Bath-induced paroxysmal events - Notes on a case report.

To the Editor

I was interested to read the case report of bathing epilepsy published by Stutchfield and Loh [1] and wish to comment on several misleading statements and factual errors. As the authors would know, we have published a comprehensive review of bath-induced events [2]. Since then, three further papers on bathing epilepsy have been published [3], [4], [5], [6] together with a letter [6] confirming that what was originally reported as neonatal-onset bathing epilepsy is in fact alternating hemiplegia of childhood.

Stutchfield and Loh [1] begin their Abstract by writing that “Bath-induced events in infants and children can be triggered by various etiologies, including cardiological, neurological, and metabolic causes.” This statement reflects the general message of the paper and its conclusion that “There is a wide differential diagnosis for reduced conscious level triggered by bathing” [1]. This contradicts the findings of our very careful review [2], which found only four conditions triggered by bathing in infants, these being bathing epilepsy — by far the commonest [2], [3], [4], [5], alternating hemiplegia of childhood [6], hyperekplexia, and paroxysmal extreme pain disorder [2]. Stutchfield and Loh [1] stated that reflex anoxic seizures (reflex asystolic syncope), cyanotic breath-holding spells (prolonged expiratory apnea), and cardiac syncope from long QT syndrome might be triggered by bathing in infancy, but to my knowledge, no such reports have been published.

With regard to the authors' EEG findings, readers should note that the unit of measurement for the amplitudes of the interictal background activity as well as the “slow build-up of irregular high amplitude (530 mV) delta activity” should be microvolts and not millivolts: indeed, the calibration at the top of Fig. 1. confirms this.

Finally, the authors' list of references deserves comment as well. Their reference [1] – De Keyzer et al. – describes a case of bathing epilepsy (bath water was at 37 °C) and not hot water epilepsy, despite its title. Their reference [3] – Fertleman et al. – was not published in JAMA Neurol (the new name for Archives of Neurology) but rather in the journal Neurology. Lastly, their reference [4] – Mikati et al. – was published in Pediatr Neurol and not J Pediatr Neurol.

Conflict of interest

None.