A 5-year-old boy with super-refractory status epilepticus and RANBP2 variant warranting life-saving hemispherotomy.

Focal cortical dysplasia (FCD) represents the most common cause of drug-resistant epilepsy in adult and pediatric surgical series. However, genetic factors contributing to severe phenotypes of FCD remain unknown. We present a patient with an exceptionally rapid development of drug-resistant epilepsy evolving in super-refractory status epilepticus. We performed multiple clinical (serial EEG, MRI), biochemical (metabolic and immunological screening), genetic (WES from blood- and brain-derived DNA) and histopathological investigations. The patient presented one month after an uncomplicated varicella infection. MRI was negative, as well as other biochemical and immunological examinations. WES of blood-derived DNA detected a heterozygous paternally-inherited variant NM_006267.4(RANBP2):c.5233A>G p.(Ile1745Val) (Chr2(GRCh37):g.109382228A>G), a gene associated with a susceptibility to infection-induced acute necrotizing encephalopathy. No combination of anti-seizure medication led to a sustained seizure freedom and the patient warranted induction of propofol anesthesia with high-dose intravenous midazolam and continuous respiratory support that however failed to abort seizure activity. Brain biopsy revealed FCD type IIa; this finding led to the indication of an emergency right-sided hemispherotomy that rendered the patient temporarily seizure-free. Post-surgically, he remains on anti-seizure medication and experiences rare non-disabling seizures. This report highlights a uniquely severe clinical course of FCD putatively modified by the RANBP2 variant.