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Letter to the Editor
Sweating as a presentation of focal epilepsy: clinical case report
Sudoración como presentación de epilepsia focal: descripción de un caso clínico
A. López-Bravoa,b,
Corresponding author
alba.lopez.bravo@gmail.com

Corresponding author.
, A.A. Sanabria-Sanchinelc, M. Marín-Graciab,c, A. Viloria-Alebesqueb,d
a Departamento de Neurología, Hospital Reina Sofía, Tudela, Navarra, Spain
b Instituto de Investigación Sanitaria de Aragón (IIS-A), Zaragoza, Spain
c Departamento de Neurología, Hospital Clínico Lozano Blesa, Zaragoza, Spain
d Departamento de Neurología, Hospital General de Defensa, Zaragoza, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Autonomic symptoms may be the first manifestation of an epileptic seizure&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The International League Against Epilepsy &#40;ILAE&#41; classification identifies autonomic seizures as focal non-motor seizures&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Autonomic symptoms may range from subclinical changes to potentially fatal haemodynamic instability&#46; The anatomical substrate of autonomic seizures generally resides in the central autonomic network&#46; This network comprises the insular cortex&#44; anterior cingulate cortex&#44; amygdalae&#44; hypothalamus&#44; periaqueductal grey matter&#44; parabrachial nucleus&#44; solitary nucleus&#44; rostral ventrolateral medulla&#44; and raphe nucleus&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> We present the case of a patient with episodes of right hemibody hyperhidrosis secondary to insular dysplasia&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 39-year-old right-handed man with no relevant medical history&#46; From the age of 28&#44; he had presented episodes of increased temperature and sweating on the right side of the face and body&#59; episodes lasted 5-10<span class="elsevierStyleHsp" style=""></span>minutes and did not involve altered level of consciousness &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> and <a class="elsevierStyleCrossRef" href="#sec0015">Appendix B</a>&#41;&#46; These episodes presented 6-7 times per day&#46; The baseline sleep-deprived electroencephalogram &#40;EEG&#41; showed no epileptiform alterations&#46; A brain magnetic resonance imaging &#40;MRI&#41; study &#40;3T scanner&#41; revealed radiological signs suggestive of polymicrogyria of the left insular cortex &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Suspecting focal autonomic seizures&#44; we started treatment with eslicarbazepine acetate at 800<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#59; this reduced the number of seizures to the current frequency of one episode per month&#46; Dosage is currently being adjusted&#59; no video EEG monitoring has been performed due to a lack of availability at our centre and the good response to treatment&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Autonomic symptoms frequently present during seizures&#44; either as the predominant manifestation or in association with other convulsive symptoms&#46; They may be classified as cardiovascular changes&#44; and respiratory&#44; gastrointestinal&#44; skin&#44; pupillary&#44; genitourinary&#44; or sexual manifestations&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Some of these signs and symptoms may help us to locate and lateralise the area of seizure onset and the subsequent route of propagation&#46; They may also assist in understanding the anatomical and functional organisation of the central autonomic network&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Previously described cutaneous manifestations include flushing&#44; pallor&#44; sweating&#44; and piloerection&#46; Autonomic symptoms have been attributed to different aetiologies&#58; Franco et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> reported a patient with ipsilateral facial sweating secondary to anti-Ma2 autoimmune encephalitis associated with testicular teratoma&#46; Sweating in the context of seizures has also been reported in a patient with a basal forebrain malformation&#44; in association with tremor and hypothermia&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Cases have also been reported of generalised sweating with other vegetative symptoms&#44; with one case secondary to a periventricular lesion extending to the limbic area&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> and another as a consequence of a parietal meningioma&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Previous cases have also been reported of episodes of hyperhidrosis and ictal piloerection of autoimmune origin in the temporal lobe&#46; Other structures participating in the central autonomic network have less frequently been associated with pilomotor seizures&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> We present the first case of seizures presenting with hyperhidrosis and no piloerection&#44; contralateral to insular polymicrogyria&#46; Insular epilepsy is difficult to diagnose due to its clinical heterogeneity&#58; with the exception of nociceptive symptoms&#44; no clinical presentation is very specific of this location&#59; autonomic symptoms have been described in this clinical entity&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> On many occasions&#44; conventional EEG does not reveal alterations due to the deep location of the insula&#44; which makes it necessary to perform video EEG monitoring in the event of treatment resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> In our patient&#44; the purely autonomic clinical presentation led us to consider the insula as a possible site of seizure onset&#44; given its role in the central autonomic network&#59; while non-specific&#44; the absence of pathological data on the EEG may be compatible with alterations in this location&#44; and the detection of a structural alteration in the MRI study together with the good response to antiepileptic drugs make us consider this diagnosis probable&#46; One limitation of this study is the lack of video EEG monitoring or stereo EEG&#44; which may help establish a more accurate electro-clinical correlate&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion&#44; we present a case of autonomic seizures with hyperhidrosis probably caused by contralateral insular polymicrogyria&#46; We consider it important to systematically describe more patients with infrequent autonomic symptoms&#44; such as sweating&#44; in order to establish the potential of these symptoms to locate and lateralise lesions&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors have received no external funding for this study&#46;</p></span></span>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos