Seizurei992;

1:203-206

CASE REPORT

Hot-water epilepsy
SPECT features

in an adult: ictal EEG, MRI and

F. LISOVOSKI, S. PRIER, P. KOSKAS, T. DUBARD, J.L. STIEVENART*,

H. DEHEN &J. CAMBIER

Clinique

Beaujon,

Neurologique

Paul Castaigne

et *Service de Mdecine

Correspondence to Dr F. Lisovoski, Clinique Neurologique
92110 Clichy, France

Nuclkaire,

Hdpital

Clichy, France

Paul Castaigne, Hbpital Beaujon, 100 Boulevard du G&&al

Leclerc,

Reflex epilepsy constitutes a rare form of epileptic seizures. We observed a 20-year-old man who presented with
seizures induced by immersion in hot water. The trigger stimulus was specific. Contrast CT scan and MRI were
all normal, not revealing any structural lesion. Ida1 EEG recorded during a hot bath showed focal epileptic
discharges in the left temporo-occipital area. Interictal SPECT showed a hypometabolism in the same cerebral
region. Neuroimaging studies were rarely performed in this uncommon type of epilepsy. Nevertheless, in our
case the result of the SPECT suggests a localized functional disturbance in the emergence of the disorder.
Key words: reflex epilepsy; partial seizures; hot water; SPECT.

INTRODUCTION
Epileptic seizures precipitated by sensory stimuli are considered as ‘reflex epilesy’ and constitute only 5-6% of all cases of epilepsy. The
nature of the critical stimulus varies: auditory,
olfactory, visual or tactile stimuli can provoke
epileptic
fits. Epilepsy
induced by water
immersion has been previously reported, especially in India. The first reports described
three children aged 10 years, 7 years and 5
months 13. Magnetic resona rice imaging (MRI)
and single photon emission computed tomography (SPECT) examination
have been performed infrequently.
Moreover, this type of
reflex epilepsy is rare in Europe, particularly
in adults.
We report a case of hot-water epilepsy in a
20-year-old patient with ictal electroencephalogram (EEG) recording, MRI and SPECT
results. We discuss the mechanism
of this
uncommon type of epilepsy.
CASE REPORT
The patient was born at full-term
and birth
was uncomplicated:
forceps were used during
1059-1311/92/030203+04

$oa~ooio

the delivery. During childhood, he presented
with dyslexia leading to a moderate school
backwardness. At the age of 10 years, he had
some episodic sleep-walking
troubles,
but
there was no psychomotor
retardation
and
neurological examination
was normal. In particular, there was no hypotonia.
He developed seizures at the age of 15 years.
These consisted of spasmodic contractions of
his right hand followed by painful paresthesias
of his right upper limb, repetition of the same
syllable, then loss of consciousness with generalized convulsions. EEG, CT scan and cerebral
angiography
were normal. Treatment
with
sodium valproate in a daily dose of 1500mg
was efficacious. No new epileptic
seizures
occurred under this treatment. Anticonvulsant
medication was continued until the age of 18
years and was then gradually withdrawn.
At
the age of 20 years, the patient began to experience stereotyped abnormal sensations when
taking his bath. Whenever he immersed himself in hot water, he immediately had a feeling
of being forced to count in his mind and felt
strange without loosing consciousness. These
episodes were always accompanied by the same
‘dream’: he saw himself in his bath at the age of
@ 1992 Baillibe Tindall

F. Lieovoski

204

et al.

Fig. 1: Transverse, coronal and sagittal slices of interictal SPECT (HMPAO Tc 99 m, transverse slices obtained 10 min after
injection in a plane parallel to the orbito-meatal line, reconstruction with a Wierner filter). Transverse views 5cm above the orbiiomeatal line show marked hypoperfusion predominating in the left temporo-occipital region.

4-5 years, playing with his toys. This dreamy
state stopped immediately after he came out of
the hot water. On one occasion the troubles
appeared whilst the patient was showering.
Neither heat nor steam was sufficient to provoke the symptoms unless bathing. Neurological examination was normal.
The results of routine blood chemistry were
normal. An EEG was recorded in usual conditions and was normal. Hyperventilation
as
well as intermittent
light stimulation
did not
provoke any abnormalities.
CT scan and MRI
were normal. SPECT showed a marked left
temporo-occipital
hypoperfusion (Fig. 1). A 24hour EEG recording was performed. When the
patient was placed into hot water (37°C) for
bathing,
he reported the feelings described
above. At the same time, the EEG showed discharges of irregular and rhythmical
spikes or
spikes and slow waves in the left temporo-occipita1 area (Fig. 2). To confirm these findings, a

repeat examination
was made under similar
circumstances
producing
the same results.
Antiepileptic
drug treatment with carbamazepine was started and found to be effective.

DISCUSSION

The outstanding
feature of the case reported
here is that the epileptic phenomenon
was
always induced by the same condition and it
was therefore considered as reflex epilepsy.
Steam alone did not provoke seizure, eliminating a reflex epilepsy induced by an olfactory
stimulus. Reflex epilepsy due to water immersion has been previously reported’”
and is
known as ‘hot-water epilepsy’ or ‘water-immersion epilepsy’, the largest series studied being
from Southern India4. In this region, the
custom for washing is to pour cupfuls of hot
water directly over the head. The temperature

Hot-water epilepsy

in adults

205

Fig. 2: EEG recording of a seizure during hot bath. A. Left temporo-occipital spikes which become more frequent in B, C and D.
Left rhythmical spikes with subsequent irregular spike and slow waves. E. End of seizure.

of water used for bathing in India ranges between 40-50 “C, which is higher than the temperature of water used in Europe. Seizure frequency depended upon the frequency of head
bathing. This disorder is more common in children, with cases more frequent among male
than female patients4. The onset of hot-water
epilepsy in adults is rare, particularly
in Europe, explaining why few studies using neuroimaging techniques have been devoted to this
type of reflex epilepsy.
The simultaneous
mechanical and thermal

stimulation constituted a highly specific stimulus: attempts
to provoke seizures by other
methods such as blowing hot air or using water
of ambient temperature
failed to induce seizures. Pouring hot water only on the head did
not lead to seizures in our patient. On the other
hand, immersion in hot water was not absolutely necessary, since a shower could induce an
attack.
Complex partial
seizures constituted
the
most frequent clinical presentation
in a previous report5. Sixteen to 38% of the patients

F. Llrovoskl

206

developed non-reflex epilepsy by the end of 2
years after the onset of hot-water epilepsy6*7,
but in very few patients non-reflex epilepsy
could precede reflex epilepsy4. In the present
case, non-reflex epilepsy preceded the reflex
partial seizures, which should be classified as
simple partial seizures with psychic symptoms
and not as complex partial seizures according
to the classification
of the International
League Against Epilepsy’.
The pathophysiology
of this type of epilepsy
is not clear. The possibility of a syncope of
vasogenic origin has been suggested in the
literatureg, but this hypothesis could be ruled
out in the present case because of ictal EEG
recordings. Few cases of hot-water
epilepsy
have been studied by MRI. It has been suggested that a structural lesion in the temporal
lobe could explain partial seizures and focal
features of ictal EEC?‘. MRI was normal in our
case, but we cannot rule out this hypothesis.
Another approach for this type of epilepsy is to
consider a locally increased excitability of cerebral structures. SPECT allowed a functional
cerebral investigation. Interictal SPECT in our
case disclosed a hypometabolism
in the left
temporo-occipital
region, which could constitute a cerebral focus inducing seizures. However, the relation between the reflex mechanism of this epilepsy and the functional
involvement
of these cerebral
structures
remains
unclear.
Nevertheless,
an ictal
SPECT study could be more useful in understanding the mechanism of this reflex epilepsy
if it could be realized during the ictal period.
Changing the method of bathing can constitute a sufficient treatment.
Considering the

et al.

existence of a potential cerebral focus, antiepileptic drug treatment
with carbamazepine
allows the best control of this epilepsy.

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