Case Presentation:
The patient was a 14‐year‐old girl with new‐onset seizurelike episodes over 3 months. Her parents identified various triggers for the events: raising her arm, standing from a sitting position, and turning her head to the left. She had loss of consciousness (LOC) but no aura or postictal state. An ambulatory VEEG was read as abnormal, and she was started on antiepileptics. She was admitted for further evaluation of seizures. Her admission exam was significant for a normal neurological exam. VEEG monitoring was done, and all medications were stopped. She continued to have drop attacks, staring spells, movements of the mouth, and writhing movements of the upper and lower extremities. Episodes were triggered by change in position from sitting to standing and also seen while in bed. The patient was unresponsive during the events and reported “seeing brown spots” and feeling “lightheaded.” EEG showed no seizure activity. EKG and Holter were normal. An arterial line was placed, and the events were triggered. She had a brief increase in blood pressure followed by a decline to 30/20 mm Hg over 10 seconds with a rapid recovery. She was referred for autonomic testing that revealed her episodes were triggered by breath holding (BH).
Discussion:
The 2 major types of BH spells are cyanotic and pallid. Cyanotic BH is more common and is usually initiated by upsetting a child. They present as rapid‐onset LOC and cyanosis and may have generalized clonic jerks but, the EEG is normal. Pallid BH spells are usually provoked by pain or startling. These are associated with apneic episodes, rapid LOC, hypotonia, and sometimes seizures. BH spells are rare before 6 months of age, usually peak at 2 years of age, and usually resolve by 5 years of age. Treatment involves reassurance of parents and avoiding reinforcement of the child's behavior. In refractory cases of pallid BH, atropine may be considered.
Conclusions:
Paroxysmal movements are often misdiagnosed as seizures. BH spells have some characteristics in common with seizures including altered level of consciousness and various movements and posturing, but children with BH spells have a normal EEG and do not respond to antiepileptic medications. Most literature describes BH spells in young children, but although rare in the adolescent population, the diagnosis should be considered based on clinical history and further workup. After seizures and cardiac causes of LOC have been ruled out, it is important to consider the diagnosis of BH spells in a patient with new‐onset seizurelike activity.
Author Disclosure:
D. Rauch, Baxter, consultant; Pfizer, consultant.