Doctors race to understand epilepsy in the time of COVID-19

Abstract

We enjoyed reading the recent article entitled, “Epilepsy self-management during a pandemic: Experiences of people with epilepsy” by Miller and colleagues published in your esteemed journal [[1]Miller W.R. Von Gaudecker J. Tanner A. Buelow J.M. Epilepsy self-management during a pandemic: experiences of people with epilepsy.Epilepsy Behav. 2020; ([published Online First: 2020/06/25])https://doi.org/10.1016/j.yebeh.2020.107238Abstract Full Text Full Text PDF Scopus (35) Google Scholar]. Although these data are extremely interesting, we have to be very careful when discussing them. Firstly, it is evident to all scientists that the new coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) infection has become a worldwide pandemic and a global health threat that mobilized healthcare workers in all disciplines [[2]Judson G.L. Kelemen B.W. Njoroge J.N. Mahadevan V.S. Cardiovascular implications and therapeutic considerations in COVID-19 infection.Cardiol Ther. 2020; ([published Online First: 2020/06/13])https://doi.org/10.1007/s40119-020-00184-5Crossref PubMed Scopus (5) Google Scholar]. Despite ongoing advances, careful clinical, diagnostic, and epidemiological studies are still necessary to acknowledge manifestations and the burden of neurological disease caused by SARS-CoV-2 [[3]Ellul M.A. Benjamin L. Singh B. Ant S. Michael B.D. Easton A. et al.Neurological associations of COVID-19.Lancet Neurol. 2020; ([published Online First: 2020/07/02])https://doi.org/10.1016/S1474-4422(20)30221-0Abstract Full Text Full Text PDF PubMed Scopus (1075) Google Scholar], including epilepsy [[4]Kuroda N. Epilepsy and COVID-19: associations and important considerations.Epilepsy Behav. 2020; ([published Online First: 2020/04/22])https://doi.org/10.1016/j.yebeh.2020.107122Abstract Full Text Full Text PDF Scopus (68) Google Scholar]. Because of the clinical importance of these considerations, we would like to add some thoughts that may open the debate about the possible increase in cases of sudden unexpected death in epilepsy (SUDEP) during this current serious pandemic. In fact, the SARS-CoV-2 pandemic that hit the central Chinese city of Wuhan in late December 2019 and subsequently spread rapidly to all provinces of China and all countries worldwide has had a negative impact on global public health [[5]Di Pasquale G. Coronavirus COVID-19: COVID-19 coronavirus: what implications for cardiology?.G Ital Cardiol. 2020; 21: 243-245Google Scholar]. Severe acute respiratory syndrome coronavirus 2 is characterized by a high contagiousness. In this sense, in 85% of cases, it causes subclinical or mild disease, but compared with flu, it easily causes more respiratory complications (e.g., severe pneumonia [ground glass opacities] and interstitial pneumonia) in 10–15% of cases [[5]Di Pasquale G. Coronavirus COVID-19: COVID-19 coronavirus: what implications for cardiology?.G Ital Cardiol. 2020; 21: 243-245Google Scholar]. Moreover, 5% of infected patients require intensive care unit (ICU) admission [[5]Di Pasquale G. Coronavirus COVID-19: COVID-19 coronavirus: what implications for cardiology?.G Ital Cardiol. 2020; 21: 243-245Google Scholar]. During these catastrophic scenarios, lethality is estimated at around 0.7–7% [[5]Di Pasquale G. Coronavirus COVID-19: COVID-19 coronavirus: what implications for cardiology?.G Ital Cardiol. 2020; 21: 243-245Google Scholar,[6]Li T. Lu H. Zhang W. Clinical observation and management of COVID-19 patients.Emerg Microbes Infect. 2020; 9: 687-690Crossref PubMed Scopus (261) Google Scholar]. On the basis of knowledge of other coronaviruses, the contagiousness of SARS-CoV-2 is higher, but the mortality is decidedly lower compared with the severe acute respiratory syndrome (SARS) of 2002 and the Middle East respiratory syndrome (MERS) of 2012, both of them related with higher mortality (9.5% and 34.4%, respectively) [[5]Di Pasquale G. Coronavirus COVID-19: COVID-19 coronavirus: what implications for cardiology?.G Ital Cardiol. 2020; 21: 243-245Google Scholar,[6]Li T. Lu H. Zhang W. Clinical observation and management of COVID-19 patients.Emerg Microbes Infect. 2020; 9: 687-690Crossref PubMed Scopus (261) Google Scholar]. Furthermore, it has been suggested that for patients with severe or critical illness, besides the respiratory supportive treatment, a more careful assessment and the treatment of various affected organs are important [[6]Li T. Lu H. Zhang W. Clinical observation and management of COVID-19 patients.Emerg Microbes Infect. 2020; 9: 687-690Crossref PubMed Scopus (261) Google Scholar]. Thus, the neurological implications of SARS-CoV-2 infection have received special attention [[3]Ellul M.A. Benjamin L. Singh B. Ant S. Michael B.D. Easton A. et al.Neurological associations of COVID-19.Lancet Neurol. 2020; ([published Online First: 2020/07/02])https://doi.org/10.1016/S1474-4422(20)30221-0Abstract Full Text Full Text PDF PubMed Scopus (1075) Google Scholar], and neuroscientists have established consensus recommendations on how to provide the best possible care for people with epilepsy during the novel coronavirus 2019 era [[1]Miller W.R. Von Gaudecker J. Tanner A. Buelow J.M. Epilepsy self-management during a pandemic: experiences of people with epilepsy.Epilepsy Behav. 2020; ([published Online First: 2020/06/25])https://doi.org/10.1016/j.yebeh.2020.107238Abstract Full Text Full Text PDF Scopus (35) Google Scholar,7Adan G.H. Mitchell J.W. Marson T. Epilepsy care in the COVID-19 era.Clin Med. 2020; ([published Online First: 2020/06/09])https://doi.org/10.7861/clinmed.2020-0207Crossref PubMed Scopus (2) Google Scholar, 8Asadi-Pooya A.A. Attar A. Moghadami M. Karimzadeh I. Management of COVID-19 in people with epilepsy: drug considerations.Neurol Sci. 2020; ([published Online First: 2020/06/27])https://doi.org/10.1007/s10072-020-04549-5Crossref Scopus (34) Google Scholar, 9Asadi-Pooya A.A. Seizures associated with coronavirus infections.Seizure. 2020; 79: 49-52Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar, 10French J.A. Brodie M.J. Caraballo R. Devinsky O. Ding D. Jehi L. et al.Keeping people with epilepsy safe during the COVID-19 pandemic.Neurology. 2020; 94: 1032-1037Crossref PubMed Scopus (99) Google Scholar]. In this context, although the medical team's first reaction was to limit access to clinics and neurological centers to preserve patients with epilepsy from being infected [[10]French J.A. Brodie M.J. Caraballo R. Devinsky O. Ding D. Jehi L. et al.Keeping people with epilepsy safe during the COVID-19 pandemic.Neurology. 2020; 94: 1032-1037Crossref PubMed Scopus (99) Google Scholar], some interesting proposals regarding healthcare facilities logistics, medical procedures and treatment (ensuring a regular supply of antiepileptic drugs), and telemedicine have also been discussed among various epileptologists operating in different regions of the world [[4]Kuroda N. Epilepsy and COVID-19: associations and important considerations.Epilepsy Behav. 2020; ([published Online First: 2020/04/22])https://doi.org/10.1016/j.yebeh.2020.107122Abstract Full Text Full Text PDF Scopus (68) Google Scholar,7Adan G.H. Mitchell J.W. Marson T. Epilepsy care in the COVID-19 era.Clin Med. 2020; ([published Online First: 2020/06/09])https://doi.org/10.7861/clinmed.2020-0207Crossref PubMed Scopus (2) Google Scholar, 8Asadi-Pooya A.A. Attar A. Moghadami M. Karimzadeh I. Management of COVID-19 in people with epilepsy: drug considerations.Neurol Sci. 2020; ([published Online First: 2020/06/27])https://doi.org/10.1007/s10072-020-04549-5Crossref Scopus (34) Google Scholar, 9Asadi-Pooya A.A. Seizures associated with coronavirus infections.Seizure. 2020; 79: 49-52Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar, 10French J.A. Brodie M.J. Caraballo R. Devinsky O. Ding D. Jehi L. et al.Keeping people with epilepsy safe during the COVID-19 pandemic.Neurology. 2020; 94: 1032-1037Crossref PubMed Scopus (99) Google Scholar, 11Conde-Blanco E. Centeno M. Tio E. Muriana D. García-Peñas J.J. Serrano P. et al.Emergency implementation of telemedicine for epilepsy in Spain: results of a survey during SARS-CoV-2 pandemic.Epilepsy Behav. 2020; ([published Online First: 2020/06/05])https://doi.org/10.1016/j.yebeh.2020.107211Abstract Full Text Full Text PDF Scopus (28) Google Scholar]. Considering this last aspect, the SARS-CoV-2 crisis has obliged physicians to adopt telemedicine in a very accelerated way to maintain essential care for patients with epilepsy during the pandemic [[11]Conde-Blanco E. Centeno M. Tio E. Muriana D. García-Peñas J.J. Serrano P. et al.Emergency implementation of telemedicine for epilepsy in Spain: results of a survey during SARS-CoV-2 pandemic.Epilepsy Behav. 2020; ([published Online First: 2020/06/05])https://doi.org/10.1016/j.yebeh.2020.107211Abstract Full Text Full Text PDF Scopus (28) Google Scholar,[12]Hare N. Bansal P. Bajowala S.S. Abramson S.L. Chervinskiy S. Corriel R. et al.COVID-19: unmasking telemedicine.J Allergy Clin Immunol Pract. 2020; ([published Online First: 2020/06/27])https://doi.org/10.1016/j.jaip.2020.06.038Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar]. On the other hand, the discussion about SUDEP and the possibility of the occurrence of a greater number of cases of premature death among individuals with epilepsy has not been receiving special attention during application of telehealth. Thus, an interesting recent study evaluated experiences of adult and pediatric epileptologists about the use of telemedicine after emergent implementation during the new SARS-CoV-2 pandemic. In brief, the authors clearly demonstrated that certain topics, such as SUDEP, were felt to be more appropriate to discuss face to face [[11]Conde-Blanco E. Centeno M. Tio E. Muriana D. García-Peñas J.J. Serrano P. et al.Emergency implementation of telemedicine for epilepsy in Spain: results of a survey during SARS-CoV-2 pandemic.Epilepsy Behav. 2020; ([published Online First: 2020/06/05])https://doi.org/10.1016/j.yebeh.2020.107211Abstract Full Text Full Text PDF Scopus (28) Google Scholar]. In this sense, while the current pandemic does not allow a personal conversation about SUDEP in a safe and effective way, it is our obligation to urgently establish new measures for this purpose since SUDEP has become a global conversation with clinicians, scientists, and the community working together to develop strategies that can reduce deaths [[13]Panelli R.J. SUDEP: a global perspective.Epilepsy Behav. 2020; 103106417Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar]. Obviously, SUDEP is one of the most important direct epilepsy-related causes of death, with an incidence in adults of 1.2 per 1000 person-years [[14]DeGiorgio C.M. Curtis A. Hertling D. Moseley B.D. Sudden unexpected death in epilepsy: risk factors, biomarkers, and prevention.Acta Neurol Scand. 2019; 139: 220-230PubMed Google Scholar]. Importantly, it has been clearly demonstrated that generalized tonic–clonic seizures (GTCSs) are the leading risk factor for SUDEP, particularly when GTCSs are uncontrolled despite polypharmacy with several antiepileptic drugs [[14]DeGiorgio C.M. Curtis A. Hertling D. Moseley B.D. Sudden unexpected death in epilepsy: risk factors, biomarkers, and prevention.Acta Neurol Scand. 2019; 139: 220-230PubMed Google Scholar]. In the current perspective, it is already known that the incidence of SARS-CoV-2 is higher in patients with active epilepsy than in the general population and that epilepsy could be considered an independent risk factor for fatality in hospitalized patients with SARS-CoV-2 [[15]Cabezudo-García P. Ciano-Petersen N.L. Mena-Vázquez N. Pons-Pons G. Castro-Sánchez M.V. Serrano-Castro P.J. Incidence and case fatality rate of COVID-19 in patients with active epilepsy.Neurology. 2020; ([published Online First: 2020/06/17])https://doi.org/10.1212/WNL.0000000000010033Crossref PubMed Scopus (58) Google Scholar]. Quite important, we are totally in agreement that it is extremely necessary to constantly provide information to patients with epilepsy and their families to prevent them from getting infected with SARS-CoV-2 [[4]Kuroda N. Epilepsy and COVID-19: associations and important considerations.Epilepsy Behav. 2020; ([published Online First: 2020/04/22])https://doi.org/10.1016/j.yebeh.2020.107122Abstract Full Text Full Text PDF Scopus (68) Google Scholar]. In addition, although there are some studies observing that infection or viral infectious disease might increase the risk of SUDEP, however, there are still no data on the association between SARS-CoV-2 and SUDEP [[4]Kuroda N. Epilepsy and COVID-19: associations and important considerations.Epilepsy Behav. 2020; ([published Online First: 2020/04/22])https://doi.org/10.1016/j.yebeh.2020.107122Abstract Full Text Full Text PDF Scopus (68) Google Scholar,[16]Andersen M.L. Tufik S. Colombo A.L. Cavalheiro E.A. Cysneiros R.M. Scorza F.A. Sudden unexpected death in children with epilepsy: the many faces of fungal pathogenicity.Med Hypotheses. 2012; 79: 127-128Crossref PubMed Scopus (4) Google Scholar,[17]Wang J. Huff K. McMasters R. Cornford M.E. Sudden unexpected death associated with HHV-6 in an adolescent with tuberous sclerosis.Pediatr Neurol. 1999; 21: 488-491Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar]. As a whole, it is time to act. Clearly, we are experiencing a pandemic that is already transforming the world in several aspects, such as, economic, political, scientific, social, cultural, environmental, and health. In fact, most of us are not prepared to deal with SARS-CoV-2 infection especially when it is associated with patients with critical illness, including patients with epilepsy. Finally, we are fully convinced that the entire healthcare systems must stay together worldwide to manage complications in cases of SARS-CoV-2. Our studies are supported by the following grants: FAPESP (Fundação de Amparo à Pesquisa do Estado de São Paulo), CNPq (Conselho Nacional de Desenvolvimento Científico e Tecnológico), and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES). The authors report no conflicts of interest.