BURN, EPILEPSY AND COVID-19

The COVID-19 pandemic is a major public health problem. It is not only a health crisis of planetary scope but also a socio-economic crisis with serious consequences. Among the dramatic repercussions in our country was the condemnation of several health structures, including ours. We report the case of a young epileptic woman who suffered a thermal burn by scalding, causing her to suffer from 3rd-degree lesions.Her treatment was delayed because of the sanitary conditions preventing an excision with a skin graft, which led us to follow this patient in directed healing. Therapeutic management in the context of an epilepsy-burn association must be multidisciplinary and adequate, hence the interest of prevention based on patient education, good compliance with treatment, and correct management of the environment.


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In General: On admission, the patient was hemodynamically stable (BP=13/08, HR=80batt/min), neurologically stable (patient conscious with GCS 15/15), and respiratory stable (FR=25cycles/min). Locally: (Table1) (Figure1)  Therapeutically: The patient benefited from washing with a dressing based on silver sulfadiazine, fatty tulles and sterile compresses, a level I analgesia; Paracetamol, tetanus serum, and a neurological opinion whose decision was to increase the dose of carbamazepine to 600mg/d instead of 300mg/d. (Figure2)  A skin graft was planned for the patient as a second step after ensuring the two necessary conditions for graft, which are a good quality subsoil and the absence of bare noble elements, but given the worsening of the pandemic situation Covid-19 and the impossibility of access to the operating room in these circumstances, the decision was to follow the patient in consultation and to lead her in directed healing until the resumption of the surgical activity.
During the first postoperative consultation, we opted for a dressing based on an anti-inflammatory topical on the 2nd finger and a lipid-colloid tulle on the 3rd finger with an appointment in 07 days but the sanitary conditions worsened in our country condemning several health structures including ours over a period of 02 months. The patient who was lost from sight presented herself after the resumption of the activity with complete healing of the lesions.

Discussion:-
Patients with epilepsy may experience severe burns during acute episodes. These patients must be identified, given specific treatment, and educated to avoid an unpredictable seizure that can result in dramatic deep burns and lead to more difficult management and, consequently, higher costs, increased morbidity, and even mortality.
Various authors report that the incidence of burns in epileptic patients can represent 5% in a study conducted by Bull et al [1] and 10% according to Meirelles et al [2], of the total admissions in a burn unit.
In our case, the epileptic burn patient was young (47 years old), which is consistent with some studies reported in the literature; the average age above 30 years being reported by most series [3][4] [5] and age around 20 years according to Jowdar [6]. According to the latter author [6], women represented two-thirds of the epileptic burn patients and in the study carried out by Adigun et al [7], the two epileptic patients who suffered burns while cooking were women. This coincides with the findings of Meirelles et al [8], who noted that a large number of patients had visual contact with the flame before the accident, suggesting that fire could be a photostimulation for the onset of an epileptic seizure, a result that is consistent with our case because our patient had visual contact with a flame in the kitchen at the time of the accident. For Jowdar [6], the confined and hot atmosphere of kitchens would also be a factor favoring the triggering of a seizure. Napoli et al [9] reviewed the medical records of 14 patients burned because of an epileptic seizure. They concluded that epileptic seizures are an important predisposing factor for burns; the burning agent emits light stimuli that trigger the onset of epileptic seizures and can affect important areas, including the face and hand. This leads us to strengthen our prevention efforts with young women.
The most important risk factors justifying the increased incidence of burns in patients with epilepsy are frequency of seizures, duration of the epileptic episode[10] [11], and lack of awareness and education about the risk of burns in these patients [8]. Other risk factors can be incriminated which are the socio-economic characteristics namely patients from rural areas and epileptics from the economically weak population [6].
Josty et al [12] performed a retrospective study of 111 patients admitted with burns secondary to an epileptic seizure. They concluded that thermal scald burns are the main cause of burns in epileptic patients. This is consistent with the findings in our case, where the patient suffered a scald burn; however, scald burns from cooking fluids were the main mechanism identified in several studies [4][9] [13][14] [15].
The topography of the burns is correlated according to the mechanism: in case of hot liquid release, the lower limbs are the most affected, whereas, in case of flame burns, the lesions concern the cephalic extremity. Whatever the etiology, the burn is not very extensive, not exceeding 20% of the body surface area in the majority of studies [4][11] [14], but is deeper in these patients, mostly in the second and/or third degree. This can be explained by the associated loss of consciousness and the absence of withdrawal reflexes during contact with heat sources, increasing the contact time and not allowing rapid cooling of the lesions.
A deep burn involves more skin components, which prevents rapid healing and scarring of the skin. Surgical interventions are necessary for deep dermal burns to accelerate healing and reduce scarring. This can be achieved by excision of the burn and skin grafting of varying thickness in most cases [9]. This surgical intervention represents the gold standard treatment of a severe burn in the acute phase [6]. In the Brosset study, dermal-epidermal graft excision was necessary for all patients [14]. In a Tunisian study, 16/20 of the patients required excision of necrotic tissue, and a dermo-epidermal graft was performed only in 2 patients, given the severity and instability of some patients, and the limitation of donor areas given the extent of the burns [13]. In our case, the patient could not benefit from an early excision graft because of the sanitary conditions and the inability to access the operating room in the acute phase.
Burns occurring during an epileptic seizure is serious, providing heavy functional and aesthetic sequelae. In a Tunisian study, 25% of patients had an amputation [13], a result comparable to that published in an Algerian series by Jowdar (24%) [6]. Adigun et al [7] studied "Amputation of a burn following an epileptic seizure" in their burn unit. A total of 250 patients were managed during the study period of 5 years. Two patients met the inclusion criteria. In the light of our case and the review of the literature, it appears that the risk of amputation is not nil but on the contrary, it is a fairly frequent intervention in the context of burns in epileptics.

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Burns occurring during an epileptic seizure is serious and sometimes leads to high mortality. In a Tunisian study [13], mortality was 25% secondary to refractory shock. Agbenorku et al. reported a death rate of 9.5%, which is lower than the overall mortality rate in their burn unit, which is 24.2% [4].
Therapeutically, the management should not only aim at treating the burn lesions but also at balancing epilepsy. For this, it will be necessary to establish an effective drug treatment in case of inaugural disease. If the epilepsy is known, it will be necessary to adjust the previous treatments, to establish rigorous modalities of surveillance and follow-up [6], and especially to ensure that these patients take their treatment because one of the main problems in patients with epilepsy is their non-compliance [16].
No impact of the burn on the epileptic disease could be demonstrated in our case: we did not find any imbalance of the epileptic disease induced by the burn in our patient. A case of imbalance of the epileptic disease by the burn is reported in the literature: Gragnani et al. report the case of a 36-year-old woman, known to be epileptic for 12 years, who developed recurrent seizures after an extensive burn, despite the maintenance of her anticonvulsant treatment [17].
Burns in epileptics is a lesion that can be avoided thanks to preventive measures that constitute the basis of any management. The literature proposes several preventive protocols to avoid recurrent epileptic seizures and therefore burns [18]: Patient and caregiver education for better cooperation. Regular intake of anti-seizure medication, as good compliance is the first preventive measure. Regular monthly follow-up of the patients in consultation for good control of the seizures, carried out by the same doctor remains essential. The understanding of the circumstances of occurrence of these burns during epileptic seizures allows considering simple prevention strategies based essentially on the avoidance of risky cooking activities during periods of therapeutic adaptation or imbalance [19], avoidance of leaving an epileptic alone near a heat source, and use of microwave ovens, self-closing fryers, and insulated plastic kettles [9] [20]. Other recommendations that may decrease the incidence of burns in epilepsy patients have been suggested by other authors: use of firewalls and heaters, flame retardant clothing, and adherence to showering advice [21][22] [23]. Audio-visual awareness and/or awareness campaigns during health caravans could also be of great help to epilepsy patients.

Conclusion:-
Patients with epilepsy should be classified in the high-risk group because of the severity of burns in these patients, which can be life-threatening and often cause dramatic aesthetic and functional complications.
Management must be adequate and multidisciplinary. The difficulty of this problem makes the prevention of burns all the more interesting, as it involves educating the patient to comply with the anticonvulsant treatment, regular follow-up, and the development of the patient's environment.