Apparent life-threatening episodes as the first manifestation of epilepsy

Abstract

Nunes ML, Appel CC, da Costa JC (Hospital São Lucas, Porto Alegre, Brazil) An apparent life-threatening episode (ALTE) is characterized by some combination of apnea, color alteration (usually pallid), a change in muscle tone (usually marked limpness), choking, or gagging. In young children, an ALTE may be an unrecognized initial manifestation of an epileptic seizure. Six cases are reviewed in which children seen between the ages of 2 months and 30 months with ALTEs were subsequently found to have epilepsy. A 4-month-old girl was admitted for cardiorespiratory monitoring after experiencing apnea, pallor, and staring. An uncle and a cousin of the child (both on the father's side) had epilepsy. Neurologic examination findings, neuropsychomotor development, and the results of an ECG, an electroencephalogram (EEG), and a brain computed tomographic (CT) scan were all normal. Treatment for mild gastroesophageal reflux was started based on results of a polysomnographic recording with esophageal pH monitoring. The spells recurred during hospitalization, however, and an ictal seizure was eventually noted when the child underwent a second polysomnographic recording. Another EEG 2 months later showed focal spikes in the left temporal region. Valproate controlled seizures for 2 years, but the seizures reappeared 3 months after the drug was discontinued. The parents refused further studies, but the child has remained seizure free for more than 1 year with normal development. Approximately 50% of infants with an ALTE receive a specific diagnosis, but the cause of the episode is unknown in the remaining 50%. Because a normal-appearing EEG does not exclude epileptic seizures, epilepsy as a manifestation of ALTE can be a diagnostic challenge. An apneic spell may be the only indication of apneic seizures or partial seizures. ALTE is considered any episode that is characterized by apnea, color changes, marked change in muscle tone, choking, or gagging. Any infant presenting to the emergency department with such symptoms is concerning enough to warrant observation and workup. It is not uncommon to find that gastroesophageal reflux is the only significant finding in the workup. This article discussed several cases in which the cause of ALTE was epilepsy. This is a diagnostic challenge because the apneic spell may be the only sign of apneic or partial seizures. Still, our emergency department management remains the same, although seizures could be higher in our differential diagnosis.