Tag Archives: tuberous sclerosis

Infantile spasms–my unanswered prayer

You never know when or if something might spring up with TSC. We came so close after surgery to having some normalcy, but it wasn’t to be just yet. About a month after surgery, on Wednesday August 22, Connor had a follow up EEG. We hadn’t seen any seizures since surgery, and now we would see how he was doing as far as the subclinical seizures that can’t be seen to the naked eye. The neurologist would read the EEG and call us with the results within a week. But on Friday morning, August 24, the moment that had lost me countless hours of sleep and stress happened. We saw his first infantile spasms. I don’t even know how much desperate begging and praying I had done that he wouldn’t develop this complication. Infantile spasms are extremely rare in the general population, but kids with TSC are at a higher risk of developing them. I had watched countless YouTube videos other parents had loaded to help others with identification, so that I would be sure if the moment came. But why so much more concern over this seizure type than what he had before? IS can cause brain damage, prevent children from reaching milestones, and even cause regression. Some people had reported their babies had regressed to a newborn state after developing these, losing any milestones they had achieved.

I had obsessed and obsessed over how things would go when these started. How long would it take to get treatment rolling? How many would he have before treatment started to work? What damage would be done between the moment we first saw them and the moment treatment became effective? One thing I didn’t worry about was whether the drug I knew he would get if this happened, Sabril (vigabatrin). would work. I’d heard amazing things about its effectiveness. I’d even obsessed over whether they would start on a Friday after the neurologist’s office closed further complicating getting treatment started. If these had come out of nowhere, meaning we knew nothing of his TSC, these would warrant going to the ER to get treatment started. But since we already had a plan in place and a neurology team, we were told just to call the office and we’d get the ball rolling. So naturally, they started on a Friday. And the office closes early on Fridays. Did I  mention I had a full blown anxiety attack on top of everything else? Because people were right. They said you’d know the spasms when you saw them. And I did.

Click to see spasms before starting Sabril:

http://youtu.be/VPpuAvNJQ30

It actually worked out well that the office was closed. Instead of going through medical assistants, I was able to directly page the doctor on call. I described what I saw and I could tell my description concerned him. They hadn’t yet reviewed his EEG, so he said he would look at that and call us back shortly. Confirmed. His EEG showed hipsarrhythmia, the scrambled pattern of brainwaves that often (but not always) accompany IS. They called in a prescription for Klonipin (clonazepam) for the weekend to help calm them, and we had the first appointment Monday morning to get him on Sabril. On the bright side, the surgery had been a success. No complex partial seizure activity. We should have been able to celebrate, but I try not to be bitter. Try.

It was a long weekend in which we saw 3-4 clusters a day (his worst day having 8). A cluster is a series of spasms. Monday morning we signed our life away on paperwork due to the fact that a possible side effect of Sabril is damage to or loss of peripheral vision. But as Wendi (the fellow TSC mom who has been there to help us and answer our questions through all this) said, “What good is 20/20 vision if their brain is mush?” I haven’t come across any stories yet about children experiencing this so hopefully he won’t either. Because of the risk, he has to undergo eye exams every three months as a precaution, including an ERG (electroretinography) at Scottish Rite. He has to be sedated and electrodes are used to check his vision. Can nothing be simple? You can’t even get Sabril at a regular pharmacy. It has to be Fedexed to your house.

After about a week and a half we seemed to be in the clear. We went three days with no spasms. Then the eye rolling started. It is now mid October and we are still trying to get a handle on the eye rolling. Presumably, they are milder spasms that are breaking through on the Sabril, but he’s doing well and continues to progress. While the full spasms were going on, he was quieter and it was harder to get a laugh, but he’s back to his giggly self. He underwent an 8-hour EEG to try and determine what was going on. Naturally, he didn’t have a single incident for the entirety of the test. Nope, not until we were in the car on the way home. I was so frustrated I might have driven my car into a tree had Connor not been in the car. But the EEG came back otherwise greatly improved, the hipsarrythmia having cleared up. So this Wednesday it’s back to the neurologist for an hour EEG (yeah right, like we’ll get lucky enough for something to happen in that small window) and an appointment to discuss his progress. I’ve been a little bit crushed that Sabril wasn’t the 100 percent miracle cure it has been for many others. I truly thought it would knock them out completely within a few days, so that we’re still seeing anything has been a bit crushing. That being said, it has immensely improved the situation and allowed him to continue on his developmental path.

What we’re currently seeing:

http://www.youtube.com/watch?v=qttWpEA3UYg&feature=youtu.be

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Mommy Mizrahi

UPS truck! UPS truck! I’m very anti t-shirt so I took it upon myself to make a couple t-shirts for TSC awareness. I like to keep it simple on the front, and put the big stuff on the back. Thank, Custom Ink, for allowing me to be a t-shirt prima donna. If anyone wants one, color and shirt style can be changed. You have to order at least 10 for discount pricing.

I have to admit I stole the Google idea from a family I came across online that had a son with autism. They were sick of the looks they would get when they were out so they made shirts for the family that said Google Autism.

Physical therapy and brain surgery

Since Connor was diagnosed at birth as having a seizure disorder, he automatically qualified for the State of Georgia program Babies Can’t Wait. This program is great because it provides physical therapy in your home at a Medicare rate. There is a common misconception in the hospitals that it is free. It’s not, but it is typically covered by insurance. I’m guessing that misconception exists because most people’s insurance covers it. Since they charge the far more reasonable Medicare rates, I would think most insurance companies don’t make an issue of it. If we went for private therapy, we’d have to pay a co-pay, drive him there, and they would charge several hundred dollars an hour. We haven’t had to pay anything out of pocket. And if for some reason, insurance doesn’t cover it, they charge you a fraction of the Medicare rate based on your income.

ImagePhysical therapy session

Seizures can impede development because you can’t take in input during one, plus they make you sleepy, so this adds up to less alert time to learn. Connor also has somewhat low muscle tone due to his neurological condition so it takes him a little longer to master a new physical activity than the average baby. (His pediatrician says his tone has improved vastly since she first saw him and it’s not expected to have a major effect on him when he’s older). At his initial assessment, which was shortly after he turned two months, he was placed in the 0-1 month category due to head lag. This means that when pulled to a sitting position from lying down, his head fell back rather than staying even with the body. I already knew he wasn’t lifting his head on par with other babies his age, so I was very nervous. He also spent the first five weeks of life in a hospital bed which didn’t help. So the first goal we tackled in therapy were exercises that would help him strengthen neck and back muscles that would help him hold his head up. He owned a pilates ball already and I had never even tried pilates.

Besides the head, the biggest difference I noticed was how wobbly he was when holding him to my side. He didn’t hold himself as erectly as other babies, so we also worked on strengthening his core. I was pretty unnerved this whole time though. Even though nobody said this would be his case, I had come across situations in which people had such low muscle tone that they were in wheelchairs or had exceptional difficulty with physical activity.

Fortunately, we went forward with brain surgery on July 27. It was performed at Scottish Rite by Dr. Joshua Chern. Oh, we love Dr. Chern. I did not expect a neurosurgeon to have a bedside manner, but he had really blown us away when we met him in the NICU in April. Very approachable and interested in making sure we understood what would be done, as well as the risks. When he tried to show us the MRI, he was unable to retrieve it in the computer system, but instead of just giving us a quick run through so he could go on with his day, he said he’d be back in an hour because he wanted us to see exactly what needed to be done.

ImageBefore going off to surgery

ImageSurgeon marking side of head for operation

He was back in about 40 minutes, and not only had he retrieved the MRI, but during that time he had spoken with Connor’s neurologist, as well as called a colleague for consult in another part of the country. Considering I feel like I have to call various medical offices eight times any time I need something medically related done, this kind of proactive go-getting was awesome. The tuber in the right frontal lobe was plain as day and according to the EEG, responsible for 80-90 percent of the seizures. And perhaps removing it would help lessen the few that were coming from the rear left occiptal lobe. It wasn’t too deep and he was confident it wouldn’t have any long term effects on him. It’s location was in a not very vital area, it was on the surface, plus at this age the brain can compensate by using other parts of the brain instead.

A little after his four month birthday we checked in for surgery at 6 am on a Friday morning. He went back at 8 am for another MRI in the operating room and the surgery was underway by 10. My parents and Chris’s sister came to the hospital for support and as we sat at the lobby Starbucks it became apparent that Chris wasn’t talking. His nervousness was palpable. I can’t really explain why I was as calm as I was (other than that I had started back on my anxiety pills a few weeks prior :). I was the mess during the NICU and Chris kept it together. Now the roles were reversed. Although his version of being a mess is much more pleasant than mine. I was just looking forward to having some sort of resolution finally. Although I will say the backpack full of thank you notes to be written and magazines to be read didn’t get touched. I wasn’t THAT good, despite hourly calls from the OR to let us know everything was going fine.

ImageBeing wheeled out of surgery

ImageThe day after surgery

Dr. Chern came to speak with us shortly after one o’clock when they finished. Everything had gone smoothly and the plan was to keep him in ICU that night and on the seizure floor until Monday. And then Connor became a rock star.

If you couldn’t see it, you wouldn’t know he’d had brain surgery. I’m a bigger baby over a headache. Surgery? I’d probably be ringing a bell and demanding to be waited on for six months. The only time he fussed was the next day when the swelling started and you could see his face getting tight. Once we told the nurse to give him the meds regularly, he was fine (side note: we actually had to tell them to give pain meds to him. We assumed that would be automatic after drilling into his head, but apparently not). Even then, all he had was tylenol and motrin. Man, even I got percocet automatically for pushing him out.

ImageMy parents with Connor after surgery

So I spent the weekend sleeping in his room, further mastering my craft of reattaching leads to his chest that would come loose and wake me up every couple hours with their incessant beeping. I relearned what the various alarms meant and which ones I could silence myself as they received no response from anyone on duty. I also enjoyed pretending to be asleep during shift change when the two nurses would peek in and talk about how cute my baby is. And finally, on Monday he went home. We haven’t seen another complex partial since, and his motor skills picked up immediately. His head was up, his core was steadier, he began to laugh more and an already awesome personality became even more incredible. He’s currently six months, getting close to seven months, and he’s well on his way to sitting independently.

ImageBack home three days after surgery

By the way, I was nursing a  headache as I wrote this, but pushed on because my kid has made it clear I’m a big wimp.

So what is this thing that has changed our lives?

Image

Has someone ever pointed out a new car model to you that you’d never seen before and suddenly you saw it everywhere you went? That’s kind of how I feel about sick children. Now that we have to contend with Connor’s health issues, I feel like everywhere I look I see people with sick kids. It’s a cruel, messed up world if the countless prayer pages for children on Facebook are any indication. Not to mention the time I’ve spent in hospitals seeing other people’s children wheeled around with tubes sticking out of them or minus their hair. Sometimes I think if I’d had this awareness before I got pregnant, I never would have had a kid at all. But now that he’s here, I wouldn’t give him up for anything. I just hope there really is something better waiting for us all in the end, or I’m going to be really ticked.

So what is TSC? Tuberous sclerosis complex is a rare multi-system disease that can cause benign tumors to grow in various organs including the brain, heart, lungs, kidneys, eyes, and skin. It CAN cause retardation or learning disabilities, autism, seizures, behavior issues, OCD, ADHD, kidney issues, lung problems and skin lesions. But every individual’s course with TSC is different. There is a full range of the severely afflicted that need constant care to those who are so mildly affected they may not even know they have it until they have a child who presents more severely.

I’ve heard many describe it as walking through a minefield. It’s a pretty apt description. We basically have a long list of things that MIGHT happen. Or they might not. Seizures. Check. Been there, done that. He started having complex partials the day he was born. Although I’m thrilled to say we haven’t seen any since surgery and none were on his most recent EEG. We are currently contending with infantile spasms, a very rare form of epilepsy seen in children, although more frequent in TSC. He’s been on Sabril for about a month now which has helped considerably, but he still has 1-2 breakthrough clusters a day which are much, much milder than what he was having. These are scary though because even though he will eventually outgrow them, they have potential to be extremely damaging and cause regression. Fortunately we’ve seen none of that and he continues to progress. We’re still working with the neurologist to get these under control. I’ll go into these more in a separate entry.

But that TSC minefield I mentioned? It means that even though the spasms will eventually go away, and even though the surgery was successful, there is no guarantee for the future. Some people’s seizures go away for good, some go 2, 10, 20 years before it happens again.

Currently we’re lucky (lucky in the most screwed up sense of the word) because we’re only dealing with brain involvement. His cardiac rhabdomyoma we saw on the ultrasound cleared up by three months old. They told us it would happen by the time he was in his early teens, so we like to think that it happened so quickly is a good sign. I just wish all the organs worked that way.

His kidney and eye scans at birth came back clear. Both have been checked again in the last month and remain clear. Lung involvement is rarer in males (thank God for small favors), but can be very problematic for females (Google LAM). He also doesn’t show any signs on his skin. The eyes may show signs of TSC, but rarely affect vision (the boy will have glasses anyway thanks to his parents). But for the rest of his life he will require annual MRIs of the brain and kidney scans so that if there are any life threatening growths, they can be treated immediately with some of the amazing new medications that have come about in the last decade for TSC or by surgical intervention.

But what is causing this? Two genes have been identified so far as being involved in tuberous sclerosis. Mutation of chromosome 9, which regulates the protein hamartin, results in a diagnosis of TSC1. Mutation of chromosome 16, which regulates the growth of tuberin, results in a diagnosis of TSC2. These proteins are growth supressors in cells, and the chromosomal damage results in the growth of the tumors seen in TSC. Connor has TSC2.

Why does he have it? After meeting with a genetic counselor after his birth, the thought was that he is most likely a case of spontaneous mutation, as are the majority of cases. There was nothing in our family histories to indicate that it has been passed down. That being said, unless Chris and I undergo genetic testing, we can’t be 100 percent sure neither of us has a mild case of it. Indeed, one of us COULD be a spontaneous mutation and passed it on to him. It is a dominant gene, so if you have it, your children have a 50 percent chance of inheriting it. The degree to which the parent is affected doesn’t foreshadow the degree to which a child will be. We don’t currently plan to have any more children, so we probably won’t be tested. Chris has no desire to know, and although I’m curious, I don’t know how I would handle that information. It sure makes you analyze yourself, though. Is TSC why I’ve had anxiety since elementary school? It this why Chris makes the bed military style and is constantly angling everything in the house just so? At any rate, I’m probably forever cursed to wonder if I could have done something different. I know I didn’t DO something wrong, but the questions are there. What if I had spent the last few years eating organic? Did I expose myself to something environmental somewhere along the way?

We simply don’t know what lies ahead, so I focus on this sentence from the Mayo Clinic website: “With appropriate treatment, however, many people who have tuberous sclerosis lead full, productive lives.”

If you would like to read even more in depth about TSC, check out http://www.ninds.nih.gov/disorders/tuberous_sclerosis/detail_tuberous_sclerosis.htm

http://www.mayoclinic.com/health/tuberous-sclerosis/DS01032

http://tsalliance.org/index.aspx

The NICU

Right after birth.

It turns out that if you spend 9 months growing a baby with Oreos (along with the requisite veggies, fruits and grains of course!), even if you significantly reduce your Oreo intake for the following 6 months, you will not be able to then jump on an elliptical and resume your previous 45 minute routine. In fact, after 4 minutes, you will probably have a near death experience. Just a random observation for today.

Soooo picking up from yesterday, the seizures began around 5 or 6. We hadn’t seen him for several hours because of both the regular newborn checkup and the cardiac one. It was actually reaching a point of, “Where is my baby?” frustration. And let me say, care at Northside Hospital is excellent. Communication between floors and departments…not so much. When we started trying to locate him, nobody could find him. We were told to call this nursery, then that and he’d always already been moved. I was told to ask my nurse.  She didn’t know either. This went on for a bit, and then I heard it. Chris was downstairs trying unsuccessfully to locate him as the alarm went off alerting the floor that a baby had been taken past the boundaries. Chris couldn’t get the elevator because they were on lockdown, and then he heard a security guard mumbling into a walkie talkie, saying something that certainly alluded to a baby being missing. This was the last straw that lead to Chris’s very loud and public demand to know where Connor was. And this is when they located him and informed us of the seizures. (The alarm was a staff member accidentally passing the boundary and would happen a couple more times while we were there. No missing babies!)

I wish I had written about this at the time because the emotions are hard to recapture 6 months later. But I could barely talk out loud about it for a couple months. But as scary as it was, we were still in the mindset of, okay, they’ll get these meds going and he’ll be home in a few more days. Well, a few more days stretched into 5 long weeks as the seizures were incredibly resistant to the medication, a hallmark of TSC. He started on phenabarbitol, then Keppra was added, and by the time he left he was on Dilantin as well. But he was still having an extraordinary number of seizures a day. At least 80 a day, maybe more. Many of them were subclinical which means only an EEG can detect it. They don’t cause the outward jerking. At this point it looked like we were gonna have to go on the surgery, so he was transferred across the street to Scottish Rite. I could have carried him over, yet it involved a $1500 ambulance transfer. Thank God for insurance.

I can’t believe there was a time when it was taxing to feed him 2 ounces (due to medication induced sleepiness) considering he’s now 6 months old and wearing 12-18 month clothing.

We met with his potential surgeon Dr. Chern at Scottish Rite. At this point we were finally miraculously seeing some improvement with the meds. He was still having a number of seizures, mostly subclinical, but it was decided that the benefits of waiting to do the surgery when he was bigger outweighed the cons. It would be safer in a few months. So after 5 weeks of driving to the hospital every day, he was finally released on April 23, 2012. And I have to say my husband got me through this. He was a rock. He had his moments, but I would have lost my mind without him. Just the simple fact of having a sick child is scary enough, but on top of that it shattered that “it can’t happen to me” belief that gets many of us through life. I’m a worrier by nature. Takeoff makes me nervous and the word cancer makes my stomach turn. And yet I still fly and could improve some health habits. Now for the first time, I truly realized that anything can happen to anyone at anytime. My plane could crash. I could actually get cancer. Fortunately we had so many other family and friends there to support us through all this. So thank you to all of you.

He never exactly had issues eating, but he would be so sleepy from meds and seizures that a feeding tube was used from time to time.

Connor’s official diagnosis wouldn’t come for several weeks. That’s the genetic test confirming his TSC, but from the rhabdomyoma in the heart, and the seizures, tuberous sclerosis was the immediate thought. He subsequently had an MRI for his brain, a kidney ultrasound, and an eye exam as those are areas most commonly affected. Thank God his kidneys and eyes were clear. But clearly the brain wouldn’t be. The tubers, including the one that would be surgically removed were evident. For my next entry I will get into the specifics of what TSC is.

Breastfeeding never worked out with all that was going on, so I pumped for the next 3 months until I couldn’t take being attached to the machine anymore. But it may have been for the best considering I had to carefully time my glasses of wine around pumping. Otherwise I probably would have knocked out a bottle on a nightly basis. When I tried going online for advice, I was shocked by how harsh and nasty a lot of the hardcore breastfeeding community is. It left me with a lot of guilt when I finally quit, but I had to for my mental state. It also left me disappointed that there was yet one more way in which women can be extremely unsupportive of other women. It’s easy to judge when everything goes hunky dory according to plan, isn’t it? I still have hostility about it. But women need to know that it’s extremely common to have problems with latching, pain, lactation failure, and many other things. So NYC’s Mayor Bloomberg can stick it where the sun don’t shine.

I can’t remember if this particular EEG was 24 or 48 hours.

Diagnosis: Tuberous Sclerosis Complex

Connor getting an EEG.

It’s insane to think six and a half months ago I didn’t even know what tuberous sclerosis was. Now it’s something I think about every day. In fact, I never even heard the words tuberous sclerosis until January of 2012 and even then it didn’t mean anything to me.

My husband and I went for our 30 week ultrasound with nothing but anticipation. Pregnancy had been a piece of cake. No morning sickness, or any other issues other than a few weeks of serious fatigue that prompted me to sleep 18 hours a day–so basically reliving my early-mid 20s, minus the drinking. The tech did the initial checkup and then the doctor came in. He expressed concern about an irregularity of the heart wall, but not in a panicked, this is an emergency manner. However, he did set us up to have another ultrasound the next day with a cardiac specialist. The appointment did NOT go well.

Naturally we were nervous to hear there was something strange, even if the doctor had said there was no problem with the functioning of the heart. But the next day’s appointment rattled us to the core. First, it was a new machine and nobody seemed particularly adept at using it. We felt like the guinea pigs while two middle schoolers triend to navigate a new gaming system for an hour with no feedback or information offered to us whatsoever. Had this been a routine appointment, I probably would have been laid back about it, but I was waiting to hear what might be wrong with the heart, so I was definitely not feeling very laid back. Medical vocabulary like rhabdomyoma, calcium deposits, and tuberous sclerosis were thrown out as vague possibilities. Nothing concrete enough to lead us in a particular direction. And when we asked what this meant for the baby, they weren’t quite so comforting as the perinatologist. We couldn’t even get a straight answer on if he’d be born. In the meantime, there were attempts to continue light, casual doctor/patient conversation that we were no longer interested in. When I started to cry, I was handed a box of tissues and they left the room, telling us to take as much time as we needed. We got the hell out of there.

Within a couple days we managed to get the perinatologist back on the phone and he quickly soothed our fears. Yes, the baby would be born, and the heart was functioning perfectly in spite of this oddity. I was to come back every couple weeks until the birth. As time went on, the ultrasounds showed it wasn’t growing and continued to have no effect on the heart. We relaxed. They induced me at 39.5 weeks as a precaution simply to be sure he could be checked out by the cardio team. Everything went fine. Then a few hours later, the seizures started.

We hadn’t looked much into tuberous sclerosis because it was mentioned in such a remote, vague way. But we did see it was rare. Estimates are 1 in 6,000 or about a million people world wide. So there was no way. A million people in the world? That was a fraction of the population of our city of residence, Atlanta. That was obviously not it.

Except it was.

I’m going to continue to recount our experiences up to now in the hopes that maybe this blog helps someone going through this. And perhaps in some small way to help draw attention to a disease that so few have heard of. The whole blog won’t necessarily be all about TSC because we are more than that, but obviously that will be a part of it. And it’s important that people hear about this genetic disorder because the research done to cure it can help people afflicted with many things, such as autism, obesity, certain cancers, ADHD, depression and tumors, even if they don’t have TSC because they share similar neural pathways and other sciency stuff that frankly I don’t get because I was never very adept at math and science.