abdominal seizures?

[Mary]

Our 5 year old son was diagnosed with Epilepsy over a year ago.  He has tonic/clonic and myoclonic seizures.  He was also diagnosed with PFAPA(fever syndrome) about a year ago, but seems to be "growing out of it" as they said he would-- only one fever in last 8 months.  Other than the fevers and seizures our child is very healthy(rarely gets colds/flu etc) and is developmentally normal.  My question pertains to something that has occurred twice in the last month or so.  In the beginning of Dec(2000) our son awoke one day feeling sick to his stomach.        He vomited and also had a 1 minute tonic/clonic seizure.  He vomited several more times in the next couple hours and I noticed that the vomit was a thick yellow color.  He did NOT  have a fever or any other symptoms.  (Just a note-- he had had only 2 tonic/clonics before this day--last one being in Feb 2000-- but many myolconics which had been increasing up to this point).    We took him into the ER and they said his white blood count was 19,000 so they did a chest xray.  They then told us he had a lung infection and put him on Zithromax.   Before even giving him the first dose of the antibiotic he was feeling better and was no longer vomiting.  He did have 3 more tonic/clonics that day-- all less than 1 minute.  The next day he was completely back to normal.  He had almost no myoclonics while on the antibiotics(and no other tonic/clonics after that day).  Once he was done with the antibiotics the myoclonics returned as usual(average of 3-5 a day) for a few weeks and then seemed to stop again for a couple weeks until yesterday.  The odd thing is what happened last week and what I have my question about.  He awoke one day last week complaining of a stomach ache and vomited twice in about a 1 hour time period.  Again it was a yellowish color.     He did not have a fever or any type of cold symptoms and did not have any seizures(tonic/clonic or myoclonic).  He was fatigued and pale looking for about another hour or two, but by lunch was feeling back to normal and ate fine the rest of the day. My questions are these:  Is the vomiting possibly a type of seizure and is the yellow color something to be concerned about?  One other note:  He is on Depakote for the seizures--has been on it since being diagnosed with Epilepsy and has been on the same dose since last April.  The vomiting was immediately upon waking in the morning before any breakfast or medicine was given.  Thanks in advance.
Mary

[Erin31]

A related discussion, Need Advice was started.

[Mary]

Thank you for your reply.  We just got back the results of a recent 24 hr EEG(done about a month ago).  They are increasing his Depakote and will be doing another MRI soon.  Below is the EEG that I have a few questions about:

EEG Descrpition:  The background showed an intermix of predominantly theta/delta activity intermixed with the same alpha/beta frequencies.  Runs of anterior dominant delta activity, some with sharp waves intermixed, were intermittently present throughout this tracing.  At other points, clear spike and sharp wave discharges were present.  Some of the spike discharges phase reversed in the F4/C4 region.  Although this was an inconsistent finding, many of the discharges were diffusely distributed.  Photic stimulation failed to activate epileptiform discharges.
ClNICAL EVENTS:  Several head drops were captured.  Ten of these were reviewed.  The typical clinical manifestations consisted of a head drop with the patient's arms up tonically for approximately one second and then was back to baseline.  With seizure #3, the patient was slow to responcd although all others appeared to be similar to the initial with normal recovery.  
EEG ICTAL CORRELATES:  Each of the head drops was associated with diffuse spike and wave discharges lasting approximately one to two seconds.  Some of these were followed by anterior dominant activity that was described above.
CLINICAL INTERPRETATION:  This record provides evidence for a high spike wave index.  There are several possibly subclinical seizures that occur during play and sleep.  These are manifest with anterior dominant spike or sharp wave followed by slow wave activity.  On some occasions, phase reversals in the right frontal regions were present.  This requires consideration of a structural lesion in the right frontal region although the dominant activity was one of generalized anterior dominant spike and wave discharges.  These patterns are consistent with that described in myoclonic astatic epilepsy of Doose although the background activity does appear to be slower than would be expected for a primary generalized epilpesy.  Nevertheless, such finding have been descirbed with myoclonic astatic epilepsy of Doose.  

I understand most of it, but my questions are these:  What exactly are phase reversals and what do they possibly signify?  What are some of the possible reasons/implications of the background slowing? (Just a note:  in 2 of the last 3 EEG's he's had there was also mention of mild background slowing)  Any other interpretations/comments are welcome.

Mary

[CCF Neuro[P] MD, RPS]

Dear Mary:

I am sorry, but it does seem that your son has epilepsy.  I am not sure why the problem with the posterior rhythm having some delta/theta as at his age there can be posterior slowing of youth that fits this exact description.  But, not seeing it I can only assume this is what the rhythm they are talking about.  Phase reversal, depending on the montage of the EEG, usually mean that the spike is either maximal or minimum at those electrodes.  So, likely the maximum is at the frontal central region on the right.  This would fit his clinical symptoms.  Although Droose described a type of "myoclonic variant", I have never heard it called astastic myoclonic epilepsy of Droose.  There is usually myoclonic activity that is followed by atonia (loss of muscle tone).  There are brief absence seizures in 62%, tonic-clonic seizures in 75%.  During the seizure event there is bursts of generalized 3/4 Hertz spike or multiple spike wave complexes.  There are theta rhythms at 4 to 7 Hertz maximum over the parietal region.  The good news is that at least half of the patients enter into remission of seizure activity.  So, it does sound like your son may have this type of myoclonic epilepsy.

I hope that I helped alittle.

Sincerely,

CCF Neuro MD

[CCF Neuro[P] MD, RPS]

Dear Mary:

I am sorry to hear about your son.  I have not heard of PFAPA before?  But febrile convulsions are very common, however we do not usually treat febrile convulsions with medications.  From what your telling me, your son has been having afebrile (without fever) seizures that occur out of sleep.  I think you need to have him evaluated with your pediatric neurologist.  I would make sure that his level of depakote or valproate is appropriate.  I think he might have changed to focal epilepsy and would have a look at his EEG once again and maybe a MRI.  I am sorry that your son is displaying a new seizure type.

Sincerely,

CCF Neuro MD