Diagnosis of epilepsy is fundamentally a clinical judgment. Clinical history should elicit details of seizure semiology, seizure provoking factors, and seizure frequency in the preceding five years.7 At times there can be discrepancy in the diagnosis of epilepsy when it is based only on a screening questionnaire. In a recent epidemiological survey in Togo of the 9,155 subjects screened by a screening questionnaire, 285 subjects (3.1%) reported loss of consciousness, 263 (2.9%) had seizures and 142 (1.5%) had foaming and urinary incontinence during the seizure; 74 (0.8%) had absence seizures, 68 (0.7%) had focal symptoms. During case ascertainment of the 304 subjects studied, diagnosis of epilepsy could be established in only 170 pa-tients.8 Documenting seizure provoking factors like sleep deprivation, photic stimulation, and hyperventilation, helps the clinician in the management of people with epilepsy.9
Family history of epilepsy, past neurological and medical history must be documented in detail and may give clue to the underlying mechanisms of the disease. In developing countries, some studies reported low incidence of family history of epi-lepsy,10-12 whereas others reported a high incidence.13-18 One study in Tanzania reported an extremely high incidence of 75%.13 Studies carried out in 9 different African countries, between 1996 and 1999, using the Questionnaire for Investigation of Epilepsy in Tropical Countries found a positive family history of epilepsy in 34% of the first-degree relatives among the 1374 patients with epilepsy interviewed.6,9 According to Farnarier et al,3 traditionally sanctioned consanguinity in endogamous relationship is very common in many developing countries. In certain situations, consanguinity could be the consequence of tribal isolation or the result of social rejection, which diminishes the possibility of a patient with epilepsy to obtain a healthy spouse, with eventual marginalization of the later.
Relevant past history should concern enquiry about the progress of mother's pregnancy, the circumstances at birth, psychomotor development, diseases during infancy and childhood, neurological sequel consequent to these diseases, and the time interval before the appearance of the symptoms. The place and the conditions during birth should be documented. The psychomotor development must be evaluated according to age specific milestones including but not limiting to sitting, walking, talking etc. A developmental abnormality is probably a sign of central nervous system (CNS) disease. In developing countries obstetrical trauma and perinatal hypoxic-ischemic brain insults are frequent. Multiparity, prematurity, malnutrition, anemia, lack of hygiene and neonatal infections are highly prevalent and may result in many types of cerebral lesions that could result in seizure disorder in later life.19 Of the 1374 patients with epilepsy studied in the community in 9 African countries, mother's pregnancy was abnormal in 14% of patients with epilepsy.9 In this study 48% were born at home, 6% had birth trauma, 7% were premature, 11% did not cry immediately after birth, and 12% had abnormal psychomotor development. In a study in Tanzania 12.1% of patients with epilepsy were products of abnormal pregnancy when compared to 1.8% in the control group.17 In many developing countries children are born at home, without qualified assistance. In a study done in Burundi, 79.1% of children aged less than 15 years were born at home.18 Prenatal, perinatal, and postnatal causes are probably the most frequent predisposing factors for epilepsy in childhood in developing countries3 and account for about 13-14% of the causes.20
Certain diseases of the young, particularly infectious diseases can predispose to epilepsy. Measles, encephalitis and meningitis are among the most serious illnesses that may be accompanied by acute symptomatic seizures, focal or global neurological deficits and later epilepsy. In the study conducted in 9 African countries, severe measles was reported in 22%, while 3% had encephalitis or encephalopathies and 3% had meningitis. Of the 300 patients with epilepsy studied in the Democratic Republic of Congo, 66 children had measles or whooping cough encephalitis and 44 had other encephalitis and meningoencephalitis.21 Japanese encephalitis is a common cause of encephalitis worldwide and endemic in most of the Asian countries and survivors may later develop epilepsy. The reported incidence of epilepsy following Japanese encephalitis ranged between 1.3%22 and 20%.23 Meningococcal meningitis is endemic to Sub-Saharan Africa and Brazil. In a study from Cameroon, of the 101 infants treated for meningitis 17.8% later developed epilepsy.24 Seizures can
be a feature of any febrile illness and febrile seizures are a major risk factor for epilepsy (odds ratio 11.0, p < 0.01).25 In a study from Tanzania, history of febrile seizures was found in 44% of patients with epilepsy when compared to 23% in the control group.17 Other childhood infections and parasitic diseases may be risk factors for epilepsy. Of the 38 patients studied by Debouverie et al26 in Burkina Faso, 11 had infectious and parasitic diseases.
In developing countries HIV infection is highly prevalent and is a major public health problem. About 60% of patients with HIV infection may have epileptic seizures during the course of the illness.27 Epileptic seizures may be manifestation of HIV encephalopathy, lymphoma, or opportunistic infections: toxoplasmosis, cryptococcosis, tuberculosis, and progressive multifocal leukoencephalopathy. Patients with HIV infection may present with new onset epileptic seizures.28,29
In the clinical evaluation, history of traumatic brain injury should be elicited and details should be documented. The reported frequency of traumatic brain injury as a putative risk factor in community-based studies in developing countries varied between 8%9 and 9%.25
History of alcohol consumption, substance abuse and exposure to various toxins should be elicited and documented. Whether consumption of large amount of alcohol, especially adulterated alcohol, is a risk factor for epilepsy is not certain.19 But in a study in Togo,15 attributed epilepsy to alcohol consumption in 8 of the 237 patients studied. The tropical world is the major region for the production and distribution of narcotics. In the developing world psychotropic drug consumption is on the rise. Over indulgence of substance abuse can provoke epileptic seizures.30 Benzene hexachloride, a pesticide used in India, has been associated with seizures.31 Consumption of certain fruits can result in fatal convulsive encephalopathy, this is more often described during famine. In Burkina Faso and other African countries epidemics of fatal convulsive encephalopathy in children have been reported following consumption of unripe ackee fruit (Blighia sapida)31,33 The traditional healers provoke seizures and even status epilepticus by administering some of the herb-als.34,35
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