1
|
Armeno M, Calligaris S, Gagiulo D, Cresta A, Vaccarezza MM, Diez CG, Alberti MJ, Viollaz R, Vilavedra F, Caraballo RH. Use of ketogenic dietary therapy for drug-resistant epilepsy in early infancy. Epilepsia Open 2024; 9:138-149. [PMID: 37759424 PMCID: PMC10839363 DOI: 10.1002/epi4.12836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/17/2023] [Indexed: 09/29/2023] Open
Abstract
OBJECTIVE There is growing evidence that ketogenic dietary therapy (KDT) can be safely and efficiently used in young children, but little evidence exists on its use in newborns. Developmental and epileptic encephalopathies starting in the neonatal period or early infancy usually present a poor prognosis. The aim of this study was to evaluate effectiveness, safety, and survival of infants younger than 3 months of age with drug-resistant epilepsy in whom KDT was used. METHODS A retrospective study was conducted to evaluate neonates and infants younger than 3 months who started KDT for drug-resistant developmental and epileptic encephalopathies at three referral centers. Data were collected on demographic features, time of epilepsy onset, epilepsy syndrome, seizure type, seizure frequency at diet onset, etiology, details regarding diet initiation, type of ketogenic formula, breastfeeding, route of administration, blood ketones, growth, length of NICU stay, and survival. RESULTS Nineteen infants younger than 12 weeks of life who received KDT with a minimum follow-up of 1 month were included; 13 had early-infantile developmental and epileptic encephalopathy, four epilepsy of infancy with migrating focal seizures, and two focal epilepsy. A >50% response was observed in 73.7% at 1 month on the diet; 37% achieved a > 75% seizure reduction, and 10.5% became seizure free. At 3 months, a >50% decrease in seizure frequency was observed in 72.2%; 15.8% had a >75% reduction; 21% became seizure free. Overall survival was 76% at 1 year on diet. Incidence of acute and late adverse effects was low and most adverse effects were asymptomatic and manageable. SIGNIFICANCE Our experience suggests that KDT is safe and effective in newborns and very young infants; however, further studies on the management of the diet in this vulnerable age group are necessary.
Collapse
Affiliation(s)
- Marisa Armeno
- Hospital de Pediatría Prof. Dr. J.P GarrahanBuenos AiresArgentina
| | | | - Daniela Gagiulo
- Hospital de Pediatría Prof. Dr. J.P GarrahanBuenos AiresArgentina
| | - Araceli Cresta
- Hospital de Pediatría Prof. Dr. J.P GarrahanBuenos AiresArgentina
| | | | | | | | | | | | | |
Collapse
|
2
|
Shelkowitz E, Saneto RP, Al-Hertani W, Lubout CMA, Stence NV, Brown MS, Long P, Walleigh D, Nelson JA, Perez FE, Shaw DWW, Michl EJ, Van Hove JLK. Ketogenic diet as a glycine lowering therapy in nonketotic hyperglycinemia and impact on brain glycine levels. Orphanet J Rare Dis 2022; 17:423. [PMID: 36471344 PMCID: PMC9720968 DOI: 10.1186/s13023-022-02581-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/20/2022] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Nonketotic hyperglycinemia (NKH) is a severe neurometabolic disorder characterized by increased glycine levels. Current glycine reduction therapy uses high doses of sodium benzoate. The ketogenic diet (KD) may represent an alternative method of glycine reduction. AIM We aimed to assess clinical and biochemical effects of two glycine reduction strategies: high dose benzoate versus KD with low dose benzoate. METHODS Six infants with NKH were first treated with high dose benzoate therapy to achieve target plasma glycine levels, and then switched to KD with low dose benzoate. They were evaluated as clinically indicated by physical examination, electroencephalogram, plasma and cerebral spinal fluid amino acid levels. Brain glycine levels were monitored by magnetic resonance spectroscopy (MRS). RESULTS Average plasma glycine levels were significantly lower with KD compared to benzoate monotherapy by on average 28%. Two infants underwent comparative assessments of brain glycine levels via serial MRS. A 30% reduction of brain glycine levels was observed in the basal ganglia and a 50% reduction in the white matter, which remained elevated above normal, and was equivalent between the KD and high dose benzoate therapies. CSF analysis obtained while participants remained on the KD showed a decrease in glycine, serine and threonine levels, reflecting their gluconeogenetic usage. Clinically, half the patients had seizure reduction on KD, otherwise the clinical impact was variable. CONCLUSION KD is an effective glycine reduction method in NKH, and may provide a more consistent reduction in plasma glycine levels than high-dose benzoate therapy. Both high-dose benzoate therapy and KD equally reduced but did not normalize brain glycine levels even in the setting of low-normal plasma glycine.
Collapse
Affiliation(s)
- Emily Shelkowitz
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado, Education 2 South, L28-4114, East 17Th Avenue, Aurora, CO, 80045, USA
| | - Russell P Saneto
- Division of Pediatric Neurology, Department of Neurology, Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, WA, 98105, USA
| | - Walla Al-Hertani
- Division of Genetics and Genomics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Charlotte M A Lubout
- Section of Metabolic Diseases, Beatrix Children's Hospital, University of Groningen, University Medical Center, Groningen, Groningen, The Netherlands
| | | | - Mark S Brown
- Department of Radiology, University of Colorado, Aurora, CO, USA
| | - Patrick Long
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado, Education 2 South, L28-4114, East 17Th Avenue, Aurora, CO, 80045, USA
| | - Diana Walleigh
- Section of Child Neurology, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Julie A Nelson
- Section of Child Neurology, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Francisco E Perez
- Department of Radiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Dennis W W Shaw
- Department of Radiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Emma J Michl
- Division of Genetics and Genomics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Johan L K Van Hove
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado, Education 2 South, L28-4114, East 17Th Avenue, Aurora, CO, 80045, USA.
| |
Collapse
|
3
|
Nonketotic Hyperglycinemia: Insight into Current Therapies. J Clin Med 2022; 11:jcm11113027. [PMID: 35683414 PMCID: PMC9181064 DOI: 10.3390/jcm11113027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 05/19/2022] [Accepted: 05/24/2022] [Indexed: 12/10/2022] Open
Abstract
Nonketotic hyperglycinemia (NKH) is a rare inborn error of glycine metabolism that is characterized by the accumulation of glycine in all tissues, especially in the central nervous system (CNS). Based on clinical outcomes, NKH can be divided into two forms, i.e., severe and attenuated NKH. A poor prognosis, including no developmental progress and intractable epilepsy, is typical of severe NKH, whereas patients with the attenuated form present with varied symptoms and neurodevelopmental outcomes. So far, no causal treatment of NKH is known. Currently, the therapy is based on sodium benzoate and NMDA (The N-methyl-D-aspartate receptor) receptor site antagonists (dextromethorphan, ketamine). Different clinical outcomes of the therapy raise doubts about the effectiveness of the treatment. The purpose of this review is to summarize the therapeutic potential, challenges and effectiveness of different NKH therapies.
Collapse
|
4
|
Bayrak H, Yıldız Y, Olgaç A, Kasapkara ÇS, Küçükcongar A, Zenciroğlu A, Yüksel D, Ceylaner S, Kılıç M. Genotypic and phenotypic features in Turkish patients with classic nonketotic hyperglycinemia. Metab Brain Dis 2021; 36:1213-1222. [PMID: 33791923 DOI: 10.1007/s11011-021-00718-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 03/14/2021] [Indexed: 10/21/2022]
Abstract
Nonketotic hyperglycinemia is an autosomal recessive inborn error of glycine metabolism, characterized by deficient activity of the glycine cleavage enzyme system. Classic nonketotic hyperglycinemia is caused by mutations or genomic changes in genes that encode the protein components of the glycine cleavage enzyme system. We aimed to investigate clinical, biochemical, radiological findings and molecular genetic data in ten Turkish patients with classic nonketotic hyperglycinemia. Ten Turkish patients who were diagnosed with classic nonketotic hyperglycinemia in a single center from 2013 to 2019 were included in this study. Their clinical, radiological, electrophysiological and laboratory data were collected retrospectively. Sixty percent of the patients were in neonatal group, while 40 % of the patients were infantile. There were no late-onset patients. 90 % of the patients had the severe form. All patients had developmental delay and seizures. Mortality ratio was 30 % in all groups and 50 % in the neonatal group, while no mortality was seen in infantile group. Median (range) values of cerebrospinal fluid (CSF) glycine levels, plasma glycine levels and CSF/plasma glycine ratios were 148 (15-320) µmol/L, 896 (87-1910) µmol/L, 0.17 (0.09-0.21) respectively. Diffuse hypomyelination and corpus callosum anomaly were the most common cranial MRI findings and multifocal epileptic activity and burst supression pattern were the most common electroencephalographic findings. Six patients had variants in GLDC gene and four in AMT gene; five novel variants including AMT gene deletion were detected. Prognosis was poor and treatment was not effective, especially in the severe form. Classic nonketotic hyperglycinemia causes high morbidity and mortality. Neonatal-onset disease was more common and severe than infantile-onset disease. The ratio of AMT gene variants might be higher in Turkey than other countries. AMT gene deletion also plays a role in the etiology of classic nonketotic hyperglycinemia.
Collapse
Affiliation(s)
- Harun Bayrak
- Department of Pediatrics, Sami Ulus Children Hospital, Ankara, Turkey
| | - Yılmaz Yıldız
- Metabolism Unit, Sami Ulus Children Hospital, Babur cad. No: 44, Altındağ, Ankara, 06080, Turkey
| | - Asburçe Olgaç
- Metabolism Unit, Sami Ulus Children Hospital, Babur cad. No: 44, Altındağ, Ankara, 06080, Turkey
| | - Çiğdem Seher Kasapkara
- Metabolism Unit, Sami Ulus Children Hospital, Babur cad. No: 44, Altındağ, Ankara, 06080, Turkey
| | | | | | - Deniz Yüksel
- Neurology Unit, Sami Ulus Children Hospital, Ankara, Turkey
| | - Serdar Ceylaner
- Intergen, Genetic and Rare Disease Diagnosis and Research Center, Genetic Laboratory, Ankara, Turkey
| | - Mustafa Kılıç
- Metabolism Unit, Sami Ulus Children Hospital, Babur cad. No: 44, Altındağ, Ankara, 06080, Turkey.
| |
Collapse
|
5
|
Ahmad SF, Ahmad KA, Ng YT. Neonatal Epileptic Encephalopathies. Semin Pediatr Neurol 2021; 37:100880. [PMID: 33892847 DOI: 10.1016/j.spen.2021.100880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/07/2021] [Accepted: 02/20/2021] [Indexed: 11/26/2022]
Abstract
The majority of neonatal seizures are related to common diagnoses, including hypoxic-ischemic encephalopathy and intraventricular hemorrhage. While relatively uncommon, neonatal epileptic encephalopathies represent an important group of neonatal seizure disorders that require immediate diagnosis and intervention. In this review, we provide a summary of the benign and severe neonatal epilepsy syndromes. While benign epilepsy syndromes have favorable prognoses, rapid and accurate diagnosis may prevent an unnecessarily long course of antiseizure medications. The severe epilepsy syndromes may be related to a number of underlying genetic disorders and often carry a poor prognosis. Herein we review diagnostic and therapeutic strategies, and provide a set or algorithms for said purposes.
Collapse
Affiliation(s)
- Samiya Fatima Ahmad
- Department of Pediatrics, Baylor College of Medicine, San Antonio, TX; The Children's Hospital of San Antonio, San Antonio, TX.
| | - Kaashif Aqeeb Ahmad
- Department of Pediatrics, Baylor College of Medicine, San Antonio, TX; The Children's Hospital of San Antonio, San Antonio, TX; Pediatrix Medical Group of San Antonio, San Antonio, TX
| | - Yu-Tze Ng
- Department of Pediatrics, Baylor College of Medicine, San Antonio, TX; The Children's Hospital of San Antonio, San Antonio, TX
| |
Collapse
|
6
|
Pressler RM, Cilio MR, Mizrahi EM, Moshé SL, Nunes ML, Plouin P, Vanhatalo S, Yozawitz E, de Vries LS, Puthenveettil Vinayan K, Triki CC, Wilmshurst JM, Yamamoto H, Zuberi SM. The ILAE classification of seizures and the epilepsies: Modification for seizures in the neonate. Position paper by the ILAE Task Force on Neonatal Seizures. Epilepsia 2021; 62:615-628. [PMID: 33522601 DOI: 10.1111/epi.16815] [Citation(s) in RCA: 150] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 12/23/2020] [Accepted: 12/23/2020] [Indexed: 12/23/2022]
Abstract
Seizures are the most common neurological emergency in the neonatal period and in contrast to those in infancy and childhood, are often provoked seizures with an acute cause and may be electrographic-only. Hence, neonatal seizures may not fit easily into classification schemes for seizures and epilepsies primarily developed for older children and adults. A Neonatal Seizures Task Force was established by the International League Against Epilepsy (ILAE) to develop a modification of the 2017 ILAE Classification of Seizures and Epilepsies, relevant to neonates. The neonatal classification framework emphasizes the role of electroencephalography (EEG) in the diagnosis of seizures in the neonate and includes a classification of seizure types relevant to this age group. The seizure type is determined by the predominant clinical feature. Many neonatal seizures are electrographic-only with no evident clinical features; therefore, these are included in the proposed classification. Clinical events without an EEG correlate are not included. Because seizures in the neonatal period have been shown to have a focal onset, a division into focal and generalized is unnecessary. Seizures can have a motor (automatisms, clonic, epileptic spasms, myoclonic, tonic), non-motor (autonomic, behavior arrest), or sequential presentation. The classification allows the user to choose the level of detail when classifying seizures in this age group.
Collapse
Affiliation(s)
- Ronit M Pressler
- Clinical Neuroscience, UCL- Great Ormond Street Institute of Child Health, London, UK.,Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Maria Roberta Cilio
- Division of Pediatric Neurology, Institute for Experimental and Clinical Research, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Eli M Mizrahi
- Departments of Neurology and Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Solomon L Moshé
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA.,Department of Pediatrics, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Magda L Nunes
- Pontificia Universidade Catolica do Rio Grande do Sul - PUCRS School of Medicine and the Brain Institute, Porto Alegre, RS, Brazil
| | - Perrine Plouin
- Department of Clinical Neurophysiology, Hospital Necker Enfant Malades, Paris, France
| | - Sampsa Vanhatalo
- Department of Clinical Neurophysiology and BABA center Children's Hospital, HUS Imaging, Neuroscience Center, Helsinki Institute of Life Science, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Elissa Yozawitz
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA.,Department of Pediatrics, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Linda S de Vries
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Chahnez C Triki
- Department of Child Neurology, Hedi Chaker Hospital, LR19ES15 Sfax University, Sfax, Tunisia
| | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Hitoshi Yamamoto
- Department of Pediatrics, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children & Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| |
Collapse
|
7
|
Mastrangelo M. Epilepsy in inherited neurotransmitter disorders: Spotlights on pathophysiology and clinical management. Metab Brain Dis 2021; 36:29-43. [PMID: 33095372 DOI: 10.1007/s11011-020-00635-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 10/16/2020] [Indexed: 01/02/2023]
Abstract
Inborn errors of neurotransmitter metabolism are ultrarare disorders affecting neurotransmitter biosynthesis, breakdown or transport or their essential cofactors. Neurotransmitter dysfunctions could also result from the impairment of neuronal receptors, intracellular signaling, vesicle release or other synaptic abnormalities. Epilepsy is the main clinical hallmark in some of these diseases (e.g. disorders of GABA metabolism, glycine encephalopathy) while it is infrequent in others (e.g. all the disorders of monoamine metabolism in exception for dihydropteridine reductase deficiency). This review analyzes the epileptogenic mechanisms, the epilepsy phenotypes and the principle for the clinical management of epilepsy in primary and secondary inherited disorders of neurotransmitter metabolism (disorders of GABA, serine and glycine metabolism, disorders of neurotransmitter receptors and secondary neurotransmitter diseases).
Collapse
Affiliation(s)
- Mario Mastrangelo
- Child Neurology and Psychiatry Unit-Department of Human Neuroscience, Sapienza Università di Roma-Umberto I Policlinico di Roma, Via dei Sabelli, 108 - 00141, Roma, Italy.
| |
Collapse
|
8
|
Gavrilovici C, Rho JM. Metabolic epilepsies amenable to ketogenic therapies: Indications, contraindications, and underlying mechanisms. J Inherit Metab Dis 2021; 44:42-53. [PMID: 32654164 DOI: 10.1002/jimd.12283] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 07/04/2020] [Accepted: 07/07/2020] [Indexed: 12/20/2022]
Abstract
Metabolic epilepsies arise in the context of rare inborn errors of metabolism (IEM), notably glucose transporter type 1 deficiency syndrome, succinic semialdehyde dehydrogenase deficiency, pyruvate dehydrogenase complex deficiency, nonketotic hyperglycinemia, and mitochondrial cytopathies. A common feature of these disorders is impaired bioenergetics, which through incompletely defined mechanisms result in a wide spectrum of neurological symptoms, such as epileptic seizures, developmental delay, and movement disorders. The ketogenic diet (KD) has been successfully utilized to treat such conditions to varying degrees. While the mechanisms underlying the clinical efficacy of the KD in IEM remain unclear, it is likely that the proposed heterogeneous targets influenced by the KD work in concert to rectify or ameliorate the downstream negative consequences of genetic mutations affecting key metabolic enzymes and substrates-such as oxidative stress and cell death. These beneficial effects can be broadly grouped into restoration of impaired bioenergetics and synaptic dysfunction, improved redox homeostasis, anti-inflammatory, and epigenetic activity. Hence, it is conceivable that the KD might prove useful in other metabolic disorders that present with epileptic seizures. At the same time, however, there are notable contraindications to KD use, such as fatty acid oxidation disorders. Clearly, more research is needed to better characterize those metabolic epilepsies that would be amenable to ketogenic therapies, both experimentally and clinically. In the end, the expanded knowledge base will be critical to designing metabolism-based treatments that can afford greater clinical efficacy and tolerability compared to current KD approaches, and improved long-term outcomes for patients.
Collapse
Affiliation(s)
- Cezar Gavrilovici
- Departments of Neurosciences and Pediatrics, University of California San Diego, Rady Children's Hospital, San Diego, California, USA
| | - Jong M Rho
- Departments of Neurosciences and Pediatrics, University of California San Diego, Rady Children's Hospital, San Diego, California, USA
| |
Collapse
|
9
|
Hung PL, Lin JL, Chen C, Hung KY, Hsieh TY, Hsu MH, Kuo HC, Lin YJ. An Examination of Serum Acylcarnitine and Amino Acid Profiles at Different Time Point of Ketogenic Diet Therapy and Their Association of Ketogenic Diet Effectiveness. Nutrients 2020; 13:nu13010021. [PMID: 33374696 PMCID: PMC7822492 DOI: 10.3390/nu13010021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 12/09/2020] [Accepted: 12/18/2020] [Indexed: 12/30/2022] Open
Abstract
Background: This study aimed to identify metabolic parameters at different time points of ketogenic diet therapy (KDT) and investigate their association with response to KDT in pediatric drug-resistant epilepsy (DRE). Methods: Prospectively, twenty-nine patients (0.67~20 years old) with DRE received classic ketogenic diet with non-fasting, gradual KD initiation protocol (GRAD-KD) for 1 year were enrolled. A total of 22 patients remaining in study received blood examinations at baseline, 3rd, 6th, 9th, and 12th months of KDT. β-hydroxybutyrate, free carnitine, acylcarnitines, and amino acids were compared between responders (seizure reduction rate ≥ 50%) and non-responders (seizure reduction rate < 50%) to identify the effectiveness of KDT. Results: The 12-month retention rate was 76%. The responders after 12 months of KDT were 59% (13/22). The free carnitine level decreased significantly at 9th months (p < 0.001) but increased toward baseline without symptoms. Propionyl carnitine (C3), Isovaleryl carnitine (C5), 3-Hydroxyisovalerylcarnitine (C5:OH) and methylmalonyl carnitine (C4-DC) decreased but 3-hydroxybutyrylcarnitine (C4:OH) increased significantly at 12th months of KDT. The glycine level was persistently higher than baseline after KDT. KDT responders had lower baseline C3 and long-chain acylcarnitines, C14 and C18, as well as lower C5, C18, and leucine/isoleucine. Conclusions: KDT should be avoided in patients with non-ketotic hyperglycemia. Routine carnitine supplementation is not recommended because hypocarnitinemia was transient and asymptomatic during KDT. Better mitochondrial βoxidation function associates with greater KDT response.
Collapse
Affiliation(s)
- Pi-Lien Hung
- Department of Pediatrics, Division of Pediatric Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (P.-L.H.); (M.-H.H.)
| | - Ju-Li Lin
- Department of Pediatrics, Division of Genetics and Endocrinology, Linkou Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyan 333, Taiwan;
| | - Chien Chen
- Department of Neurology, Taipei Veterans General Hospital, National Yang-Ming University, Taipei 112, Taiwan;
| | - Kai-Yin Hung
- Division of Nutritional Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan;
| | - Tzu-Yun Hsieh
- Department of Pediatrics, Division of Pediatric Critical Care, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (T.-Y.H.); (H.-C.K.)
| | - Mei-Hsin Hsu
- Department of Pediatrics, Division of Pediatric Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (P.-L.H.); (M.-H.H.)
- Department of Pediatrics, Division of Pediatric Critical Care, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (T.-Y.H.); (H.-C.K.)
| | - Hsuan-Chang Kuo
- Department of Pediatrics, Division of Pediatric Critical Care, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (T.-Y.H.); (H.-C.K.)
| | - Ying-Jui Lin
- Department of Pediatrics, Division of Pediatric Critical Care, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (T.-Y.H.); (H.-C.K.)
- Correspondence: ; Tel.: +886-7-731-7123 (ext. 8795); Fax: +886-7-733-8009
| |
Collapse
|
10
|
Daida A, Hamano SI, Ikemoto S, Hirata Y, Matsuura R, Koichihara R, Oba D, Ohashi H. Use of Perampanel and a Ketogenic Diet in Nonketotic Hyperglycinemia: A Case Report. Neuropediatrics 2020; 51:417-420. [PMID: 32176929 DOI: 10.1055/s-0040-1708536] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Nonketotic hyperglycinemia is a severe form of early onset epileptic encephalopathy caused by disturbances in the glycine cleavage system; the neurological damage is mainly attributed to overstimulation of the N-methyl-D-aspartate receptor. CASE The patient presented with a severe form of nonketotic hyperglycinemia and experienced frequent epileptic spasms and focal seizures, which were resistant to vigabatrin, adrenocorticotropic hormone therapy, and combined dextromethorphan and sodium benzoate treatments. By 9 months of age, perampanel reduced epileptic spasms by >50%. At 14 months of age, the ketogenic diet markedly reduced focal seizures and glycine levels in the cerebrospinal fluid. CONCLUSION Perampanel reduced fast excitatory neuronal activity, which was induced by an α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid receptor, followed by prolonged electrical depolarizations due to an N-methyl-D-aspartate receptor. Furthermore, the ketogenic diet may have modulated the excessive neurotoxic cascade through the N-methyl-D-aspartate receptor. Perampanel and ketogenic diet were effective for seizure control in our patient.
Collapse
Affiliation(s)
- Atsuro Daida
- Division of Neurology, Saitama Children's Medical Center, Saitama-City, Saitama, Japan.,Department of Pediatrics, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
| | - Shin-Ichiro Hamano
- Division of Neurology, Saitama Children's Medical Center, Saitama-City, Saitama, Japan
| | - Satoru Ikemoto
- Division of Neurology, Saitama Children's Medical Center, Saitama-City, Saitama, Japan
| | - Yuko Hirata
- Division of Neurology, Saitama Children's Medical Center, Saitama-City, Saitama, Japan
| | - Ryuki Matsuura
- Division of Neurology, Saitama Children's Medical Center, Saitama-City, Saitama, Japan
| | - Reiko Koichihara
- Division of Neurology, Saitama Children's Medical Center, Saitama-City, Saitama, Japan
| | - Daiju Oba
- Division of Medical Genetics, Saitama Children's Medical Center, Saitama-City, Saitama, Japan
| | - Hirofumi Ohashi
- Division of Medical Genetics, Saitama Children's Medical Center, Saitama-City, Saitama, Japan
| |
Collapse
|
11
|
Armeno M, Caraballo R. The evolving indications of KD therapy. Epilepsy Res 2020; 163:106340. [PMID: 32330835 DOI: 10.1016/j.eplepsyres.2020.106340] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/14/2020] [Accepted: 04/08/2020] [Indexed: 02/06/2023]
Abstract
Despite the rapid increase of clinical and basic-science knowledge on ketogenic diet therapies over the past years, it has not always been easy to determine the adequate indications of this treatment. Over the nearly 100 years of use, from being a last resource in the therapeutic algorithm, the diet has become one of the four main treatments for patients with difficult-to-control epilepsy together with antiepileptic drugs, surgery, and vagus nerve stimulation. The use of the diet has also changed. The current paper will briefly discuss the history of the diet together with a review of the literature regarding its most important indications and how they have evolved. The concept of the importance of defining the type of seizure, type of syndrome, and etiology in the selection of patients and timing of diet initiation has been gaining importance. This paper explores how the indications of the diet changed together with the shifting focus of epilepsy teams towards its use in different types of epilepsy and epilepsy syndromes and according to etiologies and as an alternative option in refractory and superrefractory status epilepticus.
Collapse
Affiliation(s)
- Marisa Armeno
- Department of Nutrition, Hospital de Pediatria Juan P Garrahan, Combate de los Pozos 1881, C1245 CABA, Buenos Aires, Argentina.
| | - Roberto Caraballo
- Department of Neurology, Hospital de Pediatria Juan P Garrahan, Combate de los Pozos 1881, C1245 CABA, Buenos Aires, Argentina
| |
Collapse
|
12
|
Li RJ, Liu Y, Liu HQ, Li J. Ketogenic diets and protective mechanisms in epilepsy, metabolic disorders, cancer, neuronal loss, and muscle and nerve degeneration. J Food Biochem 2020; 44:e13140. [PMID: 31943235 DOI: 10.1111/jfbc.13140] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 11/26/2019] [Accepted: 11/26/2019] [Indexed: 12/12/2022]
Abstract
Ketogenic diet (KD), the "High-fat, low-carbohydrate, adequate-protein" diet strategy, replacing glucose with ketone bodies, is effective against several diseases, from intractable epileptic seizures, metabolic disorders, tumors, autosomal dominant polycystic kidney disease, and neurodegeneration to skeletal muscle atrophy and peripheral neuropathy. Key mechanisms include augmented mitochondrial efficiency, reduced oxidative stress, and regulated phospho-AMP-activated protein kinase, gamma-aminobutyric acid-glutamate, Na+/ K+ pump, leptin and adiponectin levels, ghrelin levels, lipogenesis, ketogenesis, lipolysis, and gluconeogenesis. In cancer cells, KD targets glucose metabolism, suppresses insulin-like growth factor-1 and PI3K/AKT/mTOR pathways, and reduces cancer cachexia and muscle waste and fatigue. An associated increased skeletal proliferator-activated receptor-γ coactivator-1α activity alters systemic ketone body homeostasis, contributing toward attenuated diabetic hyperketonemia. Antioxidative and anti-inflammatory properties enable KD enhance endurance and sports performances while preventing exercise-induced muscle and organ debility. KD reduces metabolic syndromes-associated allodynia and promotes peripheral axonal and sensory regeneration. This review enlightens effects of KD on various disease conditions. PRACTICAL APPLICATIONS: It is increasingly being realized that diet plays a very important role in our fight against several diseases. This can range from neurological disorders to diabetes and cancer. In this context, the potential of KD, the "High-fat, low-carbohydrate, adequate-protein" diet strategy, is increasingly being realized. In this article, we provide a comprehensive analysis of the benefits of KD against many diseases and discuss the underlying biochemical mechanisms. We hope that our write-up will stimulate further research on KD and help generate an interest for the populations to adopt this healthy diet. It can help overcome the problems associated with weight and dysregulated metabolism.
Collapse
Affiliation(s)
- Rui-Jun Li
- The Handsurgery Department, The First Hospital of Jilin University, Changchun, China
| | - Yang Liu
- The Handsurgery Department, The First Hospital of Jilin University, Changchun, China
| | - Huan-Qiu Liu
- The Anesthesia Department, The First Hospital of Jilin University, Changchun, China
| | - Ji Li
- The Anesthesia Department, The First Hospital of Jilin University, Changchun, China
| |
Collapse
|
13
|
Kosaka T, Ohta G, Kometani H, Kawatani M, Ohshima Y. A case of early myoclonic encephalopathy with intractable seizures successfully treated with high-dose phenobarbital. Brain Dev 2019; 41:717-720. [PMID: 31027651 DOI: 10.1016/j.braindev.2019.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 03/20/2019] [Accepted: 04/07/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Early myoclonic encephalopathy (EME) is an epileptic syndrome that develops in neonates, commonly within 1 month of birth. The condition is characterized by irregular, partial, and asynchronous myoclonus. The seizures in EME are generally refractory to antiepileptic drugs and no effective treatment for EME has been established. We encountered a case of EME in which oral high-dose phenobarbital therapy effectively alleviated seizures. CASE REPORT A male infant developed erratic myoclonus in the face and limbs, exhibited upward gaze and facial flushing 20-30 times a day since 1 week of age. Electroencephalogram (EEG) showed a burst-suppression pattern, and considering the clinical features, EME was diagnosed. Valproate and vitamin B6 treatments were initiated; however, they were not effective. At day 58 after birth, oral high-dose phenobarbital therapy was introduced which resulted in the suppression of seizures to one or two per week and disappearance of the burst-suppression pattern on EEG. CONCLUSION Oral high-dose phenobarbital treatment may be suitable for controlling seizures in EME.
Collapse
Affiliation(s)
- Takuya Kosaka
- Department of Pediatrics, University of Fukui, Japan.
| | - Genrei Ohta
- Department of Pediatrics, University of Fukui, Japan
| | - Hiroshi Kometani
- Department of Pediatrics, University of Fukui, Japan; Department of Pediatrics, Houju Memorial Hospital, Japan
| | | | - Yusei Ohshima
- Department of Pediatrics, University of Fukui, Japan
| |
Collapse
|
14
|
Ishikawa N, Tateishi Y, Tani H, Kobayashi Y, Itai T, Miyatake S, Kato M, Matsumoto N, Kobayashi M. Successful treatment of intractable life-threatening seizures with perampanel in the first case of early myoclonic encephalopathy with a novel de novo SCN1A mutation. Seizure 2019; 71:20-23. [PMID: 31176277 DOI: 10.1016/j.seizure.2019.05.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/29/2019] [Accepted: 05/29/2019] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Early myoclonic encephalopathy (EME) is a form of developmental and epileptic encephalopathy with myoclonic seizures and a suppression burst on electroencephalogram, which occurs during the neonatal or early infantile period and is characterized by highly intractable seizures and severe development impairment. Although multiple genetic aetiologies of EME have been identified, no SCN1A mutation has been reported. METHODS We described a female patient with EME due to an SCN1A mutation. RESULTS She developed frequent myoclonic and apnoeic seizures during the neonatal period. As her seizures were refractory to many antiepileptic drugs, she underwent a tracheotomy and has since been treated with continuous mechanical ventilation. Eventually, perampanel was added, which resulted in the cessation of the apnoeic seizures. Genetic analysis revealed a heterozygous de novo missense mutation in the SCN1A gene (c.2588 T > C:p.Leu863Ser). CONCLUSION This is the first patient with EME due to anSCN1A mutation to be successfully treated with perampanel. Recently, perampanel was reported to be effective in treating Dravet syndrome, including cases with an SCN1A mutation. Perampanel may contribute to seizure reduction in patients with intractable epilepsy carrying the SCN1A mutation.
Collapse
Affiliation(s)
| | - Yuichi Tateishi
- Department of Pediatrics, Hiroshima University Hospital, Japan
| | - Hiroo Tani
- Department of Pediatrics, Hiroshima University Hospital, Japan
| | | | - Toshiyuki Itai
- Department of Human Genetics, Yokohama City University Graduate School of Medicine, Japan
| | - Satoko Miyatake
- Department of Human Genetics, Yokohama City University Graduate School of Medicine, Japan
| | - Mitsuhiro Kato
- Department of Pediatrics, Showa University School of Medicine, Japan
| | - Naomichi Matsumoto
- Department of Human Genetics, Yokohama City University Graduate School of Medicine, Japan
| | - Masao Kobayashi
- Department of Pediatrics, Hiroshima University Hospital, Japan
| |
Collapse
|
15
|
Abstract
Although the majority of seizures in neonates are related to acute brain injury, a substantial minority are the first symptom of a neonatal-onset epilepsy often linked to a pathogenic genetic variant. Historically, studies on neonatal seizures including treatment response and long-term consequences have lumped all etiologies together. However, etiology has been consistently shown to be the most important determinant of outcome. In the past few years, an increasing number of monogenic disorders have been described and might explain up to a third of neonatal-onset epilepsy syndromes previously included under the umbrella of Ohtahara syndrome and early myoclonic encephalopathy. In this chapter, we define the concept of genetic epilepsy and review the classification. Then, we review the most relevant monogenic neonatal-onset epilepsies, detail their underlying pathophysiologic mechanisms, and present their electroclinical phenotypes. We highlight that, in some cases, such as neonates with KCNQ2 or KCNT1 gene mutations, the early recognition of the electroclinical phenotype can lead to targeted diagnostic testing and precision medicine treatment, enabling the possibility of improved outcome.
Collapse
|
16
|
Kölker S. Metabolism of amino acid neurotransmitters: the synaptic disorder underlying inherited metabolic diseases. J Inherit Metab Dis 2018; 41:1055-1063. [PMID: 29869166 DOI: 10.1007/s10545-018-0201-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/09/2018] [Accepted: 05/14/2018] [Indexed: 10/14/2022]
Abstract
Amino acids are involved in various metabolic pathways and some of them also act as neurotransmitters. Since biosynthesis of L-glutamate and γ-aminobutyric acid (GABA) requires 2-oxoglutarate while 3-phosphoglycerate is the precursor of L-glycine and D-serine, evolutionary selection of these amino acid neurotransmitters might have been driven by their capacity to provide important information about the glycolytic pathway and Krebs cycle. Synthesis and recycling of amino acid neurotransmitters as well as composition and function of their receptors are often compromised in inherited metabolic diseases. For instance, increased plasma L-phenylalanine concentrations impair cerebral biosynthesis of protein and bioamines in phenylketonuria, while elevated cerebral L-phenylalanine directly acts via ionotropic glutamate receptors. In succinic semialdehyde dehydrogenase deficiency, the neurotransmitter GABA and neuromodulatory γ-hydroxybutyric acid are elevated. Chronic hyperGABAergic state results in progressive downregulation of GABAA and GABAB receptors and impaired mitophagy. In glycine encephalopathy, the neurological phenotype is precipitated by L-glycine acting both via cortical NMDA receptors and glycine receptors in spinal cord and brain stem neurons. Serine deficiency syndromes are biochemically characterized by decreased biosynthesis of L-serine, an important neurotrophic factor, and the neurotransmitters D-serine and L-glycine. Supplementation with L-serine and L-glycine has a positive effect on seizure frequency and spasticity, while neurocognitive development can only be improved if treatment starts in utero or immediately postnatally. With novel techniques, the study of synaptic dysfunction in inherited metabolic diseases has become an emerging research field. More and better therapies are needed for these difficult-to-treat diseases.
Collapse
Affiliation(s)
- Stefan Kölker
- Division of Pediatric Neurology and Metabolic Medicine, Centre for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany.
| |
Collapse
|
17
|
Ketogenic diet, a potentially valuable therapeutic option for the management of refractory epilepsy in classical neonatal nonketotic hyperglycinemia: a case report. Eur J Clin Nutr 2018; 73:961-965. [PMID: 30108280 DOI: 10.1038/s41430-018-0286-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 07/02/2018] [Accepted: 07/27/2018] [Indexed: 01/25/2023]
Abstract
Nonketotic hyperglycinemia (NKH) is a devastating inborn error of glycine metabolism caused by deficient activity of the glycine cleavage enzyme. Classically, patients present with lethargy, hypotonia, myoclonic jerks, transient respiratory depression in the first week of life and often progress to death. Surviving infants have profound psychomotor retardation, refractory epilepsy and poor quality of life. Currently, no effective therapeutic avenues exist for severe NKH. Ketogenic diet (KD) has been trialled only in a small group of patients with neonatal NKH and early myoclonic encephalopathy, in whom significant improvements in seizure control were reported. We describe an infant with classical neonatal NKH who presented on the third day of life with hypotonia, poor feeding, respiratory insufficiency resulting in ventilatory support and seizures with burst-suppression pattern on electroencephalogram (EEG). KD initiated at age 6 months for intractable seizures, lead to a dramatic decrease in seizure frequency, EEG improvements, normalisation of plasma glycine levels, reduced spasticity and improved quality of life. KD may be a valuable treatment modality for refractory seizure control in classical NKH.
Collapse
|
18
|
Bezafibrate Prevents Glycine-Induced Increase of Antioxidant Enzyme Activities in Rat Striatum. Mol Neurobiol 2018; 56:29-38. [DOI: 10.1007/s12035-018-1074-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 04/10/2018] [Indexed: 02/03/2023]
|
19
|
Li HF. [Clinical and molecular genetic characteristics of nonketotic hyperglycinemia]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19:272-274. [PMID: 28302195 PMCID: PMC7390138 DOI: 10.7499/j.issn.1008-8830.2017.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 12/20/2016] [Indexed: 06/06/2023]
Affiliation(s)
- Hai-Feng Li
- Department of Rehabilitation, Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| |
Collapse
|
20
|
Goldstein A, Vockley J. Clinical trials examining treatments for inborn errors of amino acid metabolism. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2017.1275565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Amy Goldstein
- Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jerry Vockley
- Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
21
|
Nickerson SL, Balasubramaniam S, Dryland PA, Love JM, Kava MP, Love DR, Prosser DO. Two Novel GLDC Mutations in a Neonate with Nonketotic Hyperglycinemia. J Pediatr Genet 2016; 5:174-80. [PMID: 27617160 DOI: 10.1055/s-0036-1584358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 09/09/2015] [Indexed: 10/21/2022]
Abstract
Nonketotic hyperglycinemia, also known as glycine encephalopathy (OMIM #605899), is an autosomal recessive disorder of glycine metabolism resulting from a defect in the glycine cleavage system. We report two novel mutations of the glycine decarboxylase (GLDC) gene observed in a compound heterozygous state in a neonate of mixed Maori and Caucasian parentage: c.395C>T p.(Ser132Leu) in exon 3, and c.256-?_334+?del p.(Ser86Valfs*119), resulting in an out-of-frame deletion of exon 2. Additionally, we describe our experience of implementing the ketogenic diet, alongside standard pharmacological therapy, and highlight its potential therapeutic benefit in severe nonketotic hyperglycinemia, particularly in seizure management.
Collapse
Affiliation(s)
- Sarah L Nickerson
- Diagnostic Genetics, LabPLUS, Auckland City Hospital, Auckland, New Zealand
| | - Shanti Balasubramaniam
- Metabolic Unit, Department of Rheumatology/Metabolic Medicine, Princess Margaret Hospital, Perth, WA, Australia; School of Paediatrics and Child Health, University of Western Australia, WA, Australia
| | - Philippa A Dryland
- Diagnostic Genetics, LabPLUS, Auckland City Hospital, Auckland, New Zealand
| | - Jennifer M Love
- Diagnostic Genetics, LabPLUS, Auckland City Hospital, Auckland, New Zealand
| | - Maina P Kava
- School of Paediatrics and Child Health, University of Western Australia, WA, Australia; Department of Paediatric Neurology, Princess Margaret Hospital for Children, Perth, WA, Australia
| | - Donald R Love
- Diagnostic Genetics, LabPLUS, Auckland City Hospital, Auckland, New Zealand
| | - Debra O Prosser
- Diagnostic Genetics, LabPLUS, Auckland City Hospital, Auckland, New Zealand
| |
Collapse
|
22
|
Belcastro V, Barbarini M, Barca S, Mauro I. A novel AMT gene mutation in a newborn with nonketotic hyperglycinemia and early myoclonic encephalopathy. Eur J Paediatr Neurol 2016; 20:192-5. [PMID: 26371980 DOI: 10.1016/j.ejpn.2015.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 08/24/2015] [Accepted: 08/27/2015] [Indexed: 11/25/2022]
Abstract
Early myoclonic encephalopathy (EME) presents in neonatal period with erratic or fragmentary myoclonus and a burst-suppression electroencephalography (EEG) pattern. Nonketotic hyperglycinemia (NKH) is the most common metabolic cause of EME and genetic testing confirms the diagnosis of NKH in around 75% of the patients with a clinical diagnosis of NKH. Three genes are known to cause NKH. Here we describe a case of EME caused by NKH in which a new mutation in aminomethyltransferase (AMT) gene has been detected.
Collapse
|
23
|
Hart AR, Pilling EL, Alix JJP. Neonatal seizures-part 2: Aetiology of acute symptomatic seizures, treatments and the neonatal epilepsy syndromes. Arch Dis Child Educ Pract Ed 2015; 100:226-32. [PMID: 25824891 DOI: 10.1136/archdischild-2014-306388] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 02/25/2015] [Indexed: 01/02/2023]
Abstract
Most neonatal epileptic seizures are provoked by an underlying condition or problem-'acute symptomatic seizures'. However, a few neonatal epilepsy syndromes exist, and these are defined by the constellation of seizure types, EEG findings and family history seen. Making an accurate diagnosis of an epilepsy syndrome can help direct investigations, treatment options and provide prognostic information. This article discusses the investigative approach and treatments for neonatal epileptic seizures, including the neonatal epilepsy syndromes.
Collapse
Affiliation(s)
- Anthony R Hart
- Department of Paediatric and Neonatal Neurology, Sheffield Children's Hospital NHS Foundation Trust, Ryegate Children's Centre, Sheffield, South Yorkshire, UK Department of Neonatology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Elizabeth L Pilling
- Department of Neonatology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - James J P Alix
- Department of Clinical Neurophysiology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| |
Collapse
|
24
|
Scholl-Bürgi S, Höller A, Pichler K, Michel M, Haberlandt E, Karall D. Ketogenic diets in patients with inherited metabolic disorders. J Inherit Metab Dis 2015; 38:765-73. [PMID: 26109259 DOI: 10.1007/s10545-015-9872-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 06/05/2015] [Accepted: 06/05/2015] [Indexed: 01/01/2023]
Abstract
Ketogenic diets (KDs) are diets that bring on a metabolic condition comparable to fasting, usually without catabolism. Since the mid-1990s such diets have been widely used in patients with seizures/epilepsies, mostly children. This review focuses on the use of KDs in patients with various inherited metabolic disorders (IMD). In glucose transporter type 1 deficiency syndrome (GLUT1-DS) and pyruvate dehydrogenase complex (PDHc) deficiency, KDs are deemed the therapy of choice and directly target the underlying metabolic disorder. Moreover, in other IMD, mainly of intermediary metabolism such as glycogen storage diseases and disorders of mitochondrial energy supply, KDs may ameliorate clinical symptoms and laboratory parameters. KDs have also been used successfully to treat symptoms such as seizures/epilepsy in IMD, e.g. in urea cycle disorders and non-ketotic hyperglycinemia. As a note of caution, catabolism may cause the condition of patients with IMD to deteriorate and should thus be avoided during KDs. For this reason, careful monitoring (clinical, laboratory and apparatus-supported) is warranted. In some IMDs specific macronutrient supply is critical. Therefore, in cases of PDHc deficiency the carbohydrate intake tolerated without lactate increase and in urea cycle disorders the protein tolerance should be determined. Considering this, it is particularly important in patients with IMD that the use of KDs be individualized and well documented.
Collapse
Affiliation(s)
- S Scholl-Bürgi
- Department of Pediatrics I, Inherited Metabolic Disorders, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria,
| | | | | | | | | | | |
Collapse
|
25
|
Abstract
Ketogenic diet therapies involve a collaborative healthcare team and therefore are typically offered in tertiary care centers. Centers that utilize these therapies with frequency gain valuable experience and become skilled in their practice. This chapter is a summary from the presentations of 5 practitioners including a nurse, pharmacist, and 3 dietitians who shared their expertise during the clinical session of the 2012 International Symposium.
Collapse
Affiliation(s)
- Beth Zupec-Kania
- Children's Hospital of Wisconsin and The Charlie Foundation, Milwaukee, WI, USA.
| | | | | | | | | | | |
Collapse
|
26
|
Diagnosis and management of epileptic encephalopathies in children. EPILEPSY RESEARCH AND TREATMENT 2013; 2013:501981. [PMID: 23970964 PMCID: PMC3736403 DOI: 10.1155/2013/501981] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 06/04/2013] [Accepted: 06/18/2013] [Indexed: 11/20/2022]
Abstract
Epileptic encephalopathies refer to a group of disorders in which the unremitting epileptic activity contributes to severe cognitive and behavioral impairments above and beyond what might be expected from the underlying pathology alone, and these can worsen over time leading to progressive cerebral dysfunction. Several syndromes have been described based on their electroclinical features (age of onset, seizure type, and EEG pattern). This review briefly describes the clinical evaluation and management of commonly encountered epileptic encephalopathies in children.
Collapse
|
27
|
Sharma S, Tripathi M. Ketogenic diet in epileptic encephalopathies. EPILEPSY RESEARCH AND TREATMENT 2013; 2013:652052. [PMID: 23936641 PMCID: PMC3723152 DOI: 10.1155/2013/652052] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 06/24/2013] [Indexed: 11/25/2022]
Abstract
The ketogenic diet is a medically supervised high-fat, low-carbohydrate diet that has been found useful in patients with refractory epilepsy. It has been shown to be effective in treating multiple seizure types and epilepsy syndromes. In this paper, we review the use of the ketogenic diet in epileptic encephalopathies such as Ohtahara syndrome, West syndrome, Dravet syndrome, epilepsy with myoclonic atonic seizures, and Lennox-Gastaut syndrome.
Collapse
Affiliation(s)
- Suvasini Sharma
- Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi 110001, India
| | - Manjari Tripathi
- Department of Neurology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi 110029, India
| |
Collapse
|
28
|
Abstract
About one third of patients with epilepsy are pharmacoresistent. For a subgroup of this population, the ketogenic diet can be highly efficacious and should be considered early. This review discusses the different types of ketogenic diet, proposed mechanism of actions and its evidence for use in children and adults with both generalized and focal epilepsies where surgery is not feasible. In addition we discuss a practical approach to diet initiation, maintenance and monitoring for side effects. We also summarize the emerging evidence for the use of ketogenic diet in a broad range of neurological disorders.
Collapse
|
29
|
Vogel KR, Pearl PL, Theodore WH, McCarter RC, Jakobs C, Gibson KM. Thirty years beyond discovery--clinical trials in succinic semialdehyde dehydrogenase deficiency, a disorder of GABA metabolism. J Inherit Metab Dis 2013; 36:401-10. [PMID: 22739941 PMCID: PMC4349389 DOI: 10.1007/s10545-012-9499-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2012] [Revised: 05/09/2012] [Accepted: 05/14/2012] [Indexed: 10/28/2022]
Abstract
This review summarizes a presentation made at the retirement Symposium of Prof. Dr. Cornelis Jakobs in November of 2011, highlighting the progress toward clinical trials in succinic semialdehyde dehydrogenase (SSADH) deficiency, a disorder first recognized in 1981. Active and potential clinical interventions, including vigabatrin, L-cycloserine, the GHB receptor antagonist NCS-382, and the ketogenic diet, are discussed. Several biomarkers to gauge clinical efficacy have been identified, including cerebrospinal fluid metabolites, neuropsychiatric testing, MRI, EEG, and measures of GABAergic function including (11 C)flumazenil positron emission tomography (PET) and transcranial magnetic stimulation (TMS). Thirty years after its discovery, encompassing extensive studies in both patients and the corresponding murine model, we are now running an open-label trial of taurine intervention, and are poised to undertake a phase II trial of the GABAB receptor antagonist SGS742.
Collapse
Affiliation(s)
- Kara R Vogel
- Section of Clinical Pharmacology, College of Pharmacy, Washington State University, Spokane, WA 99202-2131, USA.
| | | | | | | | | | | |
Collapse
|