Essential oils as a cause of breakthrough seizure after temporal lobectomy

Open ArchivePublished:July 06, 2009DOI:https://doi.org/10.1016/j.seizure.2009.06.001

      Abstract

      Breakthrough seizures are often encountered in patients with well-controlled epilepsy for no obvious reason. We report a case of a breakthrough seizure after temporal lobectomy secondary to topical administration of essential oils. We recommend inquiring about the use of essential oils in patients with well-controlled epilepsy who experience breakthrough seizures.

      Keywords

      1. Introduction

      Breakthrough seizures are commonly encountered in well-controlled patients with epilepsy, which results in surgical failure in patients who have undergone epilepsy surgery for treatment of refractory epilepsy. These patients are often restarted on antiepileptic drugs (AEDs) or receive additional AEDs. Here we report a case of breakthrough seizure secondary to topical application of essential oils (EO) in a previously seizure-free patient after temporal lobectomy.

      2. Case report

      The patient is a 60-year-old right-handed man with a long-standing history of temporal lobe epilepsy. The patient underwent a standard right anteromedial temporal resection in 2000. Approximately 1 year after his surgery, he was tapered off all AEDs and had been seizure-free for 8 years.
      In October of 2008, the patient received an herbal massage in the evening while on a cruise ship. Interestingly, the masseuse asked the patient whether he suffered from epilepsy. Since our patient had been seizure-free for 8 years and off his medications, he did not mention his history of epilepsy. During the night, his wife was awakened by her husband. According to his wife, the patient appeared frightened and shortly after, developed a generalized tonic-clonic seizure (his typical seizure semiology). A few weeks later, he followed up at the epilepsy clinic for a single breakthrough seizure. The patient and his wife inquired further about the herbal oil on the cruise ship as a causative agent, and brought the product information to the clinic. The particular oil used was Musclease Active Body Concentrate, manufactured by Elemis®. Upon further research, this product contains maritime pine, sea-buckthorn, sea fennel, almond oil, tocopherol, sunflower oil, and rosemary essential oil.

      Product website available at www.elemis.com. Accessed February 5, 2009.

      The patient was counseled to refrain from using this particular product and other herbal medicines and lotions. At 4 months follow-up, the patient is still seizure-free, off all AEDs.

      3. Discussion

      Our patient was seizure-free for 8 years after his temporal lobectomy. He experienced one typical seizure after a massage with Musclease Active Body Concentrate, and has been seizure-free since. Presumably, his seizure was induced by the massage oil and he was not restarted on AEDs. We suspect the pro-convulsive agent was camphor,
      • Burkhard P.R.
      • Burkhardt K.
      • Haenggeli C.
      • Landis T.
      Plant-induced seizures: reappearance of an old problem.
      • Agarwal A.
      • Malhotra H.S.
      Camphor ingestion: an unusual cause of seizure.
      a compound found in rosemary essential oil. The pro-convulsive side effects of EO have been known for more than a century.
      • Burkhard P.R.
      • Burkhardt K.
      • Haenggeli C.
      • Landis T.
      Plant-induced seizures: reappearance of an old problem.
      The exact mechanism by which EO induce seizures is unknown. However rat studies show that it may be secondary to loss of tissue sodium/potassium gradient leading to increased cellular hyper-excitability.
      • Steinmetz M.
      • Vial M.
      • Millet Y.
      Actions de l’huile essentialle de romarin et de certains de ses constituants (eucalyptol et camphre) sur le cortex cerebral de rat in vitro.
      EO have been known to induce generalized tonic-clonic seizure in non-epileptic patients,
      • Burkhard P.R.
      • Burkhardt K.
      • Haenggeli C.
      • Landis T.
      Plant-induced seizures: reappearance of an old problem.
      as well as lower seizure threshold in patients with known epilepsy as was the case in our patient. Interestingly, most reports of camphor or EO induced seizures are as a result of accidental ingestion.
      • Burkhard P.R.
      • Burkhardt K.
      • Haenggeli C.
      • Landis T.
      Plant-induced seizures: reappearance of an old problem.
      • Agarwal A.
      • Malhotra H.S.
      Camphor ingestion: an unusual cause of seizure.
      • Gouin S.
      • Patel H.
      Unusual cause of seizure.
      Our patient experienced a breakthrough seizure with topical application of EO.
      Currently, the majority of essential oils and herbal products used in the United States are not approved by the Food and Drug Administration (FDA). Potentially, many instances of EO induced seizures can be missed secondary to lack of FDA regulation and physician awareness. Without an appropriate history, EO induced seizures will be classified as spontaneous resulting in surgical failure. This has profound ramifications including loss of patient autonomy (via driving restrictions), and may result in unnecessary AED administration and healthcare cost. We suggest that questions regarding EO use should be routinely incorporated in the history obtained from patients with new onset epilepsy or in well-controlled epileptics with breakthrough seizures.

      Conflict of interest statement

      The authors report no conflicts of interest.

      References

      1. Product website available at www.elemis.com. Accessed February 5, 2009.

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