A nine-year-old girl was applying mehndi or henna on her hand like any other of her kind when she had a seizure, collapsed in a heap and convulsed, all in the space of 20 seconds. Her family got worried because three years ago, in 2019, the girl had a similar attack. Little did her family know then that she was suffering from Reflex Epilepsy, where an abnormal electrical activity in the brain is precipitated by external stimuli, with something as mundane as light flashes, certain sounds and visuals, basically any auditory or tactile stimuli. Having dismissed it as a rare aberration earlier, the girl’s family rushed her to hospital after she suffered two seizures while applying henna again recently. They got her to the Department of Neurology at Sir Ganga Ram Hospital, where Dr (Col) P.K. Sethi, Senior Consultant, zeroed in on her condition after conducting a simple test. His team applied henna on her right palm, which had a distinctive earthy smell. “As soon as the henna-applied hand was brought closer to the patient’s chest, she started having seizures. The video-electroencephalography revealed an organised background with a posterior rhythm of 9 Hz. The patient became restless, followed by seizures. This was an unusual case of Reflex Epilepsy, where epileptic seizures are consistently induced by identifiable and object–specific triggers as against other epileptic seizures which are usually unprovoked. In our reported case, seizures were consistently induced by application of mehndi and its smell,” said Dr Sethi. He has even published the case details as a rare example in the journal Clinical Neurophysiology. What was the trigger? The seizures in the girl were not triggered by the mere application of mehndi on her hands. It was the fragrance which acted as the stimulus, leading to the stimulation of functional anatomic networks. “The patient was prescribed sodium valproate and her parents were advised to avoid exposure to henna. The girl is stable with no new seizure,” he added. Recounting the test, Dr Sethi said, “The girl had her first seizure when she was just six years old. She abruptly lost consciousness while standing over a washbasin, leading to a fall, head injury and convulsive movements. No diagnostic work-up was conducted. A year later, she suffered two similar seizures while applying henna again. However, her electroencephalogram was read as a “normal awake” record. She was prescribed Levetiracetam but did not take it. Instead, the parents administered two compounded Ayurvedic medications. It took a few more seizures during mehndi application or a marriage ceremony for parents to notice a pattern and come to us. The video-electroencephalography revealed an organised background with a posterior dominant rhythm of 9 Hz. We also noted infrequent slowing of the left posterior quadrant while recording her impulses as mehndi was applied to her right hand. Soon after application, the patient had a convulsion with loss of bladder control. Before the attack, she became restless in bed, moving her legs and adjusting her position. Both hands were flexed at the elbow by the side of her head and tonic deviation of the eyes was noted towards the right. Her right arm then extended above her head (fencer posture), eyes rolled up, head arched back and then both arms extended above the head. She had a frightened expression on her face and looked at the examiner.” A 3T brain magnetic resonance imaging without contrast, which was done two hours after the recorded seizure, confirmed the diagnosis. Dr Sethi has dealt with many cases of Reflex Epilepsy and has found patients reacting to seemingly idiopathic triggers, including smell. “One of my patients from Varanasi started suffering from seizures after he chanted mantras and he couldn’t quite adjust to the hum and rhythm of the sound. Of course, smell as a trigger is rare. Sometimes patients react to flickering lights (photosensitive seizures), music (musicogenic seizures) and hot water (hot water or bathing epilepsy). Intrinsic stimuli (patient’s own activity) include either elementary motor movements, somatosensory (sensation anywhere in the body) stimuli, proprioceptive stimuli (stimuli connected with the position and movement of the body) or more elaborate cognitive activities such as thinking, calculation, abstract reasoning (thinking epilepsy, praxis epilepsy) and reading (reading epilepsy). In the absence of a classification system, reflex epilepsies are characterised according to seizure type and etiology in an individual case. In this case, we went by historicity,” said Dr Sethi. Seizures triggered by eating have also been reported though they are very rare and their estimated prevalence is nearly 1/1,000–2,000 among all patients with epilepsy. In Sri Lanka, for example, the incidence of eating epilepsy is very high and shows familial clustering in most cases possibly due to specific habits such as eating bulky meals rich in carbohydrates. 📣 For more lifestyle news, follow us on Instagram | Twitter | Facebook and don't miss out on the latest updates!
