania
- Pediatric Neurology. Consultant, Division of Pediatric Neurology, BL Kapur Superspecialiy Hospital, Delhi, India
- Consultant and Incharge, Pediatric Neurology, Department of Pediatrics, BLK Superspeciality Hospital, Delhi, India
| | - Ankit Gupta
- Fellow Neonatology, Department of Neonatology, BLK Superspeciality Hospital, Delhi, India
- Fellow Neonatology, Department of Neonatology, BLK Superspeciality, Delhi, India
| | - Kumar Ankur
- Neonatology. Consultant and NICU in Charge, Division of Neonatology, BL Kapur Superspeciality Hospital, Delhi, India
- Consultant and NICU incharge, Department of Neonatology, BLK Superspeciality, Delhi, India
| | - Sanjeev Chetry
- Neonatology. Consultant NICU, Division of Neonatology, BL Kapur Superspeciality Hospital, Delhi, India
- Consultant NICU, Department of Neonatology, BLK Superspecilaity, Delhi, India
| | - Suvasini Sharma
- Pediatric Neurology, Department of Pediatrics, Kalawati Saran Children’s Hospital, Delhi, India
- Associate Professor, Division of Pediatric Neurology, Department of Pediatrics, BLK Superspeciality, Delhi, India
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Alghamdi M, Bashiri FA, Abdelhakim M, Adly N, Jamjoom DZ, Sumaily KM, Alghanem B, Arold ST. Phenotypic and molecular spectrum of pyridoxamine-5'-phosphate oxidase deficiency: A scoping review of 87 cases of pyridoxamine-5'-phosphate oxidase deficiency. Clin Genet 2020; 99:99-110. [PMID: 32888189 PMCID: PMC7820968 DOI: 10.1111/cge.13843] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/30/2020] [Accepted: 08/31/2020] [Indexed: 12/29/2022]
Abstract
Pyridoxamine-5'-phosphate oxidase (PNPO) deficiency is an autosomal recessive pyridoxal 5'-phosphate (PLP)-vitamin-responsive epileptic encephalopathy. The emerging feature of PNPO deficiency is the occurrence of refractory seizures in the first year of life. Pre-maturity and fetal distress, combined with neonatal seizures, are other associated key characteristics. The phenotype results from a dependency of PLP which regulates several enzymes in the body. We present the phenotypic and genotypic spectrum of (PNPO) deficiency based on a literature review (2002-2020) of reports (n = 33) of patients with confirmed PNPO deficiency (n = 87). All patients who received PLP (n = 36) showed a clinical response, with a complete dramatic PLP response with seizure cessation observed in 61% of patients. In spite of effective seizure control with PLP, approximately 56% of patients affected with PLP-dependent epilepsy suffer developmental delay/intellectual disability. There is no diagnostic biomarker, and molecular testing required for diagnosis. However, we noted that cerebrospinal fluid (CSF) PLP was low in 81%, CSF glycine was high in 80% and urinary vanillactic acid was high in 91% of the cases. We observed only a weak correlation between the severity of PNPO protein disruption and disease outcomes, indicating the importance of other factors, including seizure onset and time of therapy initiation. We found that pre-maturity, the delay in initiation of PLP therapy and early onset of seizures correlate with a poor neurocognitive outcome. Given the amenability of PNPO to PLP therapy for seizure control, early diagnosis is essential.
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Affiliation(s)
- Malak Alghamdi
- Medical Genetics Division, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Department of Pediatrics, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Fahad A Bashiri
- Department of Pediatrics, King Saud University Medical City, Riyadh, Saudi Arabia.,Neurology division, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Marwa Abdelhakim
- Computer, Electrical and Mathematical Science and Engineering Division (CEMSE), Computational Bioscience Research Center (CBRC), King Abdullah University of Science and Technology (KAUST), Thuwal, Saudi Arabia
| | - Nouran Adly
- College of Medicine Research Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Dima Z Jamjoom
- Department of Radiology and Medical Imaging, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Khalid M Sumaily
- Clinical Biochemistry Unit, Department of Laboratory Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Bandar Alghanem
- Medical Research Core Facility and Platforms (MRCFP), King Abdullah International Medical, Research Center/King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), King, Abdulaziz Medical City (KAMC), NGHA, Riyadh, Saudi Arabia
| | - Stefan T Arold
- Computational Bioscience, Research Center (CBRC); Division of Biological and Environmental Sciences and Engineering, (BESE), King Abdullah University of Science and Technology (KAUST), Thuwal, Saudi Arabia.,Centre de Biochimie Structurale, CNRS, INSERM, Université de Montpellier, Montpellier, France
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