An 8 month old female with normal birth and development began to develop "seizures" at 3 weeks prior to presentation. MRI brain and initial EEG were normal. Recurrent events were encountered over 3 weeks. The semiology was one of an abrupt cry with forced exhalation and limp collapse with loss of consciousness where she would briefly "stop breathing" after vigorous crying and rapid breathing. Transient perioral acrocyanosis was present though quick recovery would occur after the events. An outside sleep-deprived EEG was interpreted as abnormal with the following features.
Figure: EEG showing left hemispheric 1-2 second waveforms developing into a bilateral sustained 3-3.5 Hz pattern. On closer inspection T5 electrode artifact and a poorly believable field led to an association with tickling. Courtesy of Dr. Maria Gieron-Korthals University of South Florida Tampa, Florida.
Cyanotic breath-holding spells were suspected by the clinical description. This common entity occurs in 5% of healthy children usually beginning in the first year of life1. Cyanotic breath-holding spells may be confused with seizures. In this case, the typical presentation was complicated by an "abnormal" EEG. The minimal movement produced by maternal tickling induced artifact that mimicked a focal seizure. EEG interpretation may be subject to misidentification of artifact, normal variants, or variations of normal patterns when electrophysiological properties are neglected due to bias or limited experience leading to diagnostic errors that translate to inappropriate treatment2. A general medical and cardiology evaluation were normal and her spells tapered and finally stopped after 3 years.
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