Home | About IPJ | Editorial board | Ahead of print | Current Issue | Archives | Instructions | Contact us |   Login 
Industrial Psychiatry Journal
Search Articles   
    
Advanced search   
 


 
CASE REPORT
Year : 2012  |  Volume : 21  |  Issue : 2  |  Page : 148-151  Table of Contents     

Challenges in the management of a case of tuberous sclerosis


Department of Psychiatry, University College of Medical Sciences and Guru Teg Bahadur Hospital, Dilshad Garden, New Delhi, India

Date of Web Publication9-Oct-2013

Correspondence Address:
Manjeet Singh Bhatia
D-1, Naraina Vihar,New Delhi - 110 028
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-6748.119635

Rights and Permissions
   Abstract 

Tuberous sclerosis complex is a multi-system disorder with autosomal dominant inheritance, which can affect the brain, heart, skin, kidneys, lungs, and retina. We hereby report therapeutic challenges faced in a case of an adolescent male suffering from tuberous sclerosis.

Keywords: Management, neuropsychiatric manifestations, tuberous sclerosis complex


How to cite this article:
Rathi A, Bhatia MS, Jhanjee A. Challenges in the management of a case of tuberous sclerosis. Ind Psychiatry J 2012;21:148-51

How to cite this URL:
Rathi A, Bhatia MS, Jhanjee A. Challenges in the management of a case of tuberous sclerosis. Ind Psychiatry J [serial online] 2012 [cited 2019 Dec 10];21:148-51. Available from: http://www.industrialpsychiatry.org/text.asp?2012/21/2/148/119635

Tuberous sclerosis complex (TSC) is a multi-system disorder with autosomal dominant inheritance, which can affect the brain, heart, skin, kidneys, lungs, and retina. [1] The birth incidence is estimated to be approximately 1 in 6000. [2] A disease causing mutation in either TSC1 or TSC2 is found in 75-85% of cases. [3],[4],[5] Although, the majority of organs are susceptible, most patients exhibit dermatological, renal, and/or neurological manifestations. [6]

Dermatological abnormalities are evident in the pediatric population. [7] Renal lesions collectively occur in 50-80% of patients. Multiple bilateral angiomyolipomas (AMLs) occur in approximately 80% of individuals with TSC and represent the leading cause of mortality in the TSC patient population secondary to spontaneous hemorrhage. [8]

Neurological abnormalities including, epilepsy, neurocognitive dysfunction, and pervasive developmental disorders like autism [9] are perhaps the most devastating and therapeutically challenging manifestations of TSC. Subependymal nodules may undergo transformation into subependymal giant cell astrocytomas, which are found in 10% of patients, and may lead to progressive hydrocephalus and death. [10] We hereby report therapeutic challenges faced in a case of an adolescent male suffering from tuberous sclerosis.


   Case Report Top


A 16-year-old adolescent male, a Sikh by religion and educated up to 2 nd standard, belonging to a middle socio-economic status with non-vegetarian dietary habits was brought to our psychiatry outpatient department by parents with chief complaints of generalized tonic-clonic seizures since 2 years of age, low-intelligence since childhood and behavior problems like stubbornness and aggression since past 5-6 years.

History of present illness revealed uneventful prenatal and perinatal course along with delayed motor, speech, and adaptive milestones. The patient had his first episode of grand-mal seizures at around 2 years of age and has been having them regularly since then but with variable frequency and duration. There has been no seizure free period since the onset of seizures. The patient started going to a school at around 6 years of age but discontinued studies after 2 years of age due to poor performance at school and being ridiculed by his peers for poor performance and for marks on his face. The patient would spend most of the time at his home playing with his younger siblings and occasionally playing with other younger children in his neighborhood. For the past 5-6 years the parents have noticed increasing behavior problems like stubbornness and not following parental instructions along with frequent episodes of verbal aggression and occasional episodes of physical aggression mostly directed towards parents and younger siblings generally when his wishes were thwarted or demands were not met.

The patient had been shown to many doctors ever since his seizures started and his treatment prescriptions showed that for past 1 year he had been taking orally sodium valproate 500 mg twice daily, phenobarbital 60 mg twice daily, carbamazepine 200 mg thrice daily, and clonazepam 0.5 mg twice daily. The family reported only a small decrease in seizure frequency even after taking these medications. There was no history of any co-morbid medical and surgical illness in the patient or any history of similar features in any of the family members.

General physical and systemic examination was within normal limits apart from the findings of facial angiofibromas [Figure 1] in the facial region. His body weight was 65 kg. Mental status examination was suggestive of low cognitive profile and did not reveal any other psychopathology.
Figure 1: Facial angiofibromas (adenoma sebaceum)

Click here to view


Computed tomography scan and magnetic resonance imaging of the patient displayed multiple subependymal nodules and small multifocal discreet lesions in bilateral cerebral hemispheres suggestive of cortical and sub-cortical tubers [Figure 2] and [Figure 3]. Electroencephalogram (EEG) of the patient was non-specific.
Figure 2: Computed tomography scan findings of the patient showing sub‑ependymal nodules

Click here to view
Figure 3: Magnetic resonance imaging revealing small multifocal discreet tubers in bilateral cerebral hemispheres

Click here to view


Management of the patient was carried out keeping in mind the following objectives:

  • Control of grand mal seizures through optimization of treatment regime
  • Assessment of patient's cognitive abilities and achievement of optimum level of adaptive functioning according to patient's cognitive abilities
  • Behavioral modification aimed at reduction of undesirable behaviors and promotion of adaptive and socially desirable behaviors
  • Detection and timely treatment of other manifestations of tuberous sclerosis to prevent complications.


As part of the management plan, the patient's medications were optimized and he was started on a single anti-epileptic drug sodium valproate at the dosage of 1000 mg/day (15 mg/kg/day). The rationale behind this step was that the patient's current medications regime comprised of multiple anti-epileptics medications two of which were enzyme inducers, i.e., carbamazepine and phenobarbital, which were reducing the effective dose of sodium valproate as well as carbamazepine resulting in reduced plasma levels. It was decided to subsequently adjust the dose of sodium valproate during subsequent follow-ups and to increase the dose gradually depending on the patient's tolerability and response to a maximum of 60 mg/kg body weight. Valproate was increased to 2 g/day in divided doses. Though, the patient's seizure frequency decreased markedly on this dose but he was not completely seizure free. Any effort to increase the dose of valproate resulted in intolerable gastrointestinal (GI) side-effects. Therefore, clobazam 10 mg/day was added to valproate and this resulted in complete improvement of patient's seizures. Currently, he is seizure free for past 2 months.

The patient's cognitive assessment (for Intelligence Quotient (IQ) assessment first parents were interviewed for development behavior on "Vineland social maturity scale" and then child was evaluated first on "Seguin form board test" and then on "Colored progressive matrices." For cognitive assessment "bender gestalt test" and "Weschler memory scale" were done) revealed an IQ of 45, i.e., moderate mental retardation and a mental age of approximately 7 years with relative strength in visual-spatial domain. Parents and family members were psycho-educated regarding the patient's limited cognitive abilities and to lower down their expectations from the patient to bring it in coherence with the patient's cognitive abilities. Behavior therapy was started to reduce the frequency and duration of undesirable behaviors and to promote desirable behaviors by using the principles of negative and positive re-enforcement. The patient was given remedial education and was started from his current level of knowledge. After 3 months of behavior therapy and remedial education, there was marked improvement in the patient's behavior as evidenced by reduced frequency and duration of anger episodes and reduced need for help in daily routine activities. By the end of 3 months, the patient was able to read road signs in English and Hindi and write his name in both the languages and was able to do simple addition and subtraction problems.

The patient also underwent following investigations: Complete hemogram, liver function tests, renal function tests, ultrasonogram whole abdomen, echocardiography, and ophthalmic examination including, retinal and fundus examination. This was carried out to detect any other systemic manifestations of tuberous sclerosis, which might need treatment. These investigations were within normal limits.

A dermatological consultation was also carried out for the treatment of cosmetically disfiguring facial angiofibromas since that was adding to the social embarrassment of the patient. The patient was started on tacrolimus 0.1% w/w ointment for topical application on the affected area. This resulted in visible reduction in the facial angiofibromas. No major adverse effects were noted except transient burning sensation at the site of application.


   Discussion Top


This case highlights the treatment challenges faced in the management of a patient suffering from tuberous sclerosis. It is evident that management of tuberous sclerosis requires a multi-disciplinary approach and an ongoing assessment for the timely management of complications that arise with increasing age. Unfortunately, majority of such patients do not have access to such multi-disciplinary team at one place. However, a systematic approach to such patients can result in the optimum utilization of abilities of these patients and their integration in the mainstream society in a cost-effective way. It is clear that both pharmacological and non-pharmacological aspects of treatment like psycho-education and involving the family in the treatment process are important in the whole management plan. The goals of treatment for patients with TSC are providing the best possible quality of life with the fewest complications from the underlying disease process, fewest adverse treatment effects, and minimum number of drugs. The major complication of TSC requiring long-term medical treatment is epilepsy but no single drug gives satisfactory relief for most of the cases. A combination of drugs is frequently required. The choice of specific anti-epileptic drugs (AED) for treating seizures in patients with TSC is based on the patient's seizure type (s), epilepsy syndrome (s), other involved organ systems, age of the patient, and AED side effect profiles and formulations available. [11] Though, Vigabatrin [12] is considered as the drug of choice for children with TSC and infantile spasms. Topiramate, lamotrigine, valproate, and adrenocorticotropic hormone are also useful. Benzodiazepines or barbiturates should be avoided as these drugs often aggravate underlying behavioral or cognitive problems. Carbamazepine, oxcarbazepine, and phenytoin may cause exacerbation of seizures, particularly in younger children and infants, and these AEDs can aggravate infantile spasms. [11] In the present case, initially the combination of carbamazepine, phenobarbitone, valproate and clonazepam and later on, valproate alone were ineffective in controlling seizures. Finally, the combination of valproate and clobazam was found to be effective in controlling seizures. Rapamycin is a new immunosuppressant with a propensity to inhibit T-cell proliferation and has been approved for use in treating facial angiofibromas in TSC patients without significant adverse effects. [13],[14] There is need of formulation of optimum evidence-based guidelines for the management of such patients.

 
   References Top

1.Roach ES, Sparagana SP. Diagnosis of tuberous sclerosis complex. J Child Neurol 2004;19:643-9.  Back to cited text no. 1
[PUBMED]    
2.Osborne JP, Fryer A, Webb D. Epidemiology of tuberous sclerosis. Ann N Y Acad Sci 1991;615:125-7.  Back to cited text no. 2
[PUBMED]    
3.Ali M, Girimaji SC, Markandaya M, Shukla AK, Sacchidanand S, Kumar A. Mutation and polymorphism analysis of TSC1 and TSC2 genes in Indian patients with tuberous sclerosis complex. Acta Neurol Scand 2005;111:54-63.  Back to cited text no. 3
[PUBMED]    
4.Au KS, Williams AT, Roach ES, Batchelor L, Sparagana SP, Delgado MR, et al. Genotype/phenotype correlation in 325 individuals referred for a diagnosis of tuberous sclerosis complex in the United States. Genet Med 2007;9:88-100.  Back to cited text no. 4
    
5.Sancak O, Nellist M, Goedbloed M, Elfferich P, Wouters C, Maat-Kievit A, et al. Mutational analysis of the TSC1 and TSC2 genes in a diagnostic setting: Genotype- Phenotype correlations and comparison of diagnostic DNA techniques in Tuberous Sclerosis Complex. Eur J Hum Genet 2005;13:731-41.  Back to cited text no. 5
    
6.Curatolo P, Bombardieri R, Jozwiak S. Tuberous sclerosis. Lancet 2008;372:657-68.  Back to cited text no. 6
[PUBMED]    
7.Józwiak S, Schwartz RA, Janniger CK, Bielicka-Cymerman J. Usefulness of diagnostic criteria of tuberous sclerosis complex in pediatric patients. J Child Neurol 2000;15:652-9.  Back to cited text no. 7
    
8.Rakowski SK, Winterkorn EB, Paul E, Steele DJ, Halpern EF, Thiele EA. Renal manifestations of tuberous sclerosis complex: Incidence, prognosis, and predictive factors. Kidney Int 2006;70:1777-82.  Back to cited text no. 8
[PUBMED]    
9.Schwartz RA, Fernández G, Kotulska K, JóŸwiak S. Tuberous sclerosis complex: Advances in diagnosis, genetics, and management. J Am Acad Dermatol 2007;57:189-202.  Back to cited text no. 9
    
10.Goh S, Butler W, Thiele EA. Subependymal giant cell tumors in tuberous sclerosis complex. Neurology 2004;63:1457-61.  Back to cited text no. 10
[PUBMED]    
11.Anisya-Vasanth AV, Satishchandra P, Nagaraja D, Swamy HS, Jayakumar PN. Spectrum of epilepsy in tuberous sclerosis. Neurol India 2004;52:210-2.  Back to cited text no. 11
[PUBMED]  Medknow Journal  
12.Sahin M. Neurocutaneous syndromes. In: Kliegman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RE, editors. Nelson Textbook of Pediatrics. 19 th ed., Ch. 589.2. Philadelphia, PA: Saunders Elsevier; 2011. p. 2049-51.  Back to cited text no. 12
    
13.Dabora SL, Franz DN, Ashwal S, Sagalowsky A, DiMario FJ Jr, Miles D, et al. Multicenter phase 2 trial of sirolimus for tuberous sclerosis: Kidney angiomyolipomas and other tumors regress and VEGF-D levels decrease. PLoS One 2011;6:e23379.  Back to cited text no. 13
    
14.DeKlotz CM, Ogram AE, Singh S, Dronavalli S, MacGregor JL. Dramatic improvement of facial angiofibromas in tuberous sclerosis with topical rapamycin: Optimizing a treatment protocol. Arch Dermatol 2011;147:1116-7.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
  
 
  Search
 
  
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Case Report
   Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed1796    
    Printed45    
    Emailed0    
    PDF Downloaded34    
    Comments [Add]    

Recommend this journal