01992 VOL. 23 NO 3

CLINICAL ELECTROENCEPHALOGRAPHY

Hot Water Epilepsy Enis Erdem, Meral Topcu, Yavuz Renda, Abdurrahman Ciger, Kubilay Varli and Turgut Zileli

Key Words Epilepsy Hot Water Epilepsy

INTRODUCTION Hot water epilepsy was first described in 1945.’ Since then, under a common hot water stimulus, a number of cases with various clinical and EEG features have been reported.’-’’ However, hot water epilepsy (HWE) s t i l l remains as a rare form of reflex epilepsy in western countries. 4-’8 In this paper, we describe 10 further cases of HWE.



PATIENTS AND METHODS The files and EEG tracings of 10 patients with HWE (seen between 1969-1988) were reviewed. Eight of the 10 were male. The mean age of onset was 4.7 years (range from 6 months to 10 years). Average follow-up was 40.9 months (range: 0-114 months). In all patients interictal EEGs were taken. EEG examinations were performed either with an 8-channel Grass or with an 8-channel Nihon-Cohden electroencephalograph. Electrodes were placed according to the International 10-20 System, utilizing referential and bipolar montages. For children younger than 3 years of age a total of 17 electrodes and for other patients 21 electrodes were used. When the patient was 5 years old or younger, tracings were taken during sleep. Sleep recordings were made for approximately an hour. For other patients, a total time of at least 15 minutes of basal and 5 minutes of hyperventilation-activated tracings were recorded. Photic stimulation was performed in all patients. Tracings were obtained with a paper speed of 30 mm/s and a typical recording sensitivity of 5 pV/mm. No ictal EEG study was done. CT was taken in two patients. In all patients anticonvulsant therapy was instituted. RESULTS Clinical and EEG features of the patients are summarized in Table 1. In 1 patient (case9) simplepartial, i n 3 (cases 3,4,10) complex partial, in 2 (cases 1,5) gener-

alized atonic, in 3 (cases 6, 7, 8) generalized tonic-clonic, and in 1 (case 2) absence seizures were seen. Three patients (cases 1, 6, 8) also had non-hot water precipitated and unprovoked seizures. In 1 patient unprovoked seizures preceded the onset of the HWE, while in the other 2 they succeeded. Past histories were unremarkable in 6 patients. There were 1 patient with minimal brain dysfunction (case 3), 1 with previous head trauma (case 4), and 1 with a history of febrile convulsions (case 7) started after the onset of HWE. In the other patient (case 9), despite the presence of an EEG abnormality, episodes of abdominal pain were equivocal as related to epilepsy. There was no family history of any form of epilepsy in our series. Neurodevelopmental milestones were on time in all patients. Physical and neurologic examinations revealed n o unusual f i n d i n g s except for hyperactivity in 1 patient (case 3). EEGs showed generalized abnormalities in 8 (cases 1, 2, 4-9), and focal abnormalities in 2 patients (cases 3, 10). CT was normal in 2 patients (cases8and 10). lncases3and7paper chromatographic analysis of the blood and urine aminoacids was within normal limits. I n i t i a l antiepileptic d r u g s were chosen according t o established principles, viz, relating to the type of seizures and, if informative, according to the EEG pattern. One patient (case 3) used his drugs too irregularly to be evaluated, whereas follow-up periods in the 3 patients (cases6,9,10) wereabsentortooshort for evaluation of the response to therapy. Three patients (cases 1 , 4, 7) had complete remission with phenytoin and it was discontinued in two. One (case 8) had a recurrent seizure after a 4

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From the Department of Neurology (Drs Erdem, Ciger, Varli, Zileli). and Department of Pediatrics, Division of Pediatric Neurology, (Drs. Erdem. T o p ~ uRenda), . Hacettepe University School of Medicine, Ankara, Turkey. Requests for reprints should be addressed to Enis Erdem, M 0 , Hacettepe University Hospitals. Division of Pediatric Neurology, 06100 Ankara, Turkey

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10.5 M

M

M

F

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3

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1 10

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9

10

8

1

7.5

before 1

Generalized atonic

state followed by loss of consciousness

Confusional

Staring

Absence

Generalized atonic

Generalized atonic, after the onset of HWE, occurred twice during 2 years, both at sleep

-

Table 1

Hyperactivity

Followed for 3 years with a diagnosis of 'minimal brain dysfunction" between ages of 6-9 Head trauma at 1 5 years of age

Unremarkable

N

Unremarkable

N

N

N

Unremarkable

Generalized, bilaterally synchronous 3-3 5 c/sec s p i ke-andwave complexes 1 Normal at 5 years 2 bilaterally synchronous centrotemporal sharp and slow waves Generalized bilaterally synchronous sharp and slow waves

Generalized, bilaterally synchronous paroxysmal sharp waves

Bilateral delta activity during hyperventilation

Clinical and EEG features of the patients

Phenobarbital. 3 mg/kg after 15 months phenytoin 5 mg/kg was

Phenobarbital, 2 mg/kg (5 years)

Carbamazepine, 20 mg/kg after 5 months was changed to phenobarbital, 3 mg/kg

Phenytoin, 4 mg/kg after a year ethosuximide was added

Phenobarbital, 4 mg/kg (5 years)

No seizure during the last 4 5 years of medication and after the withdrawal Frequency decreased from 2-3 times a month to 2-3

Frequency decreased from once a week to tw ice4 h ree times a 6 months period Used carbamazepine irregularly, not seen after phenobarbital was started

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43

No seizure 114 during the last 4 years of medication and after the withdrawal

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Hot water epilepsy.

The clinical and EEG features of 10 patients with hot water epilepsy were presented. Eight of the 10 cases were male. The mean age of onset was 4.7 ye...
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