His epilepsy was refractory to sodium valproate, lamotrigine, and levetiracetam. From 2 years, he had infrequent episodes of focal nonconvulsive status epilepticus, characterized by loss of awareness, eye deviation, and facial twitching, lasting up to 2 hours.
The EEG showed high-voltage rhythmic focal delta in the centro-parietal region. The spasms occurred every 10 to 20 seconds for 3 minutes shortly after food or liquid was put in his mouth and interfered with his ability to chew and swallow. The spasms were controlled for 2 months but then relapsed and are ongoing. His development was normal at 9 weeks; he smiled and fixed and followed by 6 weeks. Within a week of seizure onset, he regressed with loss of visual fixation and head control. By 5 months, he was rolling over, and by 8 months, he was sitting and finger-feeding. After 9 months, his development plateaued with a period of regression at 2 years.
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At 6 years, he vocalizes but is nonverbal, nor can he sit or walk independently. On examination, he was not dysmorphic and had almost continuous choreiform movements involving the limbs and orofacial region video. His limb tone was variable with axial hypotonia.
Early EEGs between 10 weeks and 4 months were normal, but multifocal epileptiform abnormalities had developed by 2 years. MRI at 1 year showed bilateral small hippocampi with left hippocampal malrotation figure, C. SCN1A is the most relevant epilepsy gene. We bring together novel cases and reanalyze the phenotype of reported cases with the recurrent mutation to identify a distinctive entity of early-onset developmental and epileptic encephalopathy with profound impairment and a prominent movement disorder.
Early infantile SCN1A encephalopathy can be readily distinguished from Dravet syndrome by several features.
It is associated with profound developmental impairment rather than the severe to mild intellectual disability usually seen in Dravet syndrome. Infantile movement disorders are not part of the Dravet phenotype, whereas our patients have a distinctive movement disorder with choreoathetosis, dystonia, and perioral hyperkinesia. Other features differentiating early infantile SCN1A encephalopathy from Dravet syndrome are epileptic spasms, which are not seen in Dravet syndrome.
Tonic seizures are described in adults with Dravet syndrome but are not part of the childhood phenotype. Three of the 8 patients with ThrMet cases 3, 4, and 6 have been previously reported as having Dravet syndrome. The phenotype, early infantile SCN1A encephalopathy, was not yet recognized, and Dravet-like features such as hemiclonic seizures led to the diagnosis of Dravet syndrome.
We have reanalyzed the phenotype of these patients, and all share a homogeneous profound phenotype. In addition, there are 2 further individuals reported with the ThrMet mutation. The remaining child presented with febrile status epilepticus at 6 months.
This could be a differential diagnosis of the movement disorder in our patients, but overall, she had better developmental progress. She also had an SCN9A variant p.
WR that may have modified her phenotype. There are 2 reports of missense SCN1A mutations at codon c. A Japanese group has previously described a single case of infantile epileptic encephalopathy with a hyperkinetic movement disorder and hand stereotypies associated with a different novel SCN1A mutation. The child also had an early-onset severe hyperkinetic movement disorder and a different SCN1A missense mutation c.
ValLeu from that found in our cohort. Somewhat counterintuitively, this more severe phenotype is associated with missense, rather than truncation, mutations. There is increasing recognition of the overlap of developmental epileptic encephalopathies and movement disorders. These disorders have been recently associated with a large, heterogeneous range of genetic etiologies. It is unlikely that the seizures or the treatment per se cause the profound developmental impairment or movement disorders, given that a similar spectrum of seizure types with onset in later infancy or childhood does not have the same developmental sequelae.
Thus, we hypothesize that specific SCN1A mutations cause the overall phenotype. However, it is conceivable that this complex phenotype could be due to frequent seizures at a younger age. It is interesting to speculate that it possibly is associated with a gain of function akin to SCN2A and SCN8A , but functional studies are required to prove the mechanism of this devastating disorder.
Supplemental data at Neurology. Sadleir and Prof. Scheffer conceived and designed the study and wrote the manuscript. Sadleir, Ms. Mountier, Dr. Gill, Dr. Davis, Prof. Joshi, Dr.
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DeVile, Dr. Kurian, Dr. Wirrell, Dr. Nickels, Dr. Murali, and Prof. Scheffer recruited and phenotyped the children. Mandelstam reviewed the neuroimaging. Carvill, Dr.
Mefford, and the DDD Study identified mutations. All authors reviewed the manuscript. Sadleir serves on the epilepsy advisory board for Nutricia. Sadleir and E.
Mountier and D. Gill report no disclosures relevant to the manuscript.
Joshi, C. DeVile, M. Kurian, S. Mandelstam, E. Wirrell, K.
Nickels, and H. Murali report no disclosures relevant to the manuscript. Carvill is a member of the scientific advisory board of Ambry Genetics. Myers reports no disclosures relevant to the manuscript. Go to Neurology. National Center for Biotechnology Information , U.
Lynette G. Nickels , MD, Hema R. Myers , PhD, Heather C. Barrett, Daniel Perrett, Daniela T. FitzPatrick, David R. Morley, Katherine Lachlan, I. Fitzgerald, Tomas W. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Correspondence to Dr. Sadleir: zn. Scheffer: ua. Coinvestigators are listed at Neurology. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Received Jan 17; Accepted Jun Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the terms of the Creative Commons Attribution License 4. This article has been cited by other articles in PMC.