Investigators at Sapienza University of Rome, Italy, describe 12 children with Panayiotopoulos syndrome (PS) misdiagnosed as gastroesophageal reflux disease (GERD). They were referred to the gastroenterological service at the mean age of 6 years (from 4 to 10 years) because of drug-resistant, recurrent nausea, retching, and vomiting. Attacks occurred mainly during sleep; 3 children also had episodes of severe headache resembling migraine with visual aura (spots, zigzag lines, colored lights, and blobs). When seen by a pediatric neurologist because of persistence of symptoms, despite antacids, antireflux diet, and sleep position, an interictal EEG showed brief multifocal and generalized sharp and slow-wave paroxysms in all patients. Brain MRI was normal. In 5 patients treated with antiepileptic drugs, episodes of vomiting, headache, and EEG abnormalities were controlled. [1]

COMMENTARY. Panayiotopoulos syndrome (PS) is defined as a benign age-related focal seizure disorder occurring in early and mid-childhood. It is characterized by seizures, often prolonged with predominantly autonomic symptoms, and by an EEG that shows shifting and/or multiple foci, often with occipital predominance [2]. Prognosis is usually favorable, but rarely, severe bradycardia and cardiac arrest have been reported [3]. In addition to GERD, nonepileptic disorders misdiagnosed as PS include syncope, and migraine. Cyclic vomiting is described as an epilepsy in an early report [4], but is usually considered an atypical migraine or periodic syndrome.

AED treatment of PS and rolandic epilepsy (RE). A clinical practice survey in the UK among 590 pediatricians who treat epilepsy found that 40% of 132 respondents reported non-treatment of PS and RE because of low frequency of seizures and parent/child preferences. They estimated 233 new cases of PS and 751 new RE cases, annually. Carbamazepine is the preferred older, and levetiracetam the preferred newer AED in randomized controlled trials [5].