We report a child, presenting with epilepsia partialis continua (EPC) following alemtuzumab for immunosuppression for solid organ transplant, and response to immunomodulatory treatment.

Supra-refractory status epilepticus can have a number of different causes, including auto-immune (AI) encephalitis. Anti-GABA-A receptor encephalitis is known to cause focal seizures. In a small subset of these patients, electroencephalogram (EEG) has shown epilepsia partialis continua (EPC). Additionally, there are case reports of EPC following alemtuzumab use in multiple sclerosis.   

Case report and review of published literature.

A 10-year-old male with bilateral renal hypoplasia received alemtuzumab and tacrolimus for immunosuppression induction following kidney transplant. Two weeks after the first cycle of alemtuzumab he presented with recurrent right arm clonic jerking, right hand weakness and aphasia.  Electroencephalogram (EEG) revealed left fronto-parietal seizures . Seizures were refractory to antiseizure medications including levetiracetam, lacosamide and fosphenytoin, and showed only transient improvement following general anesthesia with midazolam and ketamine.  He was diagnosed with EPC. Brain imaging and cerebrospinal fluid were normal including negative serum and cerebrospinal fluid autoimmune encephalitis antibody panels.  Four published cases of EPC following alemtuzumab for multiple sclerosis had responded to immune modulating treatments. The patient received five days of high dose methylprednisolone, IVIG, plasmapheresis and rituximab which led to rapid seizures resolution and marked improvement in hemiparesis, aphasia and EEG abnormalities. He was found to have a likely pathogenic variant in MT-TF mitochondrial gene. 

To our knowledge this is the first report of EPC following alemtuzumab in a child, and the first report of EPC following alemtuzumab used for immunosuppression induction for solid organ transplant. The response to immunotherapy suggests an autoimmune etiology of EPC in our patient. MT-FT variant might have contributed to decreased seizure threshold. This case adds to the literature of EPC in patients receiving alemtuzumab and expands its clinical setting.