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Falsaperla R, Sciacca M, Collotta AD, Tardino LG, Marino S, Marino SD, Privitera GF, Vitaliti G, Ruggieri M. PYRIDOXINE-dependent epilepsy (PDE): An observational study of neonatal cases on the role of pyridoxine in patients treated with standard anti-seizure medications. Seizure 2024; 118:156-163. [PMID: 38735085 DOI: 10.1016/j.seizure.2024.04.012] [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: 11/18/2023] [Revised: 04/09/2024] [Accepted: 04/12/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND The main objective of this study was to evaluate the neurological consequences of delayed pyridoxine administration in patients diagnosed with Pyridoxin Dependent Epilepsies (PDE). MATERIALS AND METHODS We reviewed 29 articles, comprising 52 genetically diagnosed PDE cases, ensuring data homogeneity. Three additional cases were included from the General Pediatric Operative Unit of San Marco Hospital. Data collection considered factors like age at the first seizure's onset, EEG reports, genetic analyses, and more. Based on the response to first-line antiseizure medications, patients were categorized into four distinct groups. Follow-up evaluations employed various scales to ascertain neurological, cognitive, and psychomotor developments. RESULTS Our study includes 55 patients (28 males and 27 females), among whom 15 were excluded for the lack of follow-up data. 21 patients were categorized as "Responder with Relapse", 11 as "Resistant", 6 as "Pyridoxine First Approach", and 2 as "Responders". The neurological outcome revealed 37,5 % with no neurological effects, 37,5 % showed complications in two developmental areas, 15 % in one, and 10 % in all areas. The statistical analysis highlighted a positive correlation between the time elapsed from the administration of pyridoxine after the first seizure and worse neurological outcomes. On the other hand, a significant association was found between an extended latency period (that is, the time that elapsed between the onset of the first seizure and its recurrence) and worse neurological outcomes in patients who received an unfavorable score on the neurological evaluation noted in a subsequent follow-up. CONCLUSIONS The study highlights the importance of early recognition and intervention in PDE. Existing medical protocols frequently overlook the timely diagnosis of PDE. Immediate administration of pyridoxine, guided by a swift diagnosis in the presence of typical symptoms, might improve long-term neurological outcomes, and further studies should evaluate the outcome of PDE neonates promptly treated with Pyridoxine.
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Affiliation(s)
- Raffaele Falsaperla
- General Pediatrics and Pediatric Emergency Department, "Policlinico G.Rodolico-San Marco" University Hospital, University of Catania, 95100 Catania, Italy; Unit of Neonatal Intensive Care and Neonatology, Policlinico "G. Rodolico-San Marco" University Hospital, University of Catania, 95100 Catania, Italy.
| | - Monica Sciacca
- General Pediatrics and Pediatric Emergency Department, "Policlinico G.Rodolico-San Marco" University Hospital, University of Catania, 95100 Catania, Italy
| | - Ausilia Desiree Collotta
- General Pediatrics and Pediatric Emergency Department, "Policlinico G.Rodolico-San Marco" University Hospital, University of Catania, 95100 Catania, Italy
| | - Lucia Giovanna Tardino
- General Pediatrics and Pediatric Emergency Department, "Policlinico G.Rodolico-San Marco" University Hospital, University of Catania, 95100 Catania, Italy
| | - Silvia Marino
- General Pediatrics and Pediatric Emergency Department, "Policlinico G.Rodolico-San Marco" University Hospital, University of Catania, 95100 Catania, Italy
| | - Simona Domenica Marino
- General Pediatrics and Pediatric Emergency Department, "Policlinico G.Rodolico-San Marco" University Hospital, University of Catania, 95100 Catania, Italy
| | - Greta Francesca Privitera
- Bioinformatics Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Giovanna Vitaliti
- General Pediatrics and Pediatric Emergency Department, "Policlinico G.Rodolico-San Marco" University Hospital, University of Catania, 95100 Catania, Italy.
| | - Martino Ruggieri
- Department of Child and Experimental Medicine, Section of Paediatrics and Child Neuropsychiatry, University of Catania, Italy
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Lugli L, Bariola MC, Guidotti I, Pugliese M, Roversi MF, Bedetti L, Della Casa Muttini E, Miselli F, Ori L, Lucaccioni L, Bertoncelli N, Rossi K, Crestani S, Bergonzini P, Iughetti L, Ferrari F, Berardi A. Neurodevelopmental outcome of neonatal seizures: A longitudinal study. Eur J Paediatr Neurol 2024; 49:17-26. [PMID: 38324990 DOI: 10.1016/j.ejpn.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/26/2024] [Accepted: 01/26/2024] [Indexed: 02/09/2024]
Abstract
INTRODUCTION Neonatal seizures (NS) are the most common neurological emergency in the neonatal period. The International League Against Epilepsy (ILAE) proposed a new classification of NS based on semiology and highlighted the correlation between semiology and aetiology. However, neurodevelopmental outcomes have not been comprehensively evaluated based on this new classification. AIMS To evaluate neurodevelopmental outcomes and potential risk factors for severe outcomes in NS. METHODS Patients with video electroencephalogram confirmed NS were evaluated. Seizure aetiology, cerebral magnetic resonance imaging (MRI) data, background electroencephalograms data, general movements, and neurodevelopmental outcomes were analysed. Severe outcomes were one of the following: death, cerebral palsy, Griffiths developmental quotient <70, epilepsy, deafness, or blindness. RESULTS A total of 74 neonates were evaluated: 62 (83.8 %) with acute provoked NS (primarily hypoxic-ischaemic encephalopathy), and 12 (16.2 %) with neonatal-onset epilepsies (self-limited neonatal epilepsy, developmental and epileptic encephalopathy, cerebral malformations). Of these, 32 (43.2 %) had electrographic seizures, while 42 (56.7 %) had electroclinical seizures - 38 (90.5 %) were motor (42.1 % clonic) and 4 (9.5 %) were non-motor phenomena. Severe outcomes occurred in 33 of the 74 (44.6 %) participants. In multivariate analysis, neonatal-onset epilepsies (odds ratio [OR]: 1.3; 95 % confidence interval [CI]: 1.1-1.6), status epilepticus (OR: 5.4; 95 % CI: 1.5-19.9), and abnormal general movements (OR: 3.4; 95 % CI: 1.9-7.6) were associated with severe outcomes. CONCLUSIONS At present, hypoxic-ischaemic encephalopathy remains the most frequent aetiology of NS. The prognosis of neonatal-onset epilepsies was worse than that of acute provoked NS, and status epilepticus was the most predictive factor for adverse outcomes.
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Affiliation(s)
- Licia Lugli
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy.
| | | | - Isotta Guidotti
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy
| | | | | | - Luca Bedetti
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy
| | | | - Francesca Miselli
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy; PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Italy
| | - Luca Ori
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy
| | - Laura Lucaccioni
- Pediatric Unit, Mother-Child Department, University Hospital of Modena, Italy
| | | | - Katia Rossi
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy
| | - Sara Crestani
- Postgraduate School of Pediatrics, Department of Medical and Surgical Sciences for Mother, Children and Adults, University of Modena and Reggio Emilia, Italy
| | - Patrizia Bergonzini
- Pediatric Unit, Mother-Child Department, University Hospital of Modena, Italy
| | - Lorenzo Iughetti
- Pediatric Unit, Mother-Child Department, University Hospital of Modena, Italy; Postgraduate School of Pediatrics, Department of Medical and Surgical Sciences for Mother, Children and Adults, University of Modena and Reggio Emilia, Italy
| | - Fabrizio Ferrari
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy
| | - Alberto Berardi
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy
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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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Drosophila carrying epilepsy-associated variants in the vitamin B6 metabolism gene PNPO display allele- and diet-dependent phenotypes. Proc Natl Acad Sci U S A 2022; 119:2115524119. [PMID: 35217610 PMCID: PMC8892510 DOI: 10.1073/pnas.2115524119] [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] [Accepted: 01/10/2022] [Indexed: 12/02/2022] Open
Abstract
Both genetic and environmental factors contribute to epilepsy. Understanding their contributions and interactions helps disease management. However, it is often challenging to study gene–environment interaction in humans due to their heterogeneous genetic background and less controllable environmental factors. The fruit fly, Drosophila melanogaster, has been proven to be a powerful model to study human diseases, including epilepsy. We generated knock-in flies carrying different epilepsy-associated pyridox(am)ine 5′-phosphate oxidase (PNPO) alleles and studied the developmental, behavioral, electrophysiological, and fitness effects of each mutant allele under different dietary conditions. We showed that phenotypes in knock-in flies are allele and diet dependent, providing clues for timely and specific diet interventions. Our results offer biological insights into mechanisms underlying phenotypic variations and specific therapeutic strategies. Pyridox(am)ine 5′-phosphate oxidase (PNPO) catalyzes the rate-limiting step in the synthesis of pyridoxal 5′-phosphate (PLP), the active form of vitamin B6 required for the synthesis of neurotransmitters gamma-aminobutyric acid (GABA) and the monoamines. Pathogenic variants in PNPO have been increasingly identified in patients with neonatal epileptic encephalopathy and early-onset epilepsy. These patients often exhibit different types of seizures and variable comorbidities. Recently, the PNPO gene has also been implicated in epilepsy in adults. It is unclear how these phenotypic variations are linked to specific PNPO alleles and to what degree diet can modify their expression. Using CRISPR-Cas9, we generated four knock-in Drosophila alleles, hWT, hR116Q, hD33V , and hR95H, in which the endogenous Drosophila PNPO was replaced by wild-type human PNPO complementary DNA (cDNA) and three epilepsy-associated variants. We found that these knock-in flies exhibited a wide range of phenotypes, including developmental impairments, abnormal locomotor activities, spontaneous seizures, and shortened life span. These phenotypes are allele dependent, varying with the known biochemical severity of these mutations and our characterized molecular defects. We also showed that diet treatments further diversified the phenotypes among alleles, and PLP supplementation at larval and adult stages prevented developmental impairments and seizures in adult flies, respectively. Furthermore, we found that hR95H had a significant dominant-negative effect, rendering heterozygous flies susceptible to seizures and premature death. Together, these results provide biological bases for the various phenotypes resulting from multifunction of PNPO, specific molecular and/or genetic properties of each PNPO variant, and differential allele–diet interactions.
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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
Treatment of PNPO deficiency related neonatal status epilepticus is challenging. Pyridoxine responsiveness is seen in huge number of cases of PNPO deficiency. Various phenotypic variants in terms of response to pyridoxine are known in PNPO disorder making the treatment complex. Immediate complete cessation of seizures or normalization of EEG on pyridoxine or pyridoxal 5 phosphate therapy is not necessary for the diagnosis, and treatment should be continued till the genetic tests are available.
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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