Seizures are one of the most common neurological symptoms of lupus – affecting about 10% of those living with SLE.  What are the causes of lupus seizures, and how are they diagnosed and treated?  Read on to find out!.

• Introduction
• More About Seizures
• Lupus and Seizures
• Diagnosing and Treating Lupus Seizures
• In Conclusion

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Introduction

Seizures are defined by the Epilepsy Foundation as a “sudden and temporary change in the electrical and chemical activity in the brain, which leads to a change in a person’s movement, behavior, level of awareness, and/or feelings.”

Since about half of those living with lupus develop some form of brain involvement, it is probably not surprising that seizures, are also not uncommon for those living with SLE.

Though estimates vary widely (from 6% – 58%), it is most likely that about 10% of all those living with lupus will experience some form of seizure in their lives.

Here are some quick facts about seizures and lupus:

• Although, some lupus seizures can be serious, most do not significantly affect a person’s quality of life.
• Seizures can occur at any time of the disease, though about 32% of those who experienced a seizure, do so right at the time of their lupus diagnosis.
• Seizures are more common in lupus patients from African descent.
• About 75% of seizures experience by lupus patients are the generalized seizures, called tonic-clonic seizures. (See below)
• About 43% of SLE patients who experience one seizure event will experience recurrent seizures or may develop epilepsy later in life.
• Seizures are one the classifying criteria that are used to diagnose SLE.

Both lupus and seizures are complex conditions, so it helps to explore both in a bit more detail!

More About Seizures

There are many kinds of seizures.  They can range from very minor episodes that are barely noticeable to extremely acute, or even life threatening events.  Two of the most common categories for those living with lupus are tonic-clonic seizures and focal onset seizures.

• Tonic-clonic seizures are the type that most of us associate with epilepsy.  They typically begin with what is called the “tonic phase.”  The person’s muscles suddenly stiffen.  This may cause them to collapse, lose consciousness, bite their tongue, and perhaps fall and injure themselves.

Soon after, the person’s body starts to uncontrollably shake; their muscles alternately contract and relax.  This is the “clonic” phase, and during this time, it can be difficult for the person to breathe.

After a few minutes, these movements slow down and the muscles eventually relax. The person begins to breathe more easily and typically regains consciousness.  If they last longer than 5 minutes, seizures can result in brain damage or may even be life threatening.

• Focal onset seizures, formerly called partial seizures, begin within a specific area of the brain.  These can cause many kinds of symptoms, including involuntary movements of individual muscles, without the all-body involvement of tonic-clonic seizures.  Often patients will experience auras, or hallucinate smells, tastes and sounds.  During the seizure, a person may appear confused, or feel a profound sense of déjà vu, or simply “stare off into space.”  These episodes can be quite short, and later, the person may not remember what happened.

It is possible for focal onset seizures to spread to other parts of the brain or lead to tonic-clonic seizures. So it is important to notice changes or symptoms that might suggest that a seizure is happening … and it is especially important, as with lupus itself, to recognize triggers and avoid them!

Note:  If anyone experiences a seizure that lasts longer than 5 minutes, it should be considered an emergency situation called status epilepticus.  911 should be called, and the person taken to a hospital as quickly as possible.

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Lupus and Seizures

About 50% of those living with lupus develop some form of brain or neurological involvement, called neuropsychiatric systemic lupus erythematosus (NPSLE).  Seizures are one example of several symptoms that NPSLE can cause.  Others include headaches, brain fog, mood swings, strokes, insomnia and more.

How does lupus cause seizures?

As with almost anything associated with lupus, there are multiple pathways that could lead to seizures.  The most common ways that lupus can directly affect the brain and cause seizures include:

• Thromboses:  Lupus autoantibodies can create microscopic blood clots that can clog the tiny vessels that keep the brain alive, and if this happens, it may lead to neuron damage and seizure symptoms.
• Vasculitis:  In this situation, lupus autoantibodies might directly attach the tiny blood vessels themselves, damaging them or the blood-brain barrier (BBB) and again, damage neurons and cause seizures.
• Neuronal Antibodies:  It is possible for lupus autoantibodies to can cause inflammation in the brain and spinal cord by directly by crossing the blood-brain barrier and directly attacking neurons.  This damage to the BBB can be caused by physical trauma or possibly by lupus flares themselves.

It is important to note that there may be other reasons for seizures that may not be directly caused by lupus.  These include:

•  Medications:  Several medications are known to cause seizures or lower their threshold, such as:
  • Antidepressants, like bupropion (Wellbutrin) or venlafaxine (Effexor);
  • Diphenhydramine (Benadryl);
  • Some stimulants, like cocaine and methamphetamines;
  • Tramadol, a synthetic codeine used for pain, and
  • Notably, hydroxychloroquine (Plaquenil) though this happens very rarely.

• Overlapping conditions that are associated with lupus and may cause seizures include:
  • Autoimmune encephalitis (AE), which can occur with lupus and creates its own autoantibodies that attack the central nervous system.
  • Antiphospholipid syndrome (APS), a disease common to those living with lupus. It also creates antibodies that forms blood clots and can damage areas of the brain.
  • Strokes are one of the symptoms of neuropsychiatric lupus.  They can lead to seizures or even the development of epilepsy.

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Diagnosing and Treating Lupus Seizures

Diagnosis

Seizures caused by lupus can be very difficult to diagnose because they can also be caused by many other conditions, such as heart problems, drug interactions, diabetes, high blood pressure or even infections.  This means that it is important for a neurologist to become part of the patient’s healthcare team. This also means that it may take a long time and many tests to accurately determine whether lupus is the cause of the seizures.

The person’s quality of life and treatment plan also depend upon an accurate diagnosis of the type of seizure and the location of possible damage.

There are several tests that may be ordered, including:

• Blood tests to determine levels and types of autoantibodies and to exclude possible metabolic causes.
• Lumbar puncture / spinal tap to determine the health of the central nervous system.
• Electroencephalogram (EEG) tests to evaluate brain activity and possible areas where focal onset seizures may be located.
• Brain imaging, especially MRIs and CT scans to locate possible blood clots or other damaged tissues.
• There are very few easy to detect biomarkers for NPSLE – especially related to seizures. However, one called TLR4 has recently shown some promise, and the dream of a quick blood test for lupus seizures may one day be possible.

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Treatment Options

Please Note:  As always, this article is for informational use only.  Consult your healthcare provider before making any changes to your own treatment plan.

As with most other serious lupus symptom, it is best to treat both the symptoms (the seizures) and the lupus itself.  Luckily some medications do both.  Medications may include:

• Anti-seizures or anticonvulsants like Depakote (divalproex sodium).
• Hydroxychloroquine, which can lessen the risk of seizures by reducing overall inflammation and perhaps lowering the ability for blood clots to form in the brain.
• Immunosuppressants, like methylprednisolone, which are used to both decrease any autoantibodies directly attacking the brain or its blood vessels (vasculitis) as well as decrease the likelihood of blood clots (thromboses) that might also damage regions of the brain.
• Blood thinners, which may also be prescribed to deal with lupus-induced blood clots or those formed by antiphospholipid syndrome.
• Corticosteroids, which are commonly used to reduce the overall inflammation, especially during severe flares that may trigger seizures in the brain.

If a person is suffering from acute seizures, or is in the middle of a severe lupus flare, high doses of some of these medications may be needed until the person’s condition is stabilized.

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In Conclusion

Seizures are not uncommon for those living with lupus, but they can be managed and they do not have to negatively affect a person’s quality of life.  As with many conditions associated with SLE:

• Stay informed with up-to-date information;
• Understand what to look for in order to detect symptoms early;
• Keep in contact with your healthcare providers, and
• Consistently follow your treatment plan.

Lupus research in this area is advancing rapidly, and there are new therapies brought online all the time.  Seizures do not need to be feared.  Ask for help if you need it, and remember, you are not alone!

 

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References

Rodrequez-Hernandez, A., Ortiz-Orendain, J., Alvarez-Palazuelos, L.E., Ganzalez-Lopez, L., Gamez-Nava, J.I., & Zavala-Cerna, M. (2021) Seizures in systemic lupus erythematosus:  A scoping review. European Journal of Epilipsy, 26, 161-167. https://www.seizure-journal.com/article/S1059-1311(21)00055-8/pdf

Andrade, R.M., Alarcón, G.S., González, L.A., Fernández, M., Apte, M., Vilá, L.M., McGwin, G., & Deveille, J.D. (2008). Seizures in patients with systemic lupus erythematosus: data from LUMINA, a multiethnic cohort (LUMINA LIV). Annals of the Rheumatic Diseases, 67(6), 829-834. https://ard.bmj.com/content/67/6/829

Appenzeller, S., Cendes, F., & Costallat, L.T.L. (2004). Epileptic seizures in systemic lupus erythematosus. Neurology, 63(10), 1808-1812. https://doi.org/10.1212/01.WNL.0000144178.32208.4F

Epilepsy Foundation (2023, November 20). What is a seizure?https://epilepsyfoundation.org.au/understanding-epilepsy/seizures/what-is-a-seizure/

Huang, Q., Shen, S., Qu, H., Huang, Y. Wu, D., Jeang, H., & Yuan, C. (2020). Expression of HMGB1 and TLR4 in neuropsychiatric systemic lupus erythematosus patients with seizure disorders. Annals of Translational Medicine, 8(1). https://atm.amegroups.org/article/view/34005/html

Jonsson, A.H., & Bhattacharyya, S. (2015, March 1). Seizures in lupus. The Rheumatologist. https://www.the-rheumatologist.org/article/seizures-in-lupus/

Mayes, B., & Brey, R. L. (1996). Evaluation and treatment of seizures in patients with systemic lupus erythematosus. Journal of Clinical Rheumatology : Practical Reports on Rheumatic & Musculoskeletal Diseases, 2(6), 336–345. https://doi.org/10.1097/00124743-199612000-00007

Raventhiranathan,N., Hussien, A.R., Mirchia, K, Swarnkar, A., & Mangla, R. (2022). Striatal dominant lupus encephalitis–Is it vasculitis or an autoimmune process? Literature review & new case report with vessel wall imaging. Radiology Case Reports, 17(4), 1205-1210. https://www.sciencedirect.com/science/article/pii/S1930043322000024

Rodriquez-Hernandez, A., Diaz-Rizo, V., Rivero-Moragrega, P., Dvalos-delaCruz, A.P., & Rocha-Muñoz, A.D. (2018). Prevalence of seizures in patients with systemic lupus erythematosus in Western Mexico. Neurology, 90(15 Supplement). https://n.neurology.org/content/90/15_Supplement/P1.127

Thomas, D.E. (2023). The lupus encyclopedia (2 edition). Johns Hopkins University Press.

Tsai, J., Lin, C., Lin, C., Sung, F., & Lue, K. (2014). Risk of epilepsy in patients with systemic lupus erythematosus – a retrospective cohort study. Neuropsychiatric Disease and Treatment, 2014(10), 1635-1643.
https://doi.org/10.2147/NDT.S64323

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Author: Greg Dardis, MS      

Professor Dardis was formerly the Chair of the Science Department at Marylhurst University and is currently an Assistant Professor at Portland State University and the American College of Healthcare Sciences.  His focus has been human biology and physiology with an interest in  autoimmunity.  Professor Dardis is also a former President of the Board of Directors of Kaleidoscope Fighting Lupus.

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