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HomeHEALTHEpilepsy not transmissible by physical contact, body fluids – Neurologist

Epilepsy not transmissible by physical contact, body fluids – Neurologist



Prof. Ikenna Onwuekwe

A professor of Clinical Neurology and Internal Medicine at the College of Medicine, University of Nigeria, Ikenna Onwuekwe, speaks about the causes and management of epilepsy, in this interview with OPEYEMI ADEFEMI

What is epilepsy?

Epilepsy is a medical term derived from the Greek language. It is used to describe a neurological condition where the brain cells,  called neurones, discharge increased amounts of  electric current in an unusual and  haphazard manner. Normally the brain cells work to coordinate and direct  actions in the entire body by a coordinated and systematic network of controlled and targeted electrical discharges. This makes for smooth and routine functioning of the body such as behaviour; muscular activities like talking, chewing and walking; feeling and reacting to sensations; being awake and aware of ourselves and our environment etc. Basically all aspects of human actions are represented and controlled by various parts of the brain in an organised manner. So, when there is a condition of unpredictable and irregular electrical discharges by these neurons usually when they are damaged or irritated, it results in the appearance of abnormal behaviours, abnormal movements and muscle actions (called convulsions), abnormal sensations and abnormalities in being awake and aware (consciousness). Any of these abnormal presentations in such a person is called a seizure.

When a person has two or more seizures in the absence of fever or has a tendency to keep having seizures, the person is said to have epilepsy.  So, epilepsy is a descriptive term used to mean a condition where an injury to brain cells (neurons) leads to recurrent seizures.

What are the early signs of epilepsy?

It is important to say that not every seizure is epileptic in nature. Someone who skipped meals can have a low blood glucose level (hypoglycemia) and this can affect the brain (which uses high amounts of glucose every minute) leading to unconsciousness and convulsions. If given sugar and blood glucose normalises, the convulsions stop and do not happen again. Such a person has what is called symptomatic seizure and not epileptic seizure because it won’t happen again as long as he eats well and his brain has no persisting injury to serve as focus of epilepsy.

 Most people are familiar with and have seen convulsions where a child or adult suddenly loses consciousness, falls to the ground and begins to foam at the mouth, while jerking the arms and legs. The eyes may roll up into the socket and there may be biting of the tongue, clenched teeth or passage of urine in the process before everything stops and the person falls into deep sleep. Everything occurs within five to 10 minutes. Some are as short as two to three minutes. These are easily recognised as seizures.

But there are more subtle types that may be missed and only a knowledgeable observer may suspect seizures. Things like suddenly stopping what one was doing (such as talking, sweeping, eating, writing) and staring into space for seconds without being aware of it; sudden change in behaviour such as getting up to repeatedly touch an object or move from part of the house to another or take off clothes without being aware of doing the action; more complex examples can be driving without being aware of it or suddenly becoming moody or angry or crying without reason and without being aware. There can be sensory seizures like suddenly feeling peppery sensations on one side of the body or sudden upsets in the intestines or heartbeats changes irregularly. These can be due to seizures. Some behaviours thought to be psychiatric in nature end up being seizures after analysis by specialists.

So, virtually any human action can be seen in a seizure.

What are the causes of epilepsy?

The causes of epilepsy are numerous and may be analysed based on age.

In the newborn and infants, issues related to pregnancy, labour and birth are responsible. Examples are infections affecting the baby in the womb, such as measles, prolonged labour denying the child of oxygen, pathological jaundice in the newborn or meningitis. A lot of chromosomal disorders in the newborn come with epilepsy such as Down’s syndrome and sickle cell anemia.

In childhood some of these genetic disorders continue to cause seizures in addition to infections like meningitis and encephalitis, amongst others. Head injury from falls and other trauma come up as causes to.

In teenagers, use of substances of abuse and recreational drugs begin to appear as causes of seizures e.g. cocaine, marijuana, alcohol, methamphetamine etc. Head injury from road traffic accidents, fights, gang violence, etc are important in this group. Other disease conditions like meningitis and cerebral malaria come up too. Tumours in the brain are also seen.

In adults, in addition to head injury and trauma, vascular causes, like stroke, emerge as important causes. Use of alcohol and recreational drugs are still important alongside brain infections. Brain tumours are still relevant while dementing disorders and other degenerative conditions start manifesting.

In the elderly population (more than 65 years), degenerative and vascular causes are uppermost; so, attention to strokes and dementia are important. Minor head injury in this age group lead to venous bleeds, called subdural haemorrhage, which may present as seizures and require urgent surgery. Tumours continue to be important as a cause in this age group.

What are the risk factors?

In terms of risk factors, any age group and gender may be affected. But the numbers are more in the very young (children) and very old (elderly). These two populations are more prone.

There are estimated to be about 70 million people with epilepsy worldwide with more than majority in low-income and developing countries. So, poverty is a risk factor. Low education attachment is a risk factor as are high burdens of malnutrition, low maternal and child health indices, low immunisation rates. Women have peculiar issues with epilepsy, which range from effects of monthly menstrual bleed, pregnancy and breastfeeding, hormonal changes from contraceptives and even access to care.

How common is epilepsy in Nigeria?

There are at least 10 million people with epilepsy in Africa and Nigeria being the most populous is estimated to have between 2 to 2.5 million people living with epilepsy.

There are less than 100 neurologists for the entire country with a population of more than 200 million, with the numbers declining weekly as doctors leave the country.

Most of these neurologists are in few centres in the major cities and are not accessible to the vast majority of PWE who typically reside in the rural and semi-rural settings.

How is epilepsy diagnosed?

The diagnosis of epilepsy is made by a competent neurologist who looks at the patient’s symptoms and signs. He proceeds usually to perform some vital investigations, especially the electroencephalography, which examines the electrical activity of the brain. Other investigations of note are brain imaging by CT/MRI, video EEG recording, infection screens and blood works for various electrolytes, amongst any other test that maybe indicated from the clinical examination.

Epilepsy is a clinical diagnosis in most cases and the management is best undertaken by a neurologist.  There may be a need for an assessment by the psychiatrist where necessary, if non-epileptic seizures patterns are seen. Other health professionals, such as nurses, psychologists,    speech and other therapists, may be involved as cases may demand.

Is epilepsy hereditary?

Yes, there are hereditary causes of epilepsy, such as sickle cell anaemia, Down’s syndrome and other degenerative brain diseases that may be seen in families. Some patients may not have family histories, as our people are poor historians and some may not even be aware of chromosomal disorders in them. Still, most cases here do not appear to be familial. It is important to state clearly that epilepsy is not infectious. Epilepsy cannot be transmitted by physical contact, by sex or by body fluids.

Epilepsy also does not necessarily mean abnormal mental capacity in most patients, as cognitive functions for those well-managed cases are as good as any other unaffected person.

People with epilepsy are capable of living and thriving. Many sportsmen, musicians, academics, professionals, politicians, leaders and successful business people are epileptics but unknown because they are well managed.

How will you describe the level of awareness about epilepsy among Nigerians?

There is generally poor level of awareness about epilepsy and seizures in Nigeria, across all ages and groups. Studies here by neurologists have revealed that this unacceptable situation has not changed appreciably over the decades. The Nigerian Society for Neurological Sciences and other bodies have called attention to this severally.

To its credit, the NSNS, working with the Federal Ministry of Health in 2020, produced the National Guidelines on Epilepsy with the support of GlaxoSmithKline Pharmaceutical Limited. Professor Adesola Ogunniyi of UCH Ibadan led the team of neurologists on this and I was privileged to have been in on it as well.

This document guides the clinicians on how to approach the management of epilepsy and it provides a guide for public health educators on awareness creation and promotion. Increasing awareness remains a work in progress.

What are the complications that can result from epilepsy?

While most epileptic seizures begin and end within five minutes, there are dangerous situations where they last longer than this or keep recurring without recovery in between. This is called status epilepticus. This dangerous situation can lead to death or significant permanent brain damage if not handled by a competent doctor as an emergency. Other complications of epilepsy include body injuries from the loss of consciousness and fall. Patients get lacerations, wounds, burns and head injuries which worsen the brain damage. Some die from the injuries sustained during a fall. Epilepsy from childhood may affect cognitive functions over time and cause learning disabilities, which put the individual at a disadvantage in life.

Social disadvantages and complications of epilepsy come as a result of stigma and discrimination, which is largely ignorance driven. But the social costs can be heavy for unfortunate victims such as sexual abuse and rape, physical violence (some PWE are deemed to be under spiritual attack and possessed by demons), manipulation by religious fraudsters, underemployment, etc.

Epileptic drivers have caused innumerable road accidents, leading to loss of lives and other injuries to themselves and passengers or bystanders.

There are reports of some reduction in fertility in men and women with epilepsy. This may be part of the disease process itself (especially epilepsy syndromes) but may also be linked to medications used in treatment.

There may be increased rates of psychiatric disorders among PWE such as depression, anxiety and psychosis. Treatment costs may be a burden on some families leading to burnout and disruptions in family dynamics. Of course, disruptions in education for the child with epilepsy carries a lot of implications for the individual and society.

What are the first steps to take when a person has an epileptic episode? 

For the general public, if you see someone fall and begin to have convulsions, please do not run away. Help the person. Get close. Loosen any tight-fitting clothing that may impair breathing, but respect privacy. Place a soft material under their head to prevent head butting on the bare ground.

Turn the individual to lie semi-prone on their side with the mouth open and lowered to allow secretions to exit. Do not place any spoon or fork or hand or clothing in between the teeth. This is dangerous. Move the person out of any dangerous position they may be in, such as fire or sharps. Call the emergency line. Allow the convulsion to subside. This typically takes about five minutes. Then when awake, help the individual back on their feet with dignity. Safeguard the person’s properties, handbag, purse, phone etc, in the interim. If the convulsions are continuing, please in the absence of an ambulance, convey the person to the nearest hospital in the same semi-prone position maintained.

Is epilepsy treatable?

Once properly diagnosed by a neurologist, there is a wide range of treatment options available for the control of epileptic seizures. These antiepileptic drugs available in various forms and are applied with knowledge by the neurologist, depending on the clinical and EEG findings.

With proper management, many PWE are able to go off medications if they remain seizure-free while on treatment for two to three years. And about 70 per cenr of PWE fall into this category. The remaining 30 per cent of PWE will have to take medications for life in order to live a happy, meaningful life with the seizures controlled on drugs.

There is a general perception that an epileptic patient cannot leave a normal life. Is that true?

People with epilepsy are capable of living and thriving. Many sportsmen, musicians, academics, professionals, politicians, leaders and successful business people are epileptics but unknown because they are well managed.

What are the commonest misconceptions about epilepsy in Nigeria or Africa?

Most issues in Africa and developing world with epilepsy bother on poverty, ignorance and disease burden, especially infectious disease burden. Improved access to education will help dispel ignorance, stigma and discrimination. Legislation will also assist in ensuring PWE are protected and cared for as necessary. Access to improved public health services will reduce burden, severity and mortality.

What are the dos and don’ts in the management of epilepsy? Are there kinds of food and drinks to avoid?

PWEs are required to refrain from certain medications, foods and drinks as well as activities that can either trigger their seizures or place them in danger of injuries and death if a seizure should break through. Stimulants like cola drinks, kola nuts, caffeine, etc are not advisable for PWE. Similarly, alcohol is discouraged in such people. Driving, cycling, operating certain machinery and swimming or working at heights are activities or occupations discouraged.

Physical activity should not be hindered in well-controlled patients. Similarly, they are encouraged to engage in mental and educational activities. They should live life as normal as possible but must avoid undue physical and mental stress, which can cause exhaustion, dehydration and agitation leading to seizures.

Fevers provoke seizures and must be treated aggressively and early in PWE. People with epilepsy are advised to take their anti-epilepsy medications religiously even while fasting, in order to ensure good control and best outcomes. Similarly, they are to keep to their clinic appointments. Stoppage of treatment is only by the neurologist.

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