Date Filed 03/28/16 Entry Number 1-1 Page 1 of 145 EXHIBIT A COMPLAINT 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 2 of 145 - .. ~~ STATE OF SOUTH CAROLINA .. Amy Williams, et al vs. Quest Diagnostics, Diagnosties, Inc, et aL I ) IN THE COURT OF COMMON PLEAS ). COUNTY OF RICHLAND • , ) ) ) Plai.ntiff(s) ) ) ) ) Athena ) Inc, CIVIL ACTION COVERSHEET '10 Wj-CP-!ll • ...oJ.\~ Defendant(s) ) (Please Print) Submitted By: Bradford W. Cranshaw Address: 2999 Sunset Boulevard, Suite 200, West Columbia, SC 29169 0 0 0 D 0 0 D 0 0 0 0 Contraeu Conswction (100} Debt Collection (l lO) EmplO)-T.!Clll (120) Gcneul (!JO) Wmni,f!Ji Breach ( 140) Toru - Pnlf'utlonal Malpnicticc Dental Malpractice (200) Lepl Malpraa.ice (.i lO) Medical Ma!pnictice (220) Otllet.Malpraaice ('.299) 0 D 0 0 D D 0 D D E8] Other(J99) SC Bar#: Telephone #: Fax#: Other: E-mail: 66456 (803) 731-0030 (803) 731-4059 T or1s - Penoaal Injury Als1111h/Slandcr/Ubcl (300) Con~(310) Motor Vehicle ~idcnt (320} Prtlllises Liability (330) Pnxlucti Liability (340) Other (399) Wrongful DC41h lom1te Petitio11s PCR(500) Sextl4l P~ator (S 10) Mlllld;mus (.520) 0 Hahea; Corpus (530) 0 Olher(S99) 0 0 0 Death Sett\cment (700) Foreil!ll Judgment {110) Magistrate's Judgment (720) Minor Seltlement (730) Trans~ript Judgment (740) Lis Pendens {750).. Other (799) SpeclaVComplu IOtller 0 Envinmmc:ntal (600) 0 Automobile Arb. (610). 0 Medi = ... ,....., ~ ,; (. ; :::; ....... ...... N i:::: at Grier, Cox & Cranshaw, LLC, Post Office Bo.x 2823, Columbia, South Carolina 29202, within thirty (30) days after service hereof, exclusive of the day of such service, and if you fail to answer the Complaint, judgment by default will be rendered against you for the relief demanded in the Complaint. {'"") -ri f ''"'l t;,'J ... .. "' ..._,,.. ., VJ ::0 ..:.:."' ,..-. ~- "Tj :t.:~ i~l"j .., --· ...:.:..1 ·- ! ) :··-:. .. ..., . ... ~ 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 5 of 145 Matthew M. McGuire (SC Bar #66586) The Ervin & McGuire Law Firm 1824 Bull Street Columbia, SC 29201 Phone: 803-708-8471 Fax: 803-708-4771 February~l6 Columbia, South Carolina ATIORNEYS FOR PLAINTIFF 3:16-cv-00972-MBS Date Filed 03/28/16 STATE OF SOUTH CAROLINA ) ) COUNTY OF RICHLAND ) ) ) AMY ELIZABETH WILLIAMS as the . PERSONAL REPRESENTATIVE of the ESTATE FOR and AMY ELTZABETH WILLIAMS individually, Plaintiffs, Entry Number 1-1 Page 6 of 145 IN THE COURT OF COMMON PLEAS FJFTH JUDICIAL CIRCUIT CASE NUMBER: 2016-CP-40- ---- ) ) ) ) ) ) ) ) ) vs. --. ... E~~f QUEST DIAGNOSTICS, INC., ATHENA ) DIAGNOSTICS, INC., ADI HOLDINGS, ) INC. ) . ; __ -· - ) ) Defendants. ~· r• •: ... 4 ~ ' The Plaintiffs, Amy Elizabeth Williams as the Personal Representative of the Estate for (hereinafter ''Williams PR'') and Amy Elizabeth Williams individually (hereinafter "Williams lD") (and when necessary, collectively hereinafter as "Plaintiffs''), by and through their counsel, complaining of the above named defendants herein, respectfully allege and show unto this Honorable Court as follows: JURISDICTIONAL FACTS 1. Plainti~ deceased child, Williams PR, is the duly appointed Personal Representative of the Estate of her (" " or "Decedent"), as will appear more fully in the records of the Probate Court for the County of Richland, South Carolina in case No. 2015-ES-4000520. Williams PR brings this action on behalf of the Estate of thos~ damages recoverable by the statutory beneficiaries of 1 and for . 3:16-cv-00972-MBS 2 Date Filed 03/28/16 Entry Number 1-1 Page 7 of 145 Plaintiff, Williams ID, is presently a citizen and resident of Horry County, South Carolina; however, Williams ID lived with , in Richland County at the time of 's death. 3. The Defendant Quest Diagnostics Incorporated (hereinafter "Quest") is, upon information and belief, a foreign corporation, organized in the state of Delaware, with its principal place of business in Madison, New Jersey. Quest is a large publicly traded company with a recently valued market capitalization of approximately Nine Billion U.S. Dollars, which offers a variety of laboratory testing products and laboratory services to clients residing in every U.S. state as well as certain clients living in a number of foreign countries. Quest, at all times relevant hereto, was doing business in South Carolina through its agents ~d subsidiaries, and through this persistent course of conduct, Quest derives substantial revenue from setVices rendered in South Carolina. Moreover, both the negligent conduct and purposeful actions and inactions of Quest, related to the Plaintiffs hert!in and as better described below, foreseeably connect Quest with the forum state of South Carolina such that Quest should reasonably anticipate being subjected to the jurisdiction of this Court, thus this court has in personam and subject matter jurisdiction over the defendants. Likewise, venue is proper in Richland County. 4. The Defendant Athena Diagnostics Incorporated (hereinafter "Athena'') is, upon information and belief, a foreign corporation, organized in the state of Delaware, and authorized to conduct business in South Carolina as registered foreign corporation with the South Carolina Secretary of State. Athena, at all times relevant hereto, was doing business in South Carolina through its agents, and through this persistent course of conduct, Athena derives substantial revenue from services rendered in South Carolina. Moreover, both the negligent conduct and purposeful actions and inactions of Athena, related to the Plaintiffs herein and as better described below, foreseeably connect Athena with the forum state of South Carolina such that Athena should 2 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 8 of 145 reasonably anticipate being subjected to the jurisdiction of this Court, thus this court has in personam and subject matter jurisdiction over the defendants. Likewise, venue is proper in Richland County. 5. The Defendant ADI Holdings Incorporated (hereinafter ';ADI") is, upon information and belief, a foreign cor:poration, organized in the state of Delaware, and at all times relevant hereto, ADI was doing business in South Carolina through its agents and 8ubsidiaries,. and through this persistent course of conduct, ADI derives substantial revenue from services rendered in South Carolina. Moreover, both the negligent conduct and purposeful actions and inactions of ADI, related to the.Plaintiffs herein and as better described below, foreseeably connc.ct ADI with the forum state of South Carolina such that ADI should reasonably anticipate being subjected to the jurisdiction of this Court, thus this court has in personam and subject matter jurisdiction over the defendants. Likewise, venue is proper in Richland County. 6. Quest, Athena, and ADI (when referred to collectively herein after, the "Corporate Defendants") are part of an interrelated amalgamation of corporate interests. Quest, the large publicly traded entity, owns all outstanding shares of ADI following its purchase of ADI in 2011. ADI, in tum, owns an outstanding shares of Athena. RELEVANT AGENTS AND ACTORS 7. Narasimhan Nagan, Ph.D. (hereinafter "Nagan") is, upon information and belief, a resident and citizen of Massachusetts. N agan was employed by Athena as Director of Genetics, and at all times relevant hereto was an agent and servant of Athena, and therefore Athena is liable for the acts of Nagao under the doctrine of respondeat superior. Moreover, both the negligent and purposeful actions, and inactions, of Nagan foreseeably caused the banns to the Plaintiffs as described below. 3 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 9 of 145 __ 8. Hui Zhu, Ph.D. (hereinafter "Zhu") is, upon information and belief, a resident and citizen of Massachusetts. Zhu was employed by Athena as Director of Genetics, and at all times relevant hereto was an agent and servant of Athena, and therefore Athena is liable for the acts of Zhu under the doctrine of respondeat superior. Moreover, both the negligent and purposeful actions, and inactions, of Zhu foreseeably caused the harms to the Plaintiffs as described below. · 9. Sat Dev Batish. Ph.D. (hereinafter "Batish") is, upon information and belief, a resident and Citizen of Massachusetts. Batish was employed by Athena as Chief Director of Genetics, and at all times relevant hereto was an agent and servant of Athena, and therefore Athena is liable for the acts of Batish under the doctrine of respondeat superior. Moreover, both the negligent and purposeful actions, and inactions, of Batisb foreseeably caused the banns to the Plaintiffs as described below. 10. Joseph J.. Higgins, M.D. (hereinafter "Higgins") is, upon information and belief: a resident and citizen of Massachusetts. Higgins was employed by Athena and served as the Clinical Laboratory Improvement Amendments ("CUA") Laboratory Director and license holder (#2200069726) for Athena, and at all times relevant hereto was an agent and servant of Athena, and therefore Athena is liable for the acts of Higgins under the doctrine of respondeat superior. Moreover, both the negligent and pur:pOsefal actions, and inactions, of Higgins foreseeably caused the hanns to the Plaintiffs as described beiow. FACTUAL BACKGROUND FOR RELIEF 11. The factual assertions contained in the averments, which follow in paragraphs Eleven {11) through Thirty Seven (37), are herein referenced by the affidavit of Robert Cook-Deegan, M.D., who is a research professor in the Sanford School of Public Policy at Duke. University, with secondary appointments in Internal Medicine (School of Medicine), and Biology (Trinity College 4 ,,___ - -- ---- 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 10 of 145 of Arts & Sciences). He is also the foundiOg director for Genome Ethics, Law & Policy in Duke's Institute for Genome Sciences & Policy. This affidavit and all of its attachments are incorporated within this complaint and affixed hereto as Exhibit A, as if set forth herein verbatim. 12. was born on August 23, 2005, and developed normally and relatively healthfully throughout his first four months. By December 23, 2005, at his four month check-up, 's health records indicate that he began suffering from febrile focal motor seizures. Accordingly, Williams ID sought treatment for his treatments, s condition from a variety of service providers. Despite 's condition developed into frequently occurring afebrile seizures of varying types, including tonic-clonic, atonic and absence seizures. These often reached status epilepticus. The medical treatments given to included the prescription of sodium channel blocking medications, including Carbamazepine (Tegretol), Oxcarbazepine (frileptal) and Lamotrigine (Lamictal). 13. These sodium channel blocking medications are used to treat frequently occurring seizures of varying types and were prescribed by treating neurologist, Timothy Scott Livingston. M.D. (hereinafter '·'Dr. Livingston"), while Dr. Livingston was employed with the University of South Carolina Medical School. However, the administration of these medications proved ineffective at treating Millare's condition. 14. In an attempt to more accurately diagnose the exact nature of blood sample was taken from ' s condition, a whole . Deoxyribonucleic Acid ("DNA") was extracted from the sample, on January 18, 2007, at the direction of treating clinical geneticists, John McKinley Shoffner, M.D. (hereinafter "Dr. Shoffner''), and, Frances Dougherty Kendall, M.D. (hereinafter "Dr. Kendall"), while they were both employed at Horizon Molecular Medicine in Atlanta, Georgia. s 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 11 of 145 15. The extracted DNA was provided to Athena's laboratory for What is known as an SCNIA DNA Sequencing Clinical Diagnostic Test (test code #535), for the purpose of 4'diagnosing or detecting an existing disease, illness, impainnent, symptom or disorder." Specifically. lCD-9 Codes: 359.9, 781.3, 780.39. 16. Sodium channe~, voltage gated, type I alpha subunit (designated "SCNlA'') is a hwnan gene that is primarily responsible for the body's creation of the NaVI.l sodium channel. A m11tation in an SCNlA gene can have a deleterious effect on a pers0n. The NaVl.1 sodium channel is primarily expressed in GABA~gic intemeurons. Without an effective NaVl.1 controlling the flow of sodium ions (charged particles) from one neuron to the next in the brain, seizures can occur. Seizures arise when neurons that excite electrical impulses are not balanced by neurons that inhibit electrical impulses. Defects in the NaV1 .1 sodium channel foster seizures because the sodhun channel is located in a neuron that inhibits electrical impulses. When the sodium channel is defective. the neuron does not inhibit electrical impulses effectively, so there is an overabundance of excitation and seizures result. 17. On June 30, 2007, an SCNIA DNA Sequencing Clinical Diagnostic Report (the "2007 Report") issued by Athena, indicated that possessed a DNA mutation in the SCN1 A gene classified as a "Variant of unknown significance." 18. Tragically for and his mother, Williams ID, the 2007 Report by Athena, which classified his SCN 1A DNA mutation as a "Variant of unknown significance," was incorrect. 19. A review of the SCN 1A DNA Sequencing Diagnostic contained in the 2007 Report, indiCates that Athena breached the standards of care set by Clinical Laboratory Improvement Amendments ("CLIA") - a federal certification process for laboratories that perform clinical diagnostic tests on human specimens in the United States - for a certified diagnostic laboratory 6 3:16-cv-00972-MBS ' Date Filed 03/28/16 Entry Number 1-1 Page 12 of 145 . perfonning high~complexity · genetic testing, through Athena's negligent failure to correctly diagnose the DNA niissense mutation in the decedent's SCNIA gene. See 42 C.F.R 491.10 et seq. 20. Jn particular, the 2007 Report erroneously made a misclassification of a DNA sequence variant: "A transversion for thymine (T) to adenine (A) at nucleotide position 1237 at codon 413 resulting in the amino acid change of tyrosine (Y) to asparagine (N)" (hereinafter designated "1237T>A, Y4J 3N" as it appears in the 2007 Report). By definition, this missense mutation should have been classified as "# 3: Amino acid change of unknown significance" instead of "#4; Variant ofunknown significance." 21. 's specific DNA mutation (1237T>A, Y413N) in the SCNlA gene not only possessed the characteristics expected of a disease causing alteration, but it had also been reported. studied, and known in patients expressing Drayet Syndrome - a severe form of epileptic encephalopathy also known as Severe Myoclonic Epilepsy ofInfancy ("SMEI"). 22. The existence of two clinical publications clearly satisfies the criteria of diagnostic DNA variant type "#1: Known disease-associated mutation", listed in the 2007 Report. criteria set forth and defined by Athena. Both of these publications, Berkovic et aL, 2006 & Harkin et al., 2007, were products of a third party laboratory granted a patent w_hich was then licensed and utilized by Athena for SCNlA DNA clinicaJ diagnostic testing in the United States (U.S. Patent# 7,078,515 - licensed to Athena by Bionomics Limited in September 2004). 23. In addition, 's mutation (1237T>A, Y413N) was also specifically cited as an SCNIA DNA mutation that "disrupts the functioning of an assembled ion channel so as to produce an epilepsy phenotype" in U.S. Patent #8,129,142. Trus patent was used for the development, validation and utilization of SCNlA DNA clinical diagnostic testing iri the United States. 7 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 13 of 145 24. Further, the 2007 Report indicates that the Chief CLIA Laboratory Director for Athena, Balish, reviewed the laboratory results and submitted the erroneous clinical information of . Batisb is one of the authors of the Harkin et aL, 2007 publication. This scholarly paper was submitted and published prior to the Jurie 30, 2007 SCNIA DNA Sequencing Diagnostic Report issued by Athena. As such, Barish clearly knew or should have known that a mistake on was apparent on the 2007 Report. 25. The errors cited above, violate the stated classification procedures of Athena's CLIA certificatinn, including: CLIA regulation 42 C.F.R. §493.1291(a), "the laboratory must have an adequate system(s) in place to ensure test results are accurately and reliably sent from the pA, Y413N). Such an error violates CLIA regulation §493.124l(c)(8), "any additional infonnation relevant and necessary for a specific test to ensure accurate and timely testing and reporting of results. including interpretation." 28. Additionally, the laboratory results and submitted clinical information within the 2015 Report were purportedly authorized and reported by Nagan, ABMG, Director, Genetics. and Zhu, ABMG, Director, Genetics. Upon information and belief, both NaganandZhu left the employment of Athena before 2009 and as such could not have possibly authorized the issuance <> f the revised 201.5 Report. This intentional misrepresentation violates CLIA regulation §493.1283(4) ~e record system must include the records and dates of all specimen testing, including the identity of the personnel who perfonned the test(s)," which are necessary to assure proper identification and accurate reporting of test results. To issue the revised 2015 Report authorized by two geneticists that are no longer employed by Athena must have been done by Quest and Athena, in concert, with an intent to circumvent or disobey CLIA 's federal regulatory standards. 29. Moreover, both Defendants Athena and Quest violated CLIA regulation §493. 1291 (k) when neither issued a properly amended clinical diagnostic report when this DNA mutation {1237T>A, Y413N) was re-classified as a "Known disease-associated mutation." "When errors in the reported patient test results are detected. the laboratory must: (k)(l) Promptly notify the authorized person ordering the test and, if applicable, the individual using the test results of 9 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 15 of 145 reporting errors, (k)(2) Issue corrected reports promptly to the authorized person(s) ordering the test and, if applicable, the individual using the test results.~' 30. Furthermore, both Defendants Athena and Quest violated the Plaintiffs' right to access protected health information (CLIA regulation §493.1291(1), and the Health Insurance Portability and Accountability Act, regulation 45 CFR §164.524(c)(3)(ii)), when it refused. to provide the completed test results to the patient (or the patient's personal representative) upon Williams PR's request in September 2014. 31. Relying on the erroneous 2007 Report issued by Athena, a diagnosis of Dravet Syndrome ("SMEI") was rejected by Dr. Shoffner, Dr. Kendall, Dr. Livingston and Dr. Clarkson. As a result, continued to be treated with increasing doses of multiple sodium channel blocking medications including Carbamazepine (Tegretol) and Lamotrigine (Lamictal) - a standard treatment for epileptic seizures not caused by Dravet Syndrome (SMEI). 32 The health records of reflect treatment with sodium channel blocking medications, including Carbamazepine (Tegretol), Oxcarbazepine (Trileptal) and Lamotrigine (Lamictal), fOT treatment from onset of seizure presentation through the end of 's life. 33. Sodium channel blocking medications, such as Lamotrigine (Lamictal) and Carbamazepine (Tegretol), have been reported in numerous publications, Hom et al., 1986, W akai et al., 1996, Guerrini et al., 1998, to worsen seizures in patients with Dravet Syndrome (SMEI). These publications include reference #ll on Millare's 2007 SCNlA DNA Sequencing Clinical Diagnostic Report issued by Athena. Furthermore, "1dentifying anticonvulsant treatments to avoid'' was also listed as an expectation of running a SCNlA DNA Sequencing Clinical Diagnostic Test (test code 535) by Athena in 2007. Identifying which treatments to avoid - such as the use ofsodium channel blocking medications - is of particular concern when treating Dravet Syndrome. 10 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 16 of 145 34. As a proximate result of Athena's negligent laboratory practices and failure to accurately diagnose and advise for the selection of appropriate therapy, lost his life on January 5, 2008 following a traumatic seizure. This causal connection between Athena's negligence and 's ensuing death is further confirmed by the affidavit of Dr. Max Wi.znitzer, M.D. (hereinafter "Dr. Wiznitzer''), a pediatric neurologist at the Rainbow Babies & Children's Hospital, board-certified by the American Board of Pediatrics in Pediatrics and board-certified by the American Board of Psychiatry and Neurology both in Neurology, with special qualification in Child Neurology, and in Neurodevelopmental Disabilities. In his affidavit, Dr. Wiznitzer notes, "that if the ( 's) SMEI condition had been properly diagnosed and had ( appropriate care for the treatment and management of SMEI, ( ) received ) would not have suffered the fatal seizure on January 5, 2008." Dr. Wizniter's affidavit, and all of its attachments, are incorporated within this complaint and affixed hereto as Exhibit B. as if set forth herein veroatim. 35. Thus, Athena's violation of multiple CLIA federal regulatory standards posed immediate jeopardy to the patient's health and safety (42 C.F.R. §493.2), "a situation in which immediate corrective action is necessary because the laboratory's noncompliance with one or more condition level requirements has already caused. is causing, or is likely to cause, at any time, serious injury or harm, or death, to individuals served by the laboratory."' 36. As such, the 2007 Report issued by Athena, breached the standard of care of a clinical diagnostic laboratory performing genetic testing by any one or all of the following: a) its negligent failure to provide an accurate genetic confirmation of a Dravet Syndrome (SMEI) diagnosis, b) failure to adhere to a post~analytic DNA variant classification system, c) failure of timely notification of the SCNlA DNA mutation reclassification, ;:ind 11 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 17 of 145 d) failure to identify anticonvulsant treatments to avoid with SMEI diagnosis. 37. Such failures, as described in the foregoing, of each Athena agent listed above as having contributed to the laboratory results have deviated. from the accepted standard of care protocol of any CLIA certified clinical diagnostic laboratory performing high-complexity genetic testing. This directly and proximately resulted in the erroneous diagnosis leading to dangerous and ineffective . As such, this erroneous 2007 Report proximately caused the death of the treatments of young child . 38. Further, such failures, as described in the foregoing, of Athena's CUA license ho.Ider Higgins have deviated from the accepted standard of care in the field of clinical diagnostic genetics, and proximately contributed to the erroneous 2007 Clinical Diagnostic Report. The clinical findings as reported lead to inappropriate treatments, thereby exacerbating the seizure disorder of and proximately contributing to the death ofthe child, . Moreover, such failures of the initial 2007 Report, as described in the foregoing, were known to all the Defendants for a considerable period of time prior to the issuance of the 2015 Report at Williams PR's request, through Dr. Clarkson. However, these defendants purposefully chose not to reveal this vital information to the Plaintiffs. FOR A FIRST CAUSE OF ACTION (Negligence/Gr<>ss Negligence Resulting in Wrongful Death) 39. Each and every allegation set forth above is fully incorporated herein. 40. Williams PR is the duly appointed Personal Representative of the Estate of she brings this action on behalf of the Estate of , and and for damages recoverable by the statutory beneficiaries of 41. At the time when 's initial 2007 Test was conducted. Athena had a duty to meet a reasonable standard of care in the course of providing CUA-licensed high complexity clinical 12 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 - diagnostic genetic testing services to Page 18 of 145 ··-·-- - -- - , in accordance with the standards of the National Committee on Clinical Laboratory Standards ("NCCLS''). However, Athena breached those duties and standards o~ care in one or more of the following particulars: a) failure to provide accurate genetic confirmation of Dravet Syndrome (SMEJ) in the 2007 Report, b) failure to adhere to post-analytic DNA variant classification system, c) failure of timely noti ti.cation of the SCN 1A DNA mutation reclassification, d) failure to identify anticonvulsant treatments necessary to avoid in patients with a SMEI diagnosis, and e) failure to follow the litany of CLIA federal regulatory standards as recited above. 42 Athena breached its duties to in each of the aforementioned particulars. Such breaches were negligent, grossly negligent, careless, and/or reckless. 43. Athena, acting through various agents, Nagan, Zhu, Batish and Higgins, reviewed or had opportunity to review. the 2007 Report wi1h the finding of DNA mutation (1237T>A, Y413N) as plainly stated on the 2007 Report- all test results are reviewed, interpreted and reported by ABMG certified Clinical Molecular Geneticists. A simple review of such findings would have confumed that 's mutation demonstrated genetic characteristics consistent with Dravet Syndrome. At minimum, the incorrect classification of 's mutation as a "Variant of unknown significance" could not be supported by the finding of a missense "DNA mutation (1237T>A, Y413N)." 44. Moreover, Athena had a duty to correctly infonn failure prevented of his SMEI condition; such from discovering more appropriate treatments available to mitigate 's condition, and a duty to aid in obtaining treatment to correct the condition, or 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 19 of 145 otherwise mitigate the known consequences of Athena's erroneous diagnostic DNA variant classification. Such a breach of this duty was negligent, grossly negligent, careless, and/or reckless. 45. Further, Athena knew, or should have known, that results from their clinical diagnostic SCN 1A genetic testing would have direct impact on a patient's treatment and clinical management. Specifically, that a treating physician would likely continue to treat or any similar patient with frequently occurring epileptic seizures not caused by Dravet Syndrome (SMEI), with sodium channel blocking medicarions such as: Carbamazepine (Tegretol) and Lamotrigine (Lamictal), and that such a treatment would likely expose a patient with Dravet Syndrome, such as , to a high risk of death, which in fact did occur. 46. The clinical findings of the 2007 Report, led to inappropriate medical treatments, thereby exacerbating 's seizure disorder and proximately caused his death. has suffered damages in an amount to ·be determined by the jury. A!3 a direct and proximate cause of the aforementioned negligent, grossly negligent, careless, and reckless actions and/or omission of Athena, acting by and through its agents, servants, and employees, as hereiriabove more particularly set forth in paragraphs Forty (40) through Forty Three ( 43). suffered a serious, severe, painful, debilitating, and fatal seizure resulting in his death on January 5, 2008. 47. 's statutory beneficiaries, as represented by Williams PR, have suffered economic loss, severe emotional distress, anxiety; grief, and sorrow for which Williams PR is entitled to recover on behalf of the statutory beneficiaries actual and punitive damages (when allowable under law) pursuant to S.C. Code§§ 15-51-10 et seq. in an amount to be detennined by the jury. FOR A SECOND CAUSE OF ACTION (Survivorship Action) 48. Each and every allegation set forth above is fully incorporated herein. 14 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 20 of 145 49. Athena, acting through its agents3 1\agan. Zhu, Batish and Higgins, as well as those who might be uncovered through discovery, committed various acts and omissions as previously outlined above, which constitutes negligence, gross-negligence, carelessness, recklessness and willfulness and wantonness. 50. As a direct and proximate result of the acts and/or omissions of Athena as listed above, , the decedent, sustained severe and permanent injuries, eventually leading to 's suffered from numerous debilitating seizures, · including the death. Prior to his death, seizure that finally ended his life. 51. Williams PR is infonned and believes that pursuant to S.C. Code § 15-5-90, is entitled to a judgment against Athena for the damages, which s estate would be entitled had he survived the erroneous findings of the 2007 Report by Athena, both actual and punitive, for each additional seizure suffered by including the seizure that ended the life of FOR A THIRD CAUSE OF ACTION (First Count of Negligent Misrepresentation and/or Constructive Fraud) 52 Each and every allegation set forth above is fully incorporated herein. 53. Upon information and belief, once the obvious mistake in the 2007 Report was discovered, the decision to hide s actual diagnostic condition was a conscious one made exclusively to protect corporate assets of defendants Athena, ADI, and Quest (when referred to collectively "Corporate Defendants"). This cover-up was done at the absolute peril of the patient, and its continued concealment, until very recently, exerted damage to , as set forth above, and damage to Williams ID through the loss of a substantial period of her child bearing years based on the false belief she passed an uncharacterized mitochondrial disorder to her son , as well as severe emotfonal distress to Williams ID. This conduct is both criminal, as a purposeful violation 15 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 21 of 145 of CLIA regulation 42 C.F.R. § 493.l806(e), and shameful. Upon information and belief, prior to 2015, the Corporate Defendants recognized that a substantial number of patients were affected by similar erroneous SCNlA DNA Clinical Diagnostic Sequencing Reports. These erroneous Clinical -Diagnostic Reports can result in ill-infonned health care choices, needl~s suffering, and death. 54. Upon information and belief, Corporate Defendants recognized the significant risks these patients posed to their respective financial assets and, in response, developed a plan to avoid responsibility for their respective acts. 55. Upon information and belief, this plan of institutional and individual fraud and deception and misrepresentation included the following: a) These Corporate Defendants knew, or ought to have known. that the 2007 Report that was a materially false representation; b) These Corporate Defendants had a pecuniary interest in making the statement; c) These Corporate Defendants owed a duty of care to see that they communicated truthful infotmation to Plaintiffs; d) The Corporate Defendants breached that d\lty by either failing to exercise due care OT by intentional omission once their mistake was known to the Cotp0rate Defendants; e) The Plaintiffs were unaware of the falsity of this report and relied on the purported truth of this representation and had a right to rely that such statement would be truthful; f) As a direct result and consequence of the Corporate Defendant's false representation the Plaintiffs suffered injury and damages as set forth below. 16 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 22 of 145 56. Upon information and belief, all actions by the Corporate Defendants were designed to 's true clinical diagnostic condition and to manage their responsibility to the deceased hide child and his mother. The Corporate Defendants fraudulently and/or negligently misrepresented facts to effectuate the same. 57. As a direct and proximate result of the acts and/or omissions of all the Corporate Defendants, including withholding of the corrected SCNlA DNA variant classification, sustained severe and pennanent injuries, eventually leading to his death. s statutory beneficiaries, as represented by Williams PR, have suffered economic loss, severe emotional distress, anxiety, grief, and sorrow for which Williams PR is entitled to recover on behalf of the statutory berieficiaries actual and punitive damages. 58. As a direct and proximate result of the acts and/or omissions of an the Corporate Defendants, including the withholding of the corrected SCNlA DNA variant classification, sustained severe and permanent injuries, eventually leading to his death, and thereby proximately causing Plaintiff Williams JD the loss of comfort, services, companionship, and society of her son and child. Moreover, Williams ID lost a significant portion of her child bearing years and incurred medical expenses for the treatment of her severe emotional distress. Williams ID is entitled to recover: the loss of her child bearing years, and the incurred medical expenses for the treatment of her severe emotional distress. FOR A FOURTH CAUSE OF ACTION (Second Count of Negligent Misrepresentation and/or Fraud) 59. Each and every allegation set forth above is fully incorporated herein. ro. Both Athena and Quest jointly issued the revised 2015 Report on the SCN1A DNA Sequencing Diagnostic and forward this revised 20 15 Re.Port to Williams ID, through Dr. Clarkson. 17 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 23 of 145 61. This revised 2015 Report does not cite any new publication references used in the r~ classification of this mutation (1237T>A, Y413N). Such an error violates CLIA regulation §493.1241(c)(8), "any additional information relevant .and necessary for a specific test to ensure accurate and timely testing and rep<>rting of results, including interpretation." 62. These purportedly new laboratory results as set forth within the 2015 Report falsely state that both Nagan and Zhu authorized and signed-off on the issuance of the report. However, upon information and belief, both agents left their employment with Athena before 2009 and, as such, could not have possibly authorized the issuance of the revised 2015 Report. 63. This intentional misrepresentation violates CLIA regulation §493.1283(4) "the record system must include the records and dates of all specimen testing, including the identity of the personnel who performed the test(s)," which are necessary to assure proper identification and accurate reporting of patient test results. 64. Such an intentional misrepresentation and intentional violation ofCLlA federal regulatory standards is criminal, pursuant to § 493 . l 806(e), and civilly actionable and has hanned the Plaintiffs. 65. This plan of institutional and individual fraud and deception in the issuance of the 2015 RepQrt included the following: a) Knowingly, and/or negligently, making a materially false representation to Williams ID that the 2015 Report was a "new" test; b) These Corporate Defendants had a pecuniary interest in making the statement to cover-up their prior negligence; 18 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 24 of 145 c) These Corporate Defendants owed a duty of care to see that they communicated truthful information to Williams ID in accordance with CLIA ·federal regulatory standards; d) The Corporate Defendarits breached that duty by either failing to exercise due care or, more likely by intentional omission once their mistake was known to the Corp<>rate Defendants; e) Williams ID was unaware of the falsity of this report and reHed on the purported truth of this representation and had a right to rely that such statement would be truthful; f) As a direct result and consequence of the Corporate Defendants• false representation Williams ID suffered injury and damages as set forth below. 65. As a direct and proximate result of the acts and/or omissions of all the Corporate Defendants, including the withholding of the corrected SCNlA DNA Variant classification, sustained severe and permanent injuries and eventually death, thereby causing Plaintiff Williams ID the loss of comfort, services, companionship, and society of her son and child. Williams ID lost a significant portion of her child bearing years and/or incurred medical expenses for the treatment of her severe emotional distress. Williams ID is entitled to recover: the loss of her child bearing years, and the incurred medical expenses for the treatment of her severe emotional distress. FOR A FOURTH CAUSE OF ACTION (Civil Conspiracy) 67. Each and every allegation set forth above is fully incorporated herein. 68. At some point between the issuance of the 2007 Report and the issuance oftlie 2015 Report, two or more of the above named Corporate Defendants (Athena, ADI, and Quest) acting through 19 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 25 of 145 their agenlc; and/or executives conspired to intentionally withhold and cover-up the corrected information as reflected by the 201 S Report. The Corporate Defendants combined and conspired together for the purpose of injuring the Williams ID and/or , thereby causing special damages, including but not limited to death, pain and suffering on the part of medical expenses, additional mental anguish caused by the delay in notification of , increased 's actual diagnosis and loss of child bearing years on the part of Williams ID, as well as the resulting incurred medical expenses for the treatment of her severe emotional distress. FOR A FIFfH CAUSE OF ACTION (Unfair Trade Practice Violations) ff), Each and every allegation set forth above is fully incorporated herein. 70. The Corporate Defendants sought to profit, and did profit, by performing SCNlA DNA and other clients. The Corporate Defendants also are among the world's leading testing on providers of diagnostic testing on human tissue and offer services that range from routine blood tests, Pap testing, and white blood cell count, to oomplex diagnostic testing such as genetic and molecular testing. 71. The Corporate Defendants engaged in deceitful conduct by concealing the initial mistake issued in the 2007 report. As more thoroughly set forth above, the Corporate Defendants lied, misrepresented, and actively concealed 's actual dia.gnosis in an attempt to protect corporate assets and hide their negligence and malfeasance. This concealment not only harmed the Plaintiffs but violated regulatory standards as set for under the CLIA. This deception prevented and Williams ID from knowing the true nature of the DNA mutation at issue. n Left with the false belief that her son died of an uncharacterized mitochondrial disorder, Williams ID vainl~ sought to uncover what disorder she may have carried that was inherited by her son, . Williams ID spent a considerable .amount of money and time in this fruitless 20 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 26 of 145 endeavor since the specific DNA mutation (1237T>A, Y413N) on the SCNlA gene was known well to express a severe form of epileptic encephalopathy also known as severe myoclonic epilepsy of infancy - Dravet Syndrome. 73. Further, Williams ID' s false belief that her son died of an uncharacterized mitochondrial dissorder and her seeming inability to obtain a clear cause of his death directly and proximately caused Williams ID suffer severe emotional distress. Williams ID thereafter sought the care of licensed medical providers at some significant personal expense. 74. The Corporate Defendants negligently, carelessly, recklessly, willfully and/or wantonly engaged in unfair or deceptive acts in the conduct of trade or commerce which are prohibited by S.C. Code Ann. § 39-5-20, et seq. (South Carolina Unfair Trade Practices Act). 75. The Corporate Defendants' unfair or deceptive acts are capable of repetition given the nature of Corporate Defendants' business and the vast number of people who depend on the numerous diagnostic tests performed by these Corporate Defendants each year. As such. these acts have an effect on the public and do concern the public interest. 76. As a direct and proximate result of the Corporate Defend_a nts' unfair or deceptive acts, which are in violation of the South Carolina Unfair Trade Practices Act, Williams ID has suffered m()netary damages, in an amount to be detennined by the jury, in addition to treble damages and attorney's fees as authorized by statute. WHEREFORE, Plaintiffs pray for judgment against the above named Defendants for actual and pullitive damages in a reasonable amount for the costs of thls action, including reasonable att .' .c- ~J ~-r: oG? (:< - ... ,, (~, :1(' ~ ,-·, ~ N ;;, ~.:: ~.": ·~ ' t-:~· r· ..,_ -..J '.:_:.r;;: ..... ~-:~ Pers-0nally appeared before me, the undersigned notary public, Robert M. Cook-Oeegan,:M:.D~ho being first du1y swom deposes and states as follows: .... .; . ·i 1. I am a research professor in the Sanford School of Public Policy at Duke University, with secondary appointments in Internal Medicine (School of Medicine), and Biology (Trinity College of Arts & Sciences). I was the founding director for Genome Ethics, Law & Policy in Duke's Institute for Genome Sciences & Policy. 2 I have been consulted by attorneys from Grier, Cox & Cranshaw, LLC and Ervin & McGuire Law Firm, LLC, on behalf of their client Amy Elizabeth Wi1Hams (Personal Representative for ) to provide an expert opinion as to the SCNlA DN A the Estate of sequencing diagnostic report performed on an extracted DNA sample from the late (August 23, 2005 ·January 5, 2008) by Athena Diagnostics, Inc., a neurology division of Quest D iagnostics, Inc. 3. l am an independent academic researcher who came to the attention of the family and their ·legal counsel in part because of work perfonned at our Center for Public Genomics on clinical implications of gene patents. 4. I ha\·e received and reviewed the SCNlA DNA sequencing diagnostic report issued by Athena Diagnostics, Inc. on June 30, 2007 (Exhibit 1), along with a second revised report issued January 30, 20 \ 5 (Exhibit 2). Additiona11y, l have receiYed and reviewed the medical records pertaining to the decedent, . Case History 5. On December 23, 2005, the medical record indicates that the decedent began suffering from febrile focal motor seizures following a routine 4th month vaccination. This condition developed into frequently occurring afebrile seizures of varying types, including tonic·clonic, atonic and absence seizures. These often reached status epilepticus. During his treatment, sodium channel blocking medications, including Carbamazepine (Tegretol), A, Y413N) in the SCNlA gene not only possessed the characteristics expected of a disease causing alteration, but it had also been reported, studied, and known in patients expressing Dravet Syndrome, a severe form of epileptic encephalopathy also kri.own as severe myoclonic epilepsy of infancy (SMEI). 2 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 30 of 145 (Exhibit4) \''4U~ .. S~lEI (Table 1-PatHat #9) fl006l Berko•A, Y413N was also cited as a SCNlA mutation that "disrupts the functioning of an assembled ion channel so as to produce an epilepsy phenotype" in U.S. Patent #S, 129, 142. This patent, filed in 2004, was one of several that the inventors obtained for the University of Adelaide and its spin-out, Bionomics Limited, for the development, validation and utilization of this SCNlA genetic test for SMEI diagnosis in the United States. 15. Furthermore, the Chief CLIA Laboratory Director that reviewed the laboratory results and submitted clinical infonnation of the decedent, Sat Dev Batish, Ph.D., is one of the authors of the Harkin et al., 2007 publication. That paper was submitted and published prior to the June 30, 2007 (Exhibit 1) SCNlA DNA sequencing diagnostic report on , issued by Athena Diagnostics, lnc. .16 The errors cited in numbers 9-13 violate the stated classification procedures of Athena Diagnostics, Inc. Clinical Laboratory Improvement Amendments (CLIA) certification (License # 2200069726), including: §493.129l(a), "the laboratory must have an adequate system(s) in place to ensure test results are accurately and reliably sent from the point of data entry to final report destination, in a timely manner" and §493 .1289(a)·"the laboratory must establish and follow written policies and procedures for an ongoing mechanism to monitor, assess, and when indicated, correct problems identified in the analytic systems." In addition, there is no date recorded for specimen collection date, violating §493.1283(a)(2), "the laboratory must maintain an information or record system that includes the date and time of specimen receipt into the laboratory ." 3 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 31 of 145 Err<1rs in Revised (January 30, 2015) SCNIA DNA Sequencing Diagnostic Report 17. The revised SCNlA DNA sequencing diagnostic report issued on January 30, 2015 (Exhibit 2) by Athena Diagnostics, Inc. does not cite any new publication references used in the reclassification of this mutation (1237T>A, Y413N). This error violates CLIA regulation §493.1241(c)(8), "any additional information relevant and necessary for a specific test to ensure accurate an~ timely testing and rep:>rting of results, inclu9ing intcrp!etation_." 18. [n addition, the laboratory results and submitted clinical information within this revised report were signed off by Narasimhan Nagan, PhD, ABMG, Director, Genetics, and Hui Zhu~ PhD, ABMG, Director, Genetics; both of whom left Athena Diagnostics, Inc. before 2009. This error violates CUA regulation §493.1283{4) "the record system must include the records and dates of all specimen testing, including the identity of the personnel who perfonned the test(s)," which are necessary to assure proper identification and accurate reporting of patient test results. 19. Moreover, Athena Diagnostics, Inc. violated CLIA regulation §493.1291(k) when it did not issue an amended report when this DNA mutation (1237T>A, Y413N) was re-classified as a '•Known disease-associated mutation." "When errors in the reported patient test results are detected, the laboratory must: (k)(l) Prompt! y notify the authorized person ordering the test and, if applicable, the individual using the test results of reporting errors. (k.)(2) Issue corrected reports promptly to the authorized person(s) ordering the test and, if applicable, the individual using the test results." 20. Furthermore, Athena Diagnostics, Inc. violated the patient's right to access protected health information (CLIA regulation §493 .1291 (1 ), HIP AA rule 45 CFR § 164 .524(c)(3 )(ii)), when it refused to provide the completed test results to the patient (or the patient's personal representative) upon request in September 2014. Failure to Properly Diagnose, Resulting in Improper Treatment, Proximately Contributing to the Child's Death 21. Relying on the erroneous June 30, 2007 SCN lA DNA sequencing diagnostic report issued by Athena Diagnostics, Inc., a diagnosis of Dravet Syndrome (SMEI) was rejected, and thus the decedent continued to be treated .with increasing doses of multiple sodium channel blocking medications including Carbamazcplne (Te~retol) and Lamotrigine (Lamlctal), a standard treatment for epileptic seizures not caused by Dravet Syndrome (SMEI). (Exhibit J) 22. Sodiwn channel blocking medications, such as Lamotrigine (Lamictal) and Carbarnazepine (Tegretol), have b een reported in numerous publications to worsen seizures in patieo1s with Dravet Syndrome/SMEL These publications include reference# 11 on the decedent's SCN lA DNA sequencing diagnostic report issued by Athena Diagnostics, Inc {Ex.htbit 1). · Furthermore, "Identifying anticonvulsant treatments to avoid" was also listed as an expectation of running~ SCNt A genetic test (test code 535) by Athena Diagnostics, Inc. in 2007. (Exhibit 6) [i 998) Guer.ini R, Dravet C, Genton P, Belmonte A, Kaminska A, Dulac 0 . Lamotrigine and seizure aggravation in severe mYoclonic epilepsy. Epilepsia. 1998;39(5):508· 12. Epub 1998/05/22. PubMed PMJD: 9596203. 4 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 32 of 145 23. As a proximate result of Athena Diagnostics, Inc. negligent diagnosis and failure to accurately advise selection of appropriate therapy, the decedent lost his life on January S, 2008 due to a traumatic seizure (Exhibit 7). Thus, Athena Diagnostics, Inc. violation of multiple CUA regulations posed immediate jeopardy to the patient's health and safety (42 C.F.R. §493.2), "a situation in which immediate corrective action is necessary because the laboratory's noncompliance with one or more condition level requirements has already caused, is causing, or is li,kely to cause, at any time, serious injury or hann. or death, to individuals served by the laboratory". Standard of Care Violation 24. It is my opinion to a reasonable degree of clinical genetic certainty that the SCNlA DNA sequencing diagnostic report issued by Athena Diagnostics, Inc. on June 30, 2007 breached the standard of care of a diagnostic laboratory performing high complexity genetic testing by its negligent failure to provide accurate genetic confirmation of Dravet Syndrome (SMEI) diagnosis, failure to adhere to post-analytic DNA variant classification system, failure of timely notification of the SCN 1A mutation reclassification, and failure to identify anticonvulsant treatments to avoid with SMEl diagnosis. 25. According to the foregoing, each Athena agent listed as having contributed to the laboratory results, Sat Dev Batish, PhD, FACMG, Chief DirectoT, Genetics, Narasimham Nagao, PhD, ABMG, Director, Genetics, Hui Zhu, PhD, ABMG, Director, Genetics, have in my opinion to a reasonable degree of clinical genetic certainty, deviated from the accepted standard of care protocol of a CUA-certified diagnostic laboratory performing high complexity genetic testing, and proximately contributed to the erroneous diagnosis as reported in Exhibit 1. Based on the clinical findings as reported, inappropriate medical treatments were employed, proximately contributing to the death of the child, 26. According to the foregoing, Athena Diagnostics, Inc's Medical Director and CUA license holder Joseph J. Higgins, M.D., F.A.A.N., (CLIA # 2200069726), has in my opinion., to a reasonable degree of medical certainty, deviated from the accepted standard of care for a medical practitioner in the field of clinical genetics, and proximately contributed to the erroneous diagnosis as reported in Exhibit 1. Further, it is my opinion that based on the clinical findings as reported, inappropriate medical treatments were employed, exacerbating tbe seizure disorder of and proximately contributing to the death ~f the child, 5 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 33 of 145 27. I reserve the right to modify, amend or elaborate on the opinions stated herein as may be necessary if further information becomes available t-0 me. '5~ : f./or"' Cu(J/,-,,a, c~; l>IM"'Ait.m Sworn to ~efore me this 04 Day of August, 2015 . R<.'f.IN )'-:.trinnf of ankoowr11 signillcanc:e). Testing .-reaiho i:s: r.h'Ongly ~.mm.e:Qdtd lo resolve tlie 111!.~:ty nf. 1hctc tr:at ~il'5. :P'.e:ue .refer to the TedIJlical ~Is arid Coo:uucnts sec!.tcms of this re-itCJ; for tm:t:ber tntm'l.Dadan. Teclmkfil Results DHA V:tr'.ant l: N!!.CIC()tide .Position: c.odon:. Ammo .Acid Oiaage: Va:rlmt Tr~ ~-sioo T > ~l~mz:ygm:s) mche Mo other ~DNA suqucace vaii;m we.os ~td remairoer tJf the aJdiDg ~ a!!d lml1'I?/aonjn.m:tion. Comments ~ ...,. N ~ ...... ..... ...,. ~ c ~ ~ ~ ~mc:aut result: A.!lalysa of this i"1ividutl'3 SCNlA. gene a DNA sequem:e vari~ or ~irudion of varimu who~ :rignifiC&Ji:ICC Ni unclear or UDkoown (~t(sj or u:nkoown slgalficaoce).• Sir.'.ce ~ ~ Of $C(jurace variant! are ~lllil2r to thmc cbrerved in ooth d!sease-a.'>soclated mutil1ions at o!lle: mcleotidc i=-OGlfimls Bild iD benign po!}rmOtplili;ms, th: natUie of 1!!ia ·~-~fon. p:-~ cle:nUitetrmm011.. 1:1i.e~ DNJ:. seq~ ~ niay or may no.! $l!llr tl1e Mo£! identL...~ - ---.. ~-·---- ---- • 21Jai.ui- OliolJ"IOllUI. ~.... "~ 1~4 . ,....... ................ Fcimiiy JC.•nuen~lllir ie be ~iliiidvely ~pmed due to tho .absence af 11ubliab.ed studies co~ tbcse 'fariant(s) with clinical pl'CSelrtl'ltiou a.i-~or pathology. T.oea:fme, bued on this stngJe ai:Wysi111. it. is not possible to coocblde · with n,xy n:ascmblc ~ of clinical certainty a.t this ~ w.hellle:r or not lhis •,!'flrlm !.s mzl!Cciak-d wi!h the p!lenotype in qoes:tion• rasslbk ;)'lrt~t~ Although the clinical $gni'fu:mlle l}f ftli.8 test ~t la not amain. sr:vera~ outco.ir.ea are possible: Normlltl- tli.e v&ritat ~ a ba::rigu polymorphism tb1ll has not t>een pre-liwsly ~ or rcpmed aud it is Ver/ lmli};cly tlW tm masation A 1237 413 T-1roolli1: > Aspit-agjbe Vm.iEI of unl:r.ot>'Ml significm-:.c __ _ ......... _.... ,... .. .. lnterpretation a .. Slllie 25-0 --- --- -- --· .A..tltuda, GA 30J38 Aii«k~!\ _s~ug Tat '!/ .... - - - . .. . .. ... One b-lll1w1'f'.ldy Park -- -- 07025148 -- --·-··· -- · folm Shoffi:ier. l\ID ...... ....._;;__ _ _ _ ___ ___________ ___ - ~- - ACUloii tiiiifu ··- - -· ·--· ~iit-··-·--·-· - DNA N Pa~e 1of6 ~.iMD11Sf ·- ------ --- ·---- noo5 N Page 34 of 145 ~ "'6 lldlif' t1rl1ltlf?~ Gl!O.~tnfil1g~ Di £Gut Sl?4ll, P ff:K4 tena diagnostics ...A! f"'6tOilQttY Entry Number 1-1 www.AtllenaDiagnostlcs.com r'~llt"/11 ~ Date Filed 03/28/16 i& m~'ble fur cliaica! S')'m!)tcma « ~ risk of disea.1e.. 1Uleca4 with less le\'fre G-Y..J!S~ (g~ epile:-y wil1J !ebr.Je ~izures plus) - the variaJJL is an ~~a:d pad:loJog.ic m;UiOD tbn does not caiise SMEI, but m;:y ti.: assodaled witl.t Jes& ~ d.inicai syJJJptoms. Affected widJ SMEI- ~ vari2m is P.l'! un..~ortej pathologjc DDJtaUOD atJd is therefore ~ '#oith the div.He. Omec variaB.ts uf lt»i sipU:i'•21ia: ~ a:c~ysjs mz.y al.so have d.ettcted other types of seqnem:e ~ as lis2d in tbe 'l:l:clmical Results aeciion. a common 4:..'XUXTCDCe Co: an analysis of drls .scop:.. ~ of n.d&tioual is genemlly of rcdu.ced ~cmwe Jmd does ~ roodify die fiDat iDtr:iP.datioo of the te&t results. Benign ool.ymoij>Ws!m, if i.CJ.mi.«:2.1 Rmtlt1 xcrfan ot tbia n:port. Puental ~ti'llg and otll:ct" follow tiJ! r~~ioJlS: T~g of me biologkal pill"CDC3 is stro!lgfy ~led (for D.O MditiOil.'ll d::ttge) ta 1:-clp re!G!.Ye the lJDCel:~ 6:i8 seql!C!lce ·re;.i~' a pllthcgco.tcey and 1te ~of tt.e pnidmd pbe:ootype. Misse:osc mr.:ation.'I ansill£ the "'1c.-e p~ asscr.:iatoo with SCN1A. Mllllll:ious {SlmI m: S:l\ttml) ~usually (>$-Q~) ~ novo. lll!:mling that .lhe n:rotlll.i02 arose in dlC affecr.od in~ mm fa not cief.l:Ctl:d in !he bfotogical p.eas.10 :twlisscme mul'r.ions auociatr.d with the mil 95 %} illtt.itcti from oue of the biologicru pnell!S.10 C.Onsultr.tro."'.l "11:1ith A:he.t:~'s est cormsel::tr (1-800-394-4493) is :ec.omm-mdec! priM tCl parmral testi:ng. « Because SCM1A llltlWiom w:t 1:~ iDhef.imd, tills inrlividwirs wrdly ~-rs :rzy ~at ri:k fur n~ or inbCJ"itin,g fJlae mi~ Cam"tl reocn.cilialion or Chti m.cJ.ecW.ar dm with w irrlM.duai's clinical and fmlily his+.ary is hlghly reoomn:~t!:ed. Atl.leJUI. reooDnie:ods gmenc caimseliug fur ·ltlis m:D.vidu.al aid bis or her fiwill.y ~. aDd ccnsiikrmoo of p~ testixlg. P"iea:e oont:d A1bcma Clie.at Senices it 1-~.Q.;:oollilalz 0613012007 &ckgroond Iuforwatioru SCNIA cr-..:.otles for the ~ voUagp--galed sodium cbanne1 alph:l l sublxnit protein. :M:na.tions in tt'J SCl~lA ge:oe hw been aa&~d. with ~ve:nl ove:!appi;ag epileps: syndrOCJCS ~ from severe to mild phenotypes (S~mt, . sr....rnn. ;;ni GEPS +). t·tO Th;: bTNe.re pbfinoiypes iDdude S.M.:.8J:, Sevea-e Myoclo:c B_p.il;J:psy of Iaf.mcy or Dtave:. syr.idro:me., l!.l)..1 si-••fEB (SliE.l boro!rlinc with so~. btl£ not all, of fue ::lwical feaJuRS of Slm!. GBPS+ Ge.l>:nlilxd Epilepsy-with f.ebr& Sci:zwes PJm, en~~ a nmge o ~~from febrile seizures to mild~ ~lies, ar..:l les.s comsmnly. includes se~ epi!eptic enw;paalci)a11Jies. Si\!ffii has ; po-'ll' pro:;nosis. ~udiIJ& ~opvmta.I df:L.V mil refractory seizmes. Fnrtt-..e:s:JllOR, ft c:onfirmoo cliagn.:>S!s (l( 5".M.llI ,u.n;y- aigniftea.nU•· ~utc i4oatwent dedsto.na. 11 • SCi."IA mntati.ons fall brwdiy int.o two grzyips.1-10 Tnmc:;.ti.on mltatio;s Glat 211..--vcrely clisropl the ~ are ~ asscciat.ed wifu sevC? ~ 3UCh as .SM.m. l"ilas~ ~ons are asst~ with . r&!!ge of p~~-:a f.rom mild to reYCre-. ·Most :mnt:a:tlons that CilllS SM:R! are de novo, « ti>lradic (ari..s-: in tb!!! afi:cted iridividcal v..t:he !llm beinx inherited.)3.SjC> an lnbefi'31lcc pa:11n11 tl!at can t-e ooafimlOO t, le$til"lg of panr-..t.s. Pa:mili.aJ ~~ are usaally associated wi:h. mil p!l:eootyi~ but can be !een in Si.\.lB!. It is ootewortby dJ:{t ri:>~~ nmtation ~ and vamble e>-.1'reui<"1 ~f a:trectad · ~r1 h:l.-ve bea o1*1:'wd in ttae synck\Jmes in silfl'..e &milies.. TJlis Sfi.ggesa tb mc..iifyi:Dg f2ant:s in1iuence die ~n o.f: ~. and h::dicues lbf the !,ook:cular analysis 1DWl be ~ reamc.ilcd. with tbc clio.id p:resr.:nmd.on m1 fam!ly Tlls101y• .- 0 ~ a;}j - -- - - - ····-·--- ····-···· t>allQ3.~Cl:.~h:.~llflll0\4 -·-··--··· ·······-·---·------ - - --------·········· ·---·- ··· - - -·········-·----- 3:16-cv-00972-MBS - 21io ~ 5"81. 2" roir diagnostics ~- - · - -- :i{l'JC•~ ~ M ·- · ·- Sad_11,...,, ~ --,_.,,.. ~f!C!hlr. -- ---- -·---- - -- ·· .......-......•__ __ .A1lansa. GA 3<1338 . .. .... . - -·- -----------~~ . Sequencitig· ... _ Test ,_ _ ~iiiiW&- .... 00'.XlOOOOO silieiiii. ·CGJlllCtlcn.Oiii · ... ____. ·- .. ·--. NO Date ............ . On.e Dunwoody :Park t~.ifca~ --- -- - ..-·-----·-·....... Diagnostic (.Symcm>maric) ___ ....... _ ..... _ _ ~_!~_n.osis ~~!1'i~~-R~~.~~ Almllior ,.....,. fvr.t-1 Nrvn.tA.;,rli-00:.;1-,-~ '1im- i . -- ..Al14rtsl ......,. Page3 of 6 070251~ ~ ii) Jolm Shoffuer, MD DNA SG.i.~lA DNA \IJllllllf nb.*furllllll!iilfndli/OOOlr~l1!slil!g~ (!DO) 394--1.498 • (508} 756-2.886 ""'Rac:!PP6-...-•Jl='llys -.. ""' iA _ _ _ _ __ _ _ _ _ - - . . - ·-- · - -·- - . .,.. s._ __ _ J1Y.l5 ~ ~ f·..;.::.:;;i'f!t: Page 36 of 145 ~l!,ll'AOl1'52 ..... ··------ ~nitliiii" ~ Entry Number 1-1 WW\Y.Athena Diagnostics .com -A l·..tlr.t;! Date Filed 03/28/16 " A111!1Sarl11~'tir. ~ii·a. - 05/03r;.(X'fl ·-- ""'l)rt0. C6/30fl007 ......., ~ 0 ~· .... ~ ID i;; ~ ~ ~ ~ .... ~ ::' Uu:iittctiOltS o·J: '~'-~ Muiatiom not <1.1mic!ed by t.b$ ~lyais .msy include lfil-ne .deleliom md. la..--ge im.mioos. P..:ixtb.moo.1.-e, this test dret r;.ot delrct. poll:lllW p~i:e nrotatiom in d?e pi"OUIOt.er. 5 • ·mu!Jdog un~ 3' llD!:reshrtJ!d md non-ieqllell.OC{i intt.11U.c ~,gi}'llili:Wlei! IM'j :ri.~eirr dink!iTiy !imilar In thtr.!e c~~ ~ tnubtiur:s ::: L~~ SCHtA gene. Allb.~:Jgb t'IC (~\~ ryf ~l!~ di~ ma)' VflIJ, patleti.1:3 wilh a !JIO~ m;yoe!arm epiletJsy 1111are some sirniW' ~ta:1'S 10 Sj'Ddrov.r.s cm!ICd by SCNl A mul.21ticns !ncit1flq rtl}'Ctlf.ic~ J.,.,elopmenL .A.!belt.t "~·c; :: ~ f~· UU,.x t~ ()Eprv~iv~ :nyccJo11us epikpsy, l3PMl , Lafura·~- ...-..d ~. :i't.1t l :Ql fitttl!er z.ss:ist in the d~ of your ptl:licnt's symplmm. sc:ositivi.ty ar11l"MClllng 99". All ~ raults ue 1:cviewed, imc~, imd rqlomd by ABMO ccrtifi.c:tf CliniC11l MolecuJar GcneticiM3. Nucleotilles and amino acids me nua.beied fu.llowing die ~y accepte1t Noro.~cl."':tmC set !:"-mh by ttle M . H0<; Committee au l\-1lltaDozl Ncn.nen::lature. 'The i.citiat'...;.;- a>dor4 :V~. is designaied as c.OOmi naml-et l in Ole cDNA. 'I'm ·-A· f1f the "Aro• initiator codon is d~ u mlcleotide +l. Ab~u rnt!d.: :.>CNJA hv.si.rc.,,aJ ~; fk;;.~·;:a.wl ~·idiJlln dOJ1,'le: ulpl.1a l .nihr..nir ); .S.4ff;I lm'l'rt tr0·ocIPtur q.>i/qJsy CJeM t- uf &("i411cy);. SllliR (ilt>rdulmt S..'.fCI): {r;m~mJi-,_,d ~prt~ ~i!,'t n-VA. (~u,i;yribomdr:c a;:iifi.. Pat fetir!°lt .~Pi~7't'S pin.t)~ 'J;P/::mzr~<.'. l~~in. AfA1reni1;1J; G(Ciuollin~J; C(()tn.•irit); 1"1'1h~:!1). 2J1il l~ ~a perfo,.,,.,,, ~ ID rilJL.lia_!l); a .Pal ""'-- .,~wiA ItoOle ~ M:et.bods J)...-..k.. Anaiysi3 of the SCNJA t-e:ne w:i..s pi:ifonned by F'CR 3qlli1ic:-..tion of highly purlill:.d ~ DNA. ibllowed by l!llomati:d lJii~ DNA ~u.."U1~ Qf ~.. 26 c"I•Jr:;;. oF the SCNJ.A gene. indtY.futg ~ nith.iy co~oo excro·iumm .splice jun~ria (e.g. err•.. .AO} 'be~!l al.I 215 mdio.i; ~t;.ons. " ~t ldlnoana.I &~ v-drian:.o- ws=re OCIC!fi:tmoci bv fJklirm.io:.liill. ~i.'q\.lefldng l);- :dr~tivc ~~t.'ilc::DE chemiatry. studiis oot.d~ hy Ai.be~• .l)~MltiC.", lno:. it'd~~ ma~ mnblti.ons hi dm :a>< a.;xt in t>~bl!" 'Sefltk!l'il"-in~ ~t,_ m (-~M>SS,\RY a.e C:e'iia!ion.-; ::i"orr. lhe •JOntu! rcfa..-Pr:« beiotr ana.1)'7.r:d. .i.'I\ W.m~n.'.l.llT d.i4-:~en, ;Ql!r.;;riuu:; ir.;.1~1 t..• fumnt in •"'lily o.1e ~Jkk i>f A ~""el~ !A• C('11.11nn dr.~ '1f~Sl!.'(; ll! llm di~e . Howe\·er. i~ is 1t.1t Utr-Onltr>3?a cc .tiav¢ tilOztt aeqt;( 1001: v~tW.:?J ~~cc of the ~,..) Dl'l"A f.t.?11 rwl) :1~Hoo. w:Jkly. 1.~ r:-~- lJN.\ sequrace * clir.1.:i.1! The D.SA ·;:ar.btii find "Qli.'Uf.~ re~ ir:· -1 ~m.l. 14 i1igrifio~ of (ndi\'i..., ~ (::.te~ ?i' a;ry r.f tbc. fuU<1l'l'..."!I. Ji>,t)ly t.:i th~s lndi.;Jt;tt.) Yufarii. Tyr,c:-.: ~ ..q· N ~ ..... oq- ~ ~ ti) I. J.;r:r.t1f;t flbe::t...-...~ nt11bdio!1S (dt;?T.l~) ~ d'.>CUll~~::t !11 !he: i1~e~\tl1!e fo be ~s~.:tja~c.rl with dik'~ miler¥~ i;l a doo:i!:ta......., 1.1Wll>~l" . 'loo iwiividu.11 Jilu!;y r" ~~'\I with. rn- p:eili!f""l~-00 tu da!~·¢.i...'"'rin:.r. :i d001iN11; g~:neti<; Ji~ . · ». ~. Predici:w di~~kd mutatinm tte ~·~·1....."'' m;oocilcd .with fhi8 individbal'a dinica1 and. mnily bi*>ry. 3. Amim> acid dr~"" of 'lrio:"ttO"l\'Ti ~c;mce ai:e Di{A scqlleDCC ~~ !ha an: d-.::kit".ted r~v.:ibty, but b..-ve r.ot b&m. con-ebii:ed l"'"lfih cbui~I i•n:M:J1Qtiua &l!rl!:;r ~og:,, i:l !ti-.! ~~- iit:..-r.llw1~. r.ar do drey ~~WI in a ~ily ~r.ed!ct•.ili~ r· ~~~ UJ.Ml ,rotein m-uctc•-i.: z::d funcrJl.)il..· Tue um~ acid c.~ h rn.~ f>~s:61 on smir~ ir.req;Id2tioni: of C!-..t .a~~ ~- JJ,y,~.,"\'r, t!~ ,;a~ I)~ of Olll«ano~~ ·may 1~ .!il1cr mnniU 1.ene sp!i~ 2Cd ~in.~. iaDd tlereby ~ mo~ significam aci ~:redkt~hle. dl~ct~. Siiu;:: ~ type8 of scqueu.;aJ ~.'Hilt.µ~-s ir.d.:dt< .i.i,a~le r.odef)lrphmm." There ty~!!S Gl...'"nte of fibnoI?rd!!f"nies in lbese ~ Inoonclusive te8'lllls are ~liy ~ by a!lnzysi.s ot a. repeat ~p?:Cimim. ~ will i:'e no c:ha.!be for Ille tq)eat analysis. P"at2:1e ~ "RBPEAT S.PBCT.MEW alGng with tli.e Ebol.'e All~ Ac~cin Nu.mber 011 th: ~tim"i.. If this tat is part cf. a i;;to!ile and a JAUVe .ru.:.it ~ o'iJtailled for l!llOui..er gem. tl~e sWmf...:9.on of a rCJ,l::tt 6. l:.u.W...enn!Ii:!-te iest RSUUs. ·willle o;..Xbodo!ogii:ail.y ;!CCU."'aie. :i...-e nOl clfaica!ly meaningful due to tile if,,c,t: of pub!ish.ed cfoJi.c:U sr..idl'-!f wm:!lating ~ :=u in 6iis :ipecim; ~goiy with clir..ical. pn::r.eofJltion t:m111or pi!lhnlogy. Dae tt> tile .ladt of puhtialiec.t filulings. !besc I.est results car:not be in1erjl.::eteG as eiim:r na:r.'il oc :Jbrv.>.""tlrl• a. 8.l 'fiiipoit~ 06/30/2007 - -- .. •-<••-----·-··"•O.· ·---.,....-------- · 1. lkrjg.'1:2 P"GW.ur,~ :'.'\A. ~lll;;";lK<: varlanre tbU ha.ye been s!:owc. llO pt:lfen:: A46" ~ dilW.at ffv:A '"'~ ~.11r;JlllllS'e. ~:- ~·'f!f~tiA LJ 11"7 ~eetltnti.t la a:'!\Wl!m'7r.!.'!' ~ ~ G: w ftitM !>Mill llCl!'IWM!t« 1111.'fs 4tl. .l!IW.:-_. o/lltf Nfltimpl~• e&;iafl r~,:r ~ f:lfXUJ. Lt!l.'\\>rdmy .rcmlts and S'llbmi~ clrok.1.! il'1form1u.fon te"JniG Director.~ 31trl. Zhu,, PhD. ABMG Direc:toi·. Genetics L-i:"'1.'Cll0ty ovtnlght prcr;iclcd by J09cph I. B~;l!_~·, F.A.A.,;."J.., CUA li~hoMer.Atllcoa O~ca (0..IA tXZD..J-~?'JUDJ T~!ing F40l1llt'1 at: · .\:Wt'1118 ~Four Biolledl P'1it:377 Plant'l.tion St Won:ester MA otm · ···---·-·· -········ ·· ·- · (t):llm."11\!m.~r41b, tlco '.!)XoQ\1101~~ .......... __ ...,....... , ................. ·····-·····- - - -................ !1 :...r.-r 11'/ r.,,,,. m~ ~ C:! .. ~ ;1~.wiDoitii" ·· ··-···· ·---------···- -··- . ·· ... M!!:liJ"111i~m: q.acimen Il,1l'!}' m>t b~ ~ :.'? - -- ·······--·-······· OS/C3!2007 S. In·.:~·1d•t~ tesi. m'JUlts aR: th.o-;e i.lll83i.e to be ~tcd as eiiiler -retelive «positive due to a tecbo.icnl ?1'<'h1cm ill fue a&Sl!Y. 1md thus can < ..,. ·- Pa~~- · - · - Atl.a!Tta, G.A 3C"J38 ··· - ·- --···-.·· ~ < ······ - 000000000 NOD.are pn;-cessi!.ig. Sir.e !he:se t'Jl:>:S of s~ •,1:ltiaJ.ttg &--e simile to ~O!l:e ol:scrvcd in iliseue~ .nmll.nmIS md benign p<:lytro.i],~. the n:ature of this varmi.on prohibfts dr:fiaith-e tl!erpxetation. ~ fM1'1~~.r· Suite 250 E ~ ..... ..... 07025148 -- ..- · - ......... · ·· ·- -·- -··--·-- - ·· - ·- ··- ···· - ~O. Se~_ Test ... ......._ f- -~lll:l·tw::r - ·- ·······-..··- ·-·- ·· ...· JObn Shoffner, MD Jt.ilt1rw M DNA 'ii:"~ .··-···· Diagnosis Service Report {800} 3!J4-44m· (508) 75&-2ml3 ......&! 0 Page 38 of 145 www.AthenaDiagnostics.com l"a!iel'i ~ Entry Number 1-1 . ,.. .. ·--·· -------- ·- 3:16-cv-00972-MBS A ~hmt 80.i. r na diagnostics Date Filed 03/28/16 wv1w.AlhenaDiagnoslics. com "°" 1.'l!l~l,1'()1762 ...JI! -=-~-·~-=-=~......,,.,---------------- · - ··--···· - ~r..;.;- ·- - ... UNA Teti C\D-.xo:Y MIPaitti' - - · Soctl Sl>::uiliifi~~- --- -·- - ·-····-·---········ DiAgnostk (Symptomatic) Temliiiiil•md --···-····-~~\DNA Seq:~ Test. - ···--- --.-·-··-·-·- ---·· ·····-·--·---------------·· ,... gs ~ ,... ,... 'l"~ ... . ····· - -- - · • ··- -·- · • .. ~11111coiiC*ii o~iii--·-·········· 1'10 Uat.e AllQ.D1a., GA 3033S 05/03/20.fnunim 000000000 Snite2SO ---· ..... _ . .. - ··· _.. ·-..·-·-···-· ......._·-...- ······-------------Mcllionll llUdfjl: N J{ll!lllr f9ir:l/-~md N11m>· ~ O~DwiFOOdy :P~ ~JD 07025148 - - .... ·-· ... ··~· · · J\ib.11 Shoffuu. MD - --···-··---- --· -··-· --·---- M P•6of6 Diagnosis Service Report (8'10} 394""93 • {EJ.8} 1IH8!li ~l;1ti-· - · · - ·--- -~ /2005 Page 39 of 145 Yd our"366~'1M~allC'JI-~~ .sm'::u. ~ -- -·· ~ ,... Entry Number 1-1 ··---- ··-···············--· ··---------· ()fjf3U/20ff1 ----- Code 536 Jn o-Idi'..t lo pwridc tt JOO~ comprehem.'vo ill~b o!ttus i.nde.nt'a SCNlA results, Atbem :Oiagu&-tiai :S reqm:stUrg amDi>!ea from the bkli,l<.n~ pa~t• ~>f ;hi~ pati.:1nt. Actr:.~na will p-~rfurm a ~rp:t maly~~ o.r. ~ ~ea !Ur varfallt(s) idemified in geiie SCN1A only md C'O u."' lbc finllin'.•&- Ct:1 help i.~n.~t d::e patkm's SCN!.A r~i~~(s} ;;t no ad~lidoo:i.! elm;:gc. Please me fills form. u tlli;: tequislllon (or P'l.tCDta.! •.~!st.W.g 110. ltll~ ~- ~ ido'IO OflC tDw.µit:f~ Corm wi!h cnh pmmt'a :mnp'fo aad ~ to Atbena. lf you bave an:;• que81ioos or rec_lUhe smppmg ki:t;,. p~ conJ:act Ailtem. ~ semoe '1t l-a00-394-4~t9J.cption 2. Ill i Specintx'n Reiruaem~.uh: 1 la~ lube (S.5ml) w1;ole b.lo«l f;WiJp.lne ~aons: .Room tm>pera!me, .avoid f..reamg B:",;".lg~ciil ~fot!!Cf ~am:>'.: ·- . . - ·----· City,Staie,.Zip: - - - - · Pl.lo.at: - - ..... ::'? -a: s~ l~frigerat.e . ______ lliclogic2~ ~..e:-Naic: ____ .... ______ ____ _ Date of Birth: Date of Binh: - - - -Ad~~: S1ou\gl! Conditions: ···- ·· . .. .. ·--·· ____ ___ . ···- - - - - ·-·----·- ------ --- Adih-ess; - - - ---·-.... ····· · - - - ------- ·- - City,S!l!ID,Zlp: - - - ···- ' --·····- ---------------···--··--- Phorie: ·- -········· ·····- eoncdion Da~: _ _ __ Sr~ '¢ Collec:jon Da&e: ~· ··········•··· _ IN ~ fndicalio?l mr Tcsaiog: --····--····-----·UP.IN: ····--.. Medical P.ractitioor.r Signamrc: . .... ·-·-·:·.:.-::a:.:;-. ;\q:~:a6tc 0.W lCD·.il t:.·ob: 1 '4':1ni>l l!.U 11-,'li !Iii !s ~ ll ~ ~~.z ;~,,. c.felt;iitsn•J tY. .l·t<:l1inr; o~~.f4; Ji>~;. illAi::;,"- ~Jt.\t;::>:q;, •:0".-:lf~"-~ JT ·.!i!W.T.k: .. ~r '.?!'~.z' Jt !. ~·- ~~"l:di.c~·.m~, • a..- l'lba:.::i:~ ........ -.;,.~~~· !JI':~ •ni~ c.•m.:rr.. 'llrW ""'1Jl'M,.,..-,,.,, ..nsiJt>lld 11y.~ ~.,..,.,•IM.- ~:c.- ;1! ·~l'.o ~ t,;;f' :rtt111~11 ?.•lb ~~-.;.+...LW:•. a, ;~ 'W •tc: l''JIV..• "",.,,.~~' •~ ~·..~.~'"' 1v: ~:..... s:mMs;\ 1'4"J Q;;(l:J..;."': 1r! .a aar1~ c-J' • r~f'"""= ~·~·:•~•1J!:. ._ .r,..·: c.c~.; '!t} ~Nit.~~ ra.: 1.-~.r 10> ~F: q> " Cl jCl. ;,:; 'IK c<:'".!L~.& f11r.1:.. ·~!!:: .,,.._...... rct ;,.>'· &':a1.:.:-..1 .-illl .:::,, "";-.:,;(,,11 ~~ii;r.~· <~ <~ ·.~ W. •~!.-.l•lli.'}I "~ .l"'"i-... "''·~-"'ca ::.:•••h. ,.,..; 11-. ~~! ~.:~•Lil•'·1' .:-~; ~ ~·i•i 'r.-. ct•...i> ·,;,.. 111w: ~--U: r,: l"ltliaill!Pll -~ 4~ i• f:fr•ii\.~l( ;•( ~f.~ "~ ..;1 ~ $!".::i'I.:lllrt tia! !!;. •:>:c~~ """'""" ......, ;~:=-•! f~ •=-«, ......,,.~. ur.J :,..,.,..,....., o.I ~ IAR.i:!'. FYr--:4~· ~~:n "'~ ~x ''"cr.'.!l=if:~~ Md ?"11"'-\c.l wil:-._ o;~ .r..\~r:-....lll- ..i. ~•1t1f1ioq ·' ~ii; t•,_;.,r. ori::or...1~11 r.'11¥·:i:.~. b·.cn. "°l.~. I a ··•Ph ,..,.,,. . ~....:!t~~·..:=-~'TI'~<--~-., ~~""- >. ••~l: .'' ' 'f'1 t;:~.r ~~ r-',~ ,. 3e.. ), \~~ :·: . · ·.... · "· M. 00$ ·, ... . .. · 0 - " ..·· '•L : · . lllt r.-~ · • · .. ·~1:.. O O z O . • " .~fil> . 'J >. ·t . ·· " • • . •• .. •• ) m " · · D1agnostu: (S~c) · ~'!'~'-~ CiUlll. • - 0 • q. .J ~, ;·~"~' .,'"' \.'·'\' ~~·refer to the . Tecba~I R.esults and Comments sections orim; RpOJt for further mfonnanon. \).\ Tedmical Resulb _.~~(\." D.NA Yaria.ot. l:Tr:ansversion T >A \J'.;·~ ·. Nucleodde Po5ilioo: 1237 ··\((l. Codon: . 413 \' ~~t' Am~ Acicl Olange: ,\.~•;' "/~f Vana.m Type: Tfrosine > ~paragme . D~ed mUWIOn (heterozyg-OUS) }/~;;: ':.'.;"iJi.~ " .;.,;..:.. " , ,'..·,. ·~·~ ~·i~ !.>:~\ " .. ., .. . .. .. .. ~:-....A11~~~,pw-.l1:iv1tt11.1Jr i:t~• . . . .. ·, . ; O • O '• .. .. .. .... ·.. . ··......, .· . ' O ••.,'.• · : . .. . •.': . . . • . , . .... .. ' .. : • • , "' •, 1 , . : · : \: . . ." ' '""." .. " .' "". " . '.. , r ' •. ;.,t~~,·t• ~ · • • O: atiJ~;¥;~~-~.:;"i: ·.:~.;1.·l•i!f4\..' ' .· r::n:~~~\....:~~ . .\,\\' t\~ ~ ~,.,, , , ,,., . ;.,,.,,r,. , }tuii·'..t.~~ ·w~:;:-.)f!:. .:\'!:~\~ r~,. x 1 No ~abnormal DNA sequence variants wer~~·~~~ ~~ ;tf~g>~~lf'.?; -..:....- f ,........,,, ---' ' I w.l.~ta~:.:.' .,.,..'f'- ,-...: • ,.,~ ... ' · re-WUQ o lbe c ......""O s~uem:e 1t11ronJe~.~ J~~Ol.1:\-)',-'.~:1 ; ;. :·;; ~~~,~~--~·~· , -. , , >.· , ., ,..~,1~) ...\; :J: ,,.··\'-~'·'.;1~'\:U .f)1:.~:JM•\')~.;\ .. i,....... j\·/ jJ:.·.,$~:;:~}~;j ~··'\"' VQ~ I~ i 1 I • ". . . . . . .. . · .. . .. ·.. · . . c,,........,.en.., -= ·! ·n·~;,;)l ' ui " · ·~t \·.• ;!'")\ f1•6.lt»i ~;,1i;;; !', ,1V }\ij-.- \•~ ·-:~ . . .... ..,.. . . .:. . ....-·. . · .-~·t ,.": ) ~ m · ....\~.~,:•.~:!!•::'.,:;:~··''\':!:}'' .. ~~•t\'i··.->·;;'i···J..#~<:>·•t' w . ". ,:-..~{:·· ·ij·,• ;·..:~ :r, ..: CD • · · • .)} ..~f ...?\~ .. .;\~·.~-;~~)·~1:c...• •• -~·· v ·"·;.x;,,.;• ,, : ~ V'! ... ....-~~···.":."' · ···.1 ·t ·..r·. . ··~~~ w • ... . . ... -~-W~.·. "~... ; ·-.~n ....·y·••S->n • :~(J~~l1:~'!'· ·h·"~--~ U'1 07025148." · .. ·· ~ ~ - ~Vf'l;'.'°•;\~' )1'\ ~" ·•\o~:.S ' ' ··..J)~ > . \t.:); 'J,.... ,"'" :)I · · · · · · · · · ·- 0 • • \. . .... . . . ......... .. The varlaol otUIJJtnow11 chnical$1yuflCallU prevlOQSly reported · sea~~Dg ~; Ii · ... : . -. · · · ~ n......J).. 1 tlC~ ·. : ·. : . · · ·. · · .. ·.. ~ • Suite 250 0 , .I ·:-;;:.. ...See Atmcaed Original R.....r-""'. ..:i\': ;;;···~;_t0 . ~ · -· . .··.. .·.... . . ' , ... . . · ... . . - .. .- ' ·. ... .:,:.·~~) CAUTION, Revised Report, disregard previous repolt. .. , .~~;{:':~~?;. ' • ' • .. . • . . ,v . _. ~ UQ' _ · '· · ·\. • • · ·: " " ' ·•,· · · · ·· · · · · · ,. JM.~ SCNlA DNA S nenci Tes . Adanta GA 30338 . .. .... . cq . , Ilg . I ...... «·: . . «.: >: ...· :~:('.,:~ '\:·'!~~ .. ,. ' ) fz ' - · • 1 ) · . tfff; ••R:Jn11sm::ltEfOR'T , .. ,... ,.. .. . .... ······.··· ,, ·f«i ! \'~l)-J . .... 1 :.., . ) · ~ • .•.. , ,. .. . . · . ·. ' .'•. .1 · i · · · . -. .y . ...... . • ' · •· · ! : . ):.; . . . ,;,,_. ,. . ·~ . '• . JolmShoffner MD . . . . .. . .. .·. . . -:. .. M· ·., ·.-.: . ', ... .. · -~ ·\, ., ·· --- ·- Yi)tJ"#'Altilai:Jl•--tclc& ·.,._. · ·,.:-.. > .-..:: ·,.: ·: -. ... -~ ~,,. .: ..... · ,;·.$~-· . . . . . . , • ..·. ·'> ... I /2 Page 40 of 145 ~;'L·,,,.-,f::' ;.. , :· -~~· lol....a -t-.nt'i-~ -~~~'*:~~~~-~~~~~~.~~ Pqelof6 · .}-,~.~~':,· \ ., • . ,SSY.,'\""''1<'\ =i ; ·" ·· t'Mit.' · · ' ·~\ i.O.m l!od · . . ·· · · ·. · ·~«,,\\:v;u, ~ :.. ...... " ~ ... _.. _...,IN'{'t{~*~, !~ ;i. ·. · ... . ... ... :.:..;... : m~N!~~·~ N . ·~ . ~ ... .-..\ · A ~ Entry Number 1-1 ---- ····----·- ..·--·- - -· ---· --~ - - · - · -·· ~~ ·J:·w ·i£mt. · .. :)'r:.~; Date Filed 03/28/16 t lr•.·,' ~ ... ~ E]-.J ..,, ,\\~ ..• ~ \·~.,,.;;.1._: ':.1(,.:, ..·:.:-· ,\,,~· '· "·/;_. ,l:<-~ ,,:t Y:-?,.J.·:·".r·~p:~~~; .::. 1 .. ,,., , •••• .•~- ..~ ... .!- . ~'·:{r~ :~:i \~~:~~~·fi~\:.:1' McJLtt Signilicaat result: AnaJysb of .U1J~\WUVidJial s i>(l,{)")A,,; ~~1~.-.,; idenlified a DNA seqw:ooe varianl dial~~ '"· --~~hed it(ilie' llt~ ·~~~. 'Ci~-. ..:....... WJW "'· SMFJ. or SMEB , .......,15eve ~':..-i!i·· ·,\ .. ' " ....~ •• ' . · ,. -G·" '· to be asso"'.w.cu ·--~ocm .. ,/_.. ,_.. :... SCN.l n." lDJtarwns.Mo · .(,-..-.~-·::-:r:~r~ry;<111iitation):'.·:r ..-..-~.:.f.;a-,:...,~r'hu~~ ·-&.:it;'<' ,,; :;· ···= ww, .~....; :,,,, ... ·.' te.1Ult i.9 comistent wilh a diagnosis of/t.jr lff~n of thtJest results. Benign~(~~~).'~ y 1fidenl1fied, art.COllsidercd normai ~are not reporced fn 'tbe'f~~t-.1 \ ; ~ ~ulrs section-Of~~ repon•. bu.I are av~bfe . upon ~\~~;·~ i · ~ ~ult ~ Gloswy fo/ a decailed e~ri. _of DNA Varfa@t.:.f~~J( 'i · in.d.icalcd U\ lhe Tcchnica Resultuecuon of this report. )..-:)'_.i·i,~\"'" . ,\. Parrntal testing and otler toUow up .recormnendatlem: Tdt~1Ji,·~:~. ti.oJogkal parcms (for no additional charge) ma>· hdp identlfy'''!Ji.b!i~~\' lhis ~ v~t ~s f!_e !1"VO or inheriled. BecauaeSCN/A ~ii!$(i9)1.i \' f can be ioheried, lh1s whviduaf's family. ~mbers may be 111 ~~H~J\ ~- ~· . . " .. r:~o ~ . g "I ..~ l '""'""', EXHIBIT z, - -- r a :l, ff· ~. ~ ll ii!! ~ 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 ._,_.. \ ... ;'.~lt~~ A ,,__,..;~ - . " •. ~.. ~-;.~...'· " ·: · . ·. J~~ • . ··.? . .:.:.: ,:. . ~1 ;~ ~ ~ :,.~~~.... .. • ~~,::.::/-.~:.::.;·!:'-«\;,'.··. ·> . ~:·) i:~_-_:_, _.: ~-~-·-: ·.. ::; ,._ .· oia&nOstic (Symptomatic}. ~i!~ • .. . .. ·- ..· · . . . · . -. . ·,. . ~ . . . x . ~--~ . :.:~> ~I ~ -~. ~.:: . ~..~ ;" ... .• • • .. . ., . .. . , .. , , .... , ,., ..... . ~ <_.. -. ... -., .. : . . , -..- ., . • _-., iohilSboffner MD · · · '· · . . . . . ,_· ·::'rl. .. ·.. ·:. '_: ··.· ·::·.·.·.' · . . '.' ~~ Dunw~~y Part· · . , .. ~ '. · .. .· : ' > .. . , .. " ., . • , Suite 259' • . . .. .. .. . . . . . -.. . . . " . . !fLW. ..... .. Oit" . . . -. . . •fri.:..... 'Ji~,;,,,·,· ~ - Atlao!a. GA ~3~ . .. ; . ,., . .. , . , ; , ,., .. : , .. _. ., ; , .. , - - OS~~gqcf!(l"'!>':,·'.\~.:;~:~~/~.').1_~." J>Ol'SCSsing or imeriting lhese mutat.ioo~ Cooeful recoodliation of this motecwat data -.·ith this individual's <:lillica\ aOO family history is bighl{ ~· ~C?Olme~ . . Adtena r~m.me&ls genetic c.~ toe- lbls -·t >ndividual and his or Iler family '!le•rs..and coosideration of pare~l ~Yi "• testlng.. Pteas~ c~t Atilena Client Sety1Ct.S at ~ -800-394-44!13 or ~as1t t<~ WWW .athenadia~!~·CCJ!> fo.r fur~r ~tton on paren~ ~ng. ~~?,,. 1'he a~ed reqws1uon ~ will. facil!18r.e ti~ submlS.Sloo and proccssang ofparenul !l)CCuntns for dU! tesUng .scrvtee. :l Badground lnformatioa: .SCNJA ent:()(fes Cw lb: neurvoal vQkage-gcued sodium chaoncl alpha 1 Sllbunil procetn. Mutatiom ia. lhe SCNlA gene ~ve been mociatt.d .with several overlaJlping epifep&y ...f;: S\·ndromes raogmg from severe lo mdd phenot;ypes {SMEI; SMEB, and i\ G~FS+ >.1-10 The sev~ pherotypcs ml.Ide SMEI. S«:vete Myocl~ l.::: ¥.ep6Y of Infancy« Dtavet syndrome, and SMEB {SM.El borderlmt) W!lhsome.butnot an. of the ~Ical featu.M of SMEr. GEFS+, Generalized Epilq:lgy _with _Febrile Se~res P11lS,_ e~pas~ a range of phenotypes from fd'lrUe SCJ.ZUres to mild g:netal1Ztd ~1lep.~s. and less ~"!~ y.-, commonly, inclu~ sevete epileptic ~halopalhks. SMEt has a ·;\~~:~~ poor prognosis, including ~<11~ delay and re[r~y sei~. .... \ ' \ .'li: ) ' furdtennore, a C90f"H'med d~ of SM'EI may significantly guidt ~'.\"' 1n'atment ckd.sinM. u • . . :'1~~.' SCNlA ~fall broacly inro lWO group6.HG '!'runcauonnwr.attons chat severely disrupt the ~ are usuall~ a~ ~Im ~vere phWOC)'pe$ such as SMEJ. Mr~ruae mutations aR! ~ociatt.J. wJtb a range of phenotypes from mild to severe. Most mutanom lhat cause •.;-: ,··~ :";; ~.?1 ~·.J I ;1;l ~ ..l.. ~ti~ ...--...---· f)· ge It \\~~! :..:;.il,/'f.:\~>~:- :..·-i:·,\~~!:.~) :::s • -.,:t'\~"·..r\ .~; ~ ·S.rV!l"' ~~nit~ -:.;..· ·~~~1\'i;·;· N 2of 6 · .: : ;:·7~~ ' · :-,: _:-~ ··:.:· :. . 'lut~~];rt{~~i~ ~ ~~ _... Pa = ~CNtA DN~ Seque«mg Tes~.... . . . . :\'. ·}}h .. ·; . ;· . _- .: :. ,-_ '· . .,.; :, ":, :_ :,· ;;,\ ;_ ,-. ,-'_._:;·;, '. ·. . . . . . · . ,_,_ .. ww;·~ma~..eom -~·--.~~,.,~V!J',~~;i'~~~~ Jei¥(~~ ,'l.A~~"*"~. (41»C · · · ... ·· ··· : :.,:_. ~H~• . .. ... ···· ,fir, i200S " M.., · · · · : '. · ":-, · ______ -- ___ ______________ ---·- ·-·---- • =· •• . ..... ·..... ~ ... ··- ·••: · .. . . ·.-.,. ~ •. ~ : .-... . ... ~ · · t. t"'f-"'lllito \.-;·( ~ff · .... ·· ~ Page 41 of 145 • •' H • ••• ·-----··-·""'. • • • • aff<#cl\V SMEJ are de novo, or sporadic (arise in the ~~~lfi_a~~;~~y; Ej Utan beiDg ioherited)l.S.lO an inberitm::e ~{~ ~{ ~ ~~~~ ~~':~: ·: ,' 1 testing ofparea~. Familial~ ar7 ~.J1~9Cia~~~W'(DUJ9i,>;':~? j p~~ypes b~l can bes~ m SMEI.•It 1s ~~~,lha~ ~~~h~~ ::~ v mutation ~mers ard v:mable e~re8Sl.On ~t,,..,,tr~,~~~~:~v~: Jl¥.~Ii/:i O~f'~ m mtse syndromes m ~e i'·~}.ff~i. l J1mS. ~~-st$:/~~{~~'.? mocbfymg fac.lon hl1~1eix:e the exp~1~·rf·~~;.and, ~t-~~·'.-.'M~J!c/~ \he mol~lar analy~IS ~t be carcf~~~:t~~~ted wi~\~.:~!Jj~/J. prcmnaoonaod family hiSU>ry. n~.l~v~:?~·t ----~-I ::-~·:::i·r~~:~r:.?·::r\ Limita1• a.naJ,'S~ Mu.tatiuns ~\~· by dlis.·:~~~~{~~y~.:;;;W_:: incld lat'ge~lons a1ld l~rge inse.~~~~~i1hennore, dll$:;.~\~~<.~;),~ not de(ect pcitential palhogeruc mu'8.tt~· the promo..~. :~/:-. ~-~!!i '°' 1'··· l -'li ;· >:;•J ,·~· · . -:~~: '-·" ~~ ..:· ··~ •.,,,.,. ~ 2005 ,:_:'·V DNA' . . ;;,.;.<,\:( ........ . i/~~. . FF~· . ~ " · .' . . .. :1__ •.t,\ ~ · Page 42 of 145 - ·---·--- -----.. --·--- - / ~~~ •• '.... .»~ .. .... ,.,.;.,;· Entry Number 1-1 .............. ... · • Date Filed 03/28/16 • .. ..,,,. ·· -~-t· f';llll • ' • • ' ·, ,/J~··•.akiohM.il'fr• ·lt~t..i..;o,; • ) t . .. . . . .... ...... •• . ... f ""·~·'""!' ' · . .,. ' " • ·. p .. .~ ,, _.,. • • ' ,, , '\'\.. .!1:·.-' ~;!:~~ '."·.~:: .';: ~:~i ..:~~~ / · . mi~ ?....... •:-.· ::.... .... .~ .' . . ... . '.". ': ·t :·· _:-. -) . One Dunwoody Puk ·" · · · ~ · · · .... · Di°"iio'O~dic ...................:,.). ~ ~ \~1™t""1uall\ol . :. . . •' . . .. • . . \'• • · • • Suite 2SO. . . . .. . . . .. cettifi~ and reported by ABMG cthrical Molecular Genedcists. N~ aod amino adds are numbend following chc iruernatiomlly acceplr"'4 N~nciature Qet forth '- the Ad Iroc Committee oo MuWioo ~ vr ' . . . a-A n-..ANi)menc.lanirc. The initiator codon. M.eduorune, JS des~~u;u as ~· munbtr I in lbe cDNA. The rA~ of lhe "ATG" initWOf codon JS designated as ouc~ +1. J= 111ulalilfl .smoin! ii ptl/bmttt! plV1lltllll rq a 1'C1t llmlft agrl1Dlltffl :1'1rl! kt- Mobr:rMJr 2. Wallatt, RH et al (2001) Am. J Hum Genet 68: 8594165 3. Claes, L ct al (2001) Am J Hum Genet 68: 1327-1332 4. Wallace, RH et al {2003) Neurolog,y 61: 765-769 . ! }:~ . . ~ .. .. !, 1t< - ~},f{· : ~. .'~.(;~~~r.~~;~ ~lil( 6l1~'Po~ : •• • •• - .... ... .. ,• .;:.';l:,:\I · ~ . .~ ,., \)X{!~·}~t:~:~!.~)~~:\~ ~. .. - .Q:"(n~.~Y.. '.". •;;! '"i'"'· Q1 · · . ,, ..,......,: ;.,/:·~iYt·;;~;~~.r\ so ·' NO, , ~;:~!-. '"~·~'ii"''~""·!." ~'.l!..'- ~ ~ .. .. ... , ... • ' ·. ;:· . .;~: .•: ,· .; ..../ ........ . . .. .. • · · , . . ... • • ., .: . . .. .. ... . . . . . .. " • -r. '"INntJ..r-.f~,':'-.\i~· A~,.,.~\.!\~ U'I ~-' " ® as 1 'v.,,,,.·~? ~I, T~)Np•'t...' ~ ~,.,.,, .......~.,:<: ..... .,...,~'{•'" : , ; \•co :·,.'<~•.1 <\~' ~ ·.\:1:..• i.iiit ·; '·"'r1\':'·l"·'"·""'i""·· 1tVY·; ¥i~·1'!t. ; ~~ill~~l ~ -'"~::, ~$~".·,~ ~ ';}:1._.\ !• .....·'"'(" 8. Kllllill, Ka al (2004) Neurology 63:. 329--3'.J~~~i~ :1~*·x~'Z~t~:;. ~{,\,~·~::: Hl 9. c.eutemam, B.PGM el~ (2004) Pe :: · · : ·. ·" · ·: · · ··. · ·· A(Adenine); G{CA«lnut1); C(Cyto1urt); T(f1ry1111ne}. .'.\:) l~·~· ge . · i!J ...... ~-'"'·· ·· .... .... _ t1·~ ·~-- ,\·:1' ~ ...... a1 ·. ' . . .. . . . . . . . · . ". . SMEI (ievtu myockJruc epiltpsy t!f in/~J)i S!JEB (bortkrWi1 SMEI); GEFS+ (gtnmiliztd ~lkl'!Y tt11h fttm~ smJJrts pfusJ; DNA (tkgxyfiJJOMcle~ acid]: PCR .(p()Jymtra?e c_bain reoction): .'\i: • Atlan.ta,GA.30338 , .. .. 11. . ..... · ;•, ...... ,,, ., :·.: · ,,, . ' ','. '. . "."', . • . l . . . . • . .. •. .· •,, ~ .··-" ,. ... .. •.. - ..., . . ''&\'·~liil Abbm"ia1ions rr!~d: SCNJtt (~t l'Ol~ge--~d SO . . . . . . . . . . ~~ . . . fl .. ...,,.,,.~....~.>,~,,··~.';,·~':'. Cll /1 . 1..i.. Shoffn MD v'·•;:. ...... ,,(.. ..., ..... -· }., · ·. · · · · · · · ·. · · uu11 er. . .. , . . . , .. , , ~''l'"'h\i;i-,< .. .. • .. ~ I .t>K;. ini~"'~"~~a~~~~~· n .... ·· ... · :;....L;...:..:.·~ .....~ · ·:. ~ · • ...:....... . • . .. • • • • • • • • • ,. ' 'tt:\.·.~:~:;-~..·\ \\;.;::}:~\ b':.~'.fl)~~~:;_.· ... 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 43 of 145 -. _,, ..... ···----·-- ·- ---- -------- .... _..., ....... ;~~li I~~.' ·,~:1:1 ··' :,•.\ ( }%'.! A ... ,. "'· ;,. Pli&ii ., •, 'ot -~ -~; 'f.\·.~t ..... .... , ('t#i;.·.1, : ,.., .•(c5}1~ . . . . . . . . . .. . ' : '•;- ',~ ' ., ._ " ' . . . .. . • S • ' . • • 12005 .., l ' .. • • • ~ "-TA . . ... ·- 1·. "" '"·/·:.;.' .1.·:.~ • ... . .• , • . . ·.-... ,. •.. '...... D re. ·;. ·i~·t Diagnosuc (Symptomattc) . ~ '.\ ·\~;,i ~~~~ ~CNIA DNA_Seqneocmg T~. . , . , . . . • .. I • .. ' . . . . • .. • !., .... ·. • .• • · . .· ·: : : • ~-~~ . · .. . ' . . M . •,. ·.: . : : . #,~'. ·llfi~C "" · i: .: ">.:..".. ~ -. · ..? . • ••• . .. . . . . . ~. . .. . ~· i : • , • ...,, .;., 't"'" ) r~ . ~1;i -;~:,. '· •• , ........ . ... . . " ' ~~nY • !\''...:. ·'f]i~ ' II ;; ,,r·•"• '~ ' \·;_, •. . . . . . . . . . . . . ...... , . . • · ·. . h , : • .. ' ........ : .. ·Suite ·. 250. .. ... "":'. • y . · . . ......,, . . .. ....... :. • • I • • .. • .. . 1:.,:·: = ..... •• - -~~ ·'·'"'"""·1~"i~";:"·"" '; t.;',-\;·{~{'...-~:-}f;:.,_.£...~.~-~ ..:~ ~ ·; . ' t nV-:.,";.•) •.:.·.•\» ..~~->\••<:.£,\>'' ., ""' ·"1~...>.)•'".·,··*..1 ~: l•':,. "" . --~~i~::;}?J~~~~~:t ~ · .. . . : ,', .. ~.~~~...• ,.,,\~.~~~~·:;::~:.~~:r-t\X):''I'. .. . • .... . " fi'"il~.'14, . . .... =u.........:,;jeiiilii!l~1:,''·r,!>:"~}· ~,. .........~. ... . " . ....,..t,•... ·\~.., ... ~ t ·:~ . . . , ' · · .. . · .. '· · . .. .. .• .. 0 ,' · · ·,k!/·~~~·i~.,i-.=;J'.{~'">.'~i' \: g;,:i J ••. ~;.i~.}·i,~:~~'.{'~~~frA~<;;\:~( ~ • : ..... ,;,r..-~,\·:':"~-.:~,.·~i.~"=' 1 ;).: ~tlanta., OA ~~~, ..·; ........ , . . ..... , .. : ., : ... , .. .. . . . ' ' .' ' : : -~'f~*.' ... ·. . ... : .: ~ :. ·... · . . ~;:~~~~~~~t~~1~ ! by die dominant gene, Typical CMmJ>les im:lude frmne shill .IDllf.atiom., or "i.nironic pol~.· mutJl.tlon:., Cl' Thc~~~~~f,)ii~~:~~th::- ~ ~~ ;~pl.e~t:~~-:~\!'-:'.· ! ~ have no effect. but may sometimes alrer processin~. ~ince these t~t of~ "ar.~~3 ~~.:. s· ~·, ··~-~~ ~~r·) 1 observed u1 disease...associated mua.auons f8j)ly~•-~~~-~~~: ::~ v ~ ~. ~;. •t .,:·1· .. naUU'e of dus variation probibics definitl~.~iP;.)l. , p. ;-:1y-;,_~·:.'~~~,;;•{;:.;:; ~ • • #' • • • and·m:. • . ... .. .. , iVo:i'!'J.,.~':f,!,.:c'.'! ••• ( . · · · · ~\.-';i',,.~-.-,~:?: ;;-.:(1••·:: 5. ~cluiv~ !CSt resul~ m ~ ~~);tt~.·~x:~erp~~..,, ,,,4~w:·11-.: negauve <>': ~ltrve due to a redmic:al p~~;i#.~1" ~~l ~~ ~.~l~·:~ ~-· rule out neither the presence nor ab$eUQC..~t~,,rtahtJes 111 ~ -~$;$\;':: :.:: Ioc~h1'ive results .are typlca11y re~~-~·~Y.- ·anat~ .. ~·:.. ~:-~.~~aW;~~:~,:~ spec.rmi:m. There will be no c~:-tbr.·:·1f.i.t' repeat arialysfy,..,;, A~~·:: i}·\· :--t· ,.., •Dcr»col·T sp,r:-cnJOC>.I" •l'i.;'.t.La00 A.t.-~·"1,,!,;J~~ .. ~,..,~-<,.;·'· uwt.<:aw z:. Ul",ll;d'I ..i-'!'J"''":',':~t .. i ~....- .;~t/ ... ·;·/:.-,.,; \~ .....~~ :.<:;\·,~~· ~~ 3. Amie<> fteid daallgu of unknown aignificance are DNA seqience varla11t! that are detected reproducibly. but have not been correlated with clinical prescm!ation and/or paillology in the cur~nt Jiterawre, oor do Ibey ~suit i1l a readily predictable e&ct upon protein strUCture and function. The amin.o acid change is predicttd based on simple .f.'\..l;;)l"J;J'I, interpretatl.00$ of the genelic code.. However. these sanle lypes of. alterations may .some6mes attet normal gene spli:iog 3Jld processing. and •//~·'\. .y1.~l )fi>\'::~j.~.;;"~\+.::\ t? 6. b1dtterminate test r~lts, White~~ologic.illy ~~fw~ 1~~ \ }\ 1t clin.kally meao.in@ful due «> die la<:k of. published curt!~ l'sliJdiei: i \' r+ correlating Wl results in tltis speciflc.caregory witb clinical· ~1\bitl~· f~ ·1 ~ and/or palhology. ~ to the laci ~ publisJ_lcd findinPi~Jt:Sti;-: ~ · ;;· 4. Vtrlantsofontnownsignifieanceare DNA sequence valiants chaL :~~~ •. • , thereby cause more significant and W!pxediciable effecrs, Since lbese types -0f sequence variants are .similar to lhose obsetved in diseas.eassociated muwions and benign polymorphisw. the nature of this variation pr-Ohlbits defmitive interp.retarion. .l • ,_ " ' ; , ; \o "l'I "· . ". .. . .. . ... -~ , .. · · .. . . . . . . . . . . . . . , . . ,. ; , , , : . : · . '\ · !,~:I .. Joon Shoffner. MD . . . • . . . . • • . . . . . . • . '!;.,. .. .- .. : . .. . ·.• . -·. •. ........ ,. .... ·0' Du -·--..t. n...-L. . • ' . ' : ne 0""""1\l. ..--a•a. • • ff~ '> • • • • splicing muwions. nonsense 01.ltacforu, and. deletions or duplications f>f (·...._,,.~,", ¢11Ure exoos. Currat lite~ indicates mat .ON.A sequence varlan!s of (,' lhls type are assocla~ wilh dtsease.. However, due to lhe ~ of :Wi established ~et'IQ~ a>m!lations fur ~ ~pecU~ DN_A ~.~,.;~ sequence va.naM, th~ result s.b.ould be carefully reeoociled wil:b thlS individwd's dinical and family hlstoey. .,~. . . . 1$ ' • Gil. ~~~4~-~---j~._..,fd :~~~f.t•~•·ro:~¥i~~*.i9ta~ . .. . . .. . . . ~., .. . . . .. . . -~ ~~~1!J.rw • "· .... .: G'~~·,_ ...... , ' . . ;:.. , \ '\ .. resuhs ~ be tnteqireled ~ eilber ootmal. oc ·~*°~~ i '/ ~ !od~e results are gmerally cau9!d by test results mac ratniol&id~-..~. o£ the established interpretive criteria. lndettrmimue ttsl resuJ'tS. !~'; ~~H: resolved b}' ana1)-sig of a rep~ specimen, · .:-'1' : ~ . .. ;f \ .~,:- ..~, \ arc detecced reprodUcib1y, but have not be.en com:laled with cliniul pusenlal.ion 81ldloc pathotogy In the c:urreru. litefacute, nor do tbey result in a readily p~ictable offctt upon proccifl strucnn~ and fuI!Clion. Typical ex.am.p.les itclude single 1U1Cleotide changes in ~ cod.iDg or noncQding. regions of lhe g.enc that are somcd.me& labeled as • sileDt m·; '. 7. Be.Aign po.lym01"pbi.mu are O.NA senr•n<'P ":l-- varl.'Ul.fs that ·~r~~~iht ' v · ,1 ~ ::-. l.J ;? "'9 "l /!•:<\.: i I N-..?)~~~~~\: ....... \· _.. . an I : ·:•x+,-i.~·r.~:~~~~,.~~-~~.. · · · ·-- "' • • • • • • • .... • • .. f • . (., t , ,, ) ' • 1 ) • • ' • • t t ., • •:·_ :~; >~:~);~. ?IS. 3:16-cv-00972-MBS \.;\·), '':i':.~j; ,·}ift~ .. '~:·~i·~ .. ~-,,,, '~ ~~~t{Q) -~ : . 200S.. ~:::·.~?~" ~,.:_t(~:~ :~i ;~~~ ·.~~~...: ...~:· ,. .,'!·.~ ? :.: ~'\\~.l .. ·.~: ~ ,~ ~~-~;;1 ·:Y1·-:1 ~ ~f !~• ~' :·~i?N tt\j;~ :1<~ • ' : t ·. M · ·., · : . ·· : . . Diagoo~ic: {Symptomatic)_ ..... , . . . . . ~~ '·· ., _SCNlA DNA Sequencing Test. . . . . . . . . . . . . .. . ' ·. . . ., ·~ .·. .. .. - 4::.. . ~-:. ' 7 -~~* ·~ • : . . •• : • ·a ·, . ._ ,· : . · -~ • • • . . >" • •' • '• > • ' •• ~- • • • • • • I • •. .•· . ; ' I . • ., ; -. · ; ., •: . • " • • ' : .'. • . • . ., '> ._- • ... • .Suite.250.· ·. ·. . .·.: . .. . . ·... .. .. 5i i t i ,,,. Lab0tu1ory O\~nl.PI provided by Joseph J. J:.l~~!-~-,;>., F.A.•~.N.• ("I.JA !iomse bolder. Ariem D~rtl:'$ (C(JA I n.DOOfHTl6) ' '.t • • •• •• - . . ~.• 'J ·1 ·1·" ·~··.:···,. ••~,;·~"..:-.·, Cl_c"/,.f ..·,<,,,_•./ -<'• l ·,•1); 1 , .!J \l.,~-1~t-l~.(/ ;{ ~ i ~i'", \f.'.·t .-~· /~~1:!l;~J~~ii' . "c.}J.f_~{\J:tr l~i;f[~1<;>' '<~t~1' / 1 ~;· ~.tr , •"'i ~t• I .;• J...,."' ''"'O •·,; .. ' ") I\ ho .. ~ (''~fh~~ift ·~\.!l;:\'' .,... 1 ,• • .. ~~~. I ' .... ;.·,.~.~:.t},~.tJ".}'..\ . . ~..\ ·.\. .._,~.....:·{·f 'It:<"~";:! ... ;. .• :~~~f: ·~~~~:~r'~l.f&1~~¥·~~H::,:..~.;;·.:.r .~,·, · · -; ;' ~:.~i~~f{ilt~t1~\~t~ ··)!\~:~::: i,:;,'.i~l~{t'! Cl :). ~, ~-.t" ,~t~~3;~r" t z s.,s (}\~p :. . t.'l '~ ~\ ~. '~ 0 ~ ! ,' ' , • ;, .. • I (,~lj;'.~ ,:,'.;·. \ \'·~ . t .i:-.:n 'l , i,"r '~ • ·.~ .. .( 1,\:\ ~.-~; ~. -~ l ,( ., "(l• \ ~ \ ' !/.:~.! :~~·~~=~;~ ·;~. ;~;i/~ . ,·· ~ ........u .t. .-, \' \. ,. \ .·:··'Jl'1..iX:-.... )[l . -~ "!.,: • ,! · ··~··· ~ . . ' . . ' . • ·..... . ·t;lE~~:-~',, '1 a ~·\,(~iJWi1k: . tYr+ : \">~ 'V J i ) \::I i ' l ''t;·,1' :~ ·,'. • ' ·v·. I, l .~ •.~1l• ... lI~.. . ~ lf:~l~~r ~lif~~~I~ ~ j' :..:~!l..,.\!JJa:1-•.•i}!-:r.;' Narasimhan N~ao, PhD, ABMG Drector, Ge.netk:s · ... - - ---~----------------------· 0\ :i£:~Dt~:t(~~;MfJ~'.r.HY;7~~~~S' ; t''(~h·· ...'•i ~· • t • m • \. • :1 '•, CS) .t 0'.'.;;:;\~~~\r·. ..... ·~•. j \V"·~ ..'\' U1 ·'-'i i';·. VIVLJ ··• . ' • . • • • . b .....,;~d:"><'tl'.:Lb:i<_\"r-. ..,tt)':\'...., r,uw,~ ·~ --,1'lJ.\' ' •_ ~_:._ • .L_~..~~ · ~:~"'_ .._.......:..._·........._: _ :,. ----~ Adlena Diagnostics Foor Biorecll P.art Jn Plawcioo St WOlttSIC!' MA 01005 < • . ,, .·,,.·\"...·\ : resting pcrfonnechi: •, . • ... ; ;.·.. , ,., .. , ., , .· .... · , . ; .... ., . , , . A=~: ?9~~ , . . : ·, ,u: ~ . . ...... ' . . . ......:.......~ ~:_:__._~...:_........:....._ ... !___:__~·~·--2. .. " ·. 1 .// f,J, • . . .. . . .. . . . . . . . . . laboratory r~ and ~bmiued clinical infonnation l'C'Viev.ied by, I I • •.• 1 • ..... .\1 l· ... ,»'• ·'q\\)"-' , N m1 _ . dti'L'lopttl Olllf In ~tt darri~ d«1"""'*11 bt AlluM DitJit1W11'c.t, 0 '\ • .• ...,."""'"".,.5~~~~~~.~J~~:~~:-~;yii_{Al\~. ..~. be. If llM1'1Jt l><:m dmn:d"' ~II; llr~ u..s. FllOlla Drq "'1nitlfmutlon. ~ l"1M b atrrRJ/Jr«I Ill~ slll'la demrl;(, Col' oJip(f;l'lld/ ii 11111 ~_,. 'T1lis fUI' u 11Uldf11r c#IJWaiJ pttrpOm Mil flta.41 IWll lw reptfed .., im-arlfr,al(tinal t r Jl>r 1-.:Turtrl.r. ..uai.o DJdpamrs ~ litttl:tttf lllrtltl' llir O llllotll ~.,,, ~ ~ '1/1~ !(lJ.tJ ro wlbmrltJtltOfJll~~cJUrkdl ~. N'-1 Dia~ .Ms ~rfo1141!4 4lS4:} "'1JdatiDlt im&r aJfll ftin ktftlupN. ia itlb«alOfY ~Is otl4 Dp11Ulil1g ~MN-n 111 mrsJJ!ratJ«r M'dl apms iN Ifie Jkltl «rt/ iJt om wdanrt 1t.illt d. JtNllbttr tf ,,,, twftrMI Qwnlllltrtt"" aiJlkd ~..., ~ ~Q.\l. ·~ = ·o~~p..L'. ' / · ; : . '-.:·.- ·... . .... i~':,·:;~~?~~~t~~Y~Rl; ~ : •** REVISED REPORT **•ver 1.<> ,.,·; ".• IJlo.~.',.'.:1);\•,. MN!.c ·~·· • ·..• •• . OQnsk\ered nocmal variatioos ml arc oot re,orted in the Tuchnical Results section of this report, but are available upon requcsL " ?'.{\i·~(fr::~< , .~\ N • are ..... _ . . . .. .. ,;,"if,:~~ ~.,~!l'.~ ...At~1?.iii;.b.4. c\;\, :....:~ \./ ...... ,'; t~m;e 3ar"it,i: / g·\,\.~~·-·1 fit . . . .. .. •. shown to be present in unafiected ~ subjeets. and considered •benign" (n.on·patt»&eruc) sequence variants. If identified, dlCSe ate This ' P~ge 5 of 6 .. "'~~ .....~~~ . .~ --;"!'!."""'~"!'"<", ... ~t- John Shoffner. MD Hui Zhu. PhD. ABt\'lG Director. Genaks .~j/i; ...... !'T"'· · ' : ···· · :"' • • \.~::' l·~· ~ '~.! ·-·~ ·· ~ ·. •..,\. Sal Dev Batish, PbD. FACMG Ch.i~f Direccor, Gelletics ~m: 11 -~~-f;t..iw..~~ · · . .• ~t~:t ~~U!! Page 44 of 145 .. -~. if ~; ~..-·: ··, '.'" ;"~,<~. .··. ~llf' Entry Number 1-1 --~~ .1'. I. ,,.. ~ma~b*.Cbti • .. -~~ .~I , • • . • · ·b.·····~~ ·. · '.i$ll ' ": .. • • ~· " •..~ : . r'\~ Date Filed 03/28/16 i ,, ' ;· ... ... ... VJ ~ ~ • ~ ··r .' : , : '•' ·>' " ' ... . "; ; . .. ' >':i::-:.51')~t·;~( ~ .;.:."'\rf.~J '· "- ~ ••~,·~· S\)! ~ ... ' '• ~~-{~~15';1:}. 3:16-cv-00972-MBS Date Filed 03/28/16 .. ·---··-----········--· ______ ~~~~JI. ,\rfit ·f.~j~ r···· t~t A{J irWf ·· ..tt~ : .· .~ · ;A~~- wr" ' o ' , •,' '• ' 'I . ' '· · O ,.... .,.. ,"... , .• .: \· .. '. . . ~ l2M': ,,. M. · : , : . : - . : •• · : :·. -. ; .· :·.· 1: · '.~ . r~ ~ -· 0 ·,.·: f~; Klf: .;};f ~CNlA DNA Seqgenccog Tes.~. . .. . . . :_\/ »N1,.;.,t4: ...- 'GI~,: ·. .' : :.: :' : ·." • '.' .. "".. ~c(Sympto~) ..... . ·. ·..:..·.. "..·~ .:.· \·. ·, !; _',,\l n..,__.....,HIVR for b.-~ T~ UJUPl!i ~ r.n:11111t ~ ', ' ~I~ , _ _; " .,' t· :, ' ' · ,; : , · ' ·~' 1 O .. , o ' -~ . . doe Dmlwood I ' • .. y . Adanta, 0 ' Pat~ · . S~~:..\.' ":·'~· . : .· .. ' • .. • • - • " \. -... ~ . _.. •• • •• • : • • • • . . .. . . .. ·. • .;-,.. ~'<'\'-'~·•;,·:·( =i . ·.. ~., ,_~ ·:s :·IJ\•t')·\ .s\ "I 4 :. ..~- -~·rvt ·· !ftl~ ~-,; ·-~,r · "-...• '- ' .... . . . ' : " . . . . .. . :· . I , 25'148." 0702 .·.' ) ' ' tot; : .' . .·:::-.· .. . ... ,•'...; . ,. ··, ..... ·· · :.' ·: · .;..,.·.. ..·.... .. ' > ., .::·_·: .. ,.,..... , ,;:..·.: .,.,,.·..·, Rt!;~ . .· ' JobnShoffner.Mq .. . . . . . . . . . . > ':.·~? .~ ·(~J~ ... c... Pa°"' ·tt- 6 of 6 '·· 1 • I l: :,:;1".,.J . ·., ·,.rii : ··· ~i'- .., . , "· tt:~r ·'· · "~--·~· • :~: - -~~ -~--~~---: "~~~:~ . . . . . ·. ~~ DNA . . . } ' : '! ~r.~;-~Q1i·"'·~~ -~~~··· ~°'1i't4'- : ·. : : ____. -· --- -- - -------- ~~-~~ts$ii' ... "•,; '\I , ~- :,~' ,. Page 45 of 145 ,, "' ·- · · · · a1 -~~~~~ ' Entry Number 1-1 : ••.• ' : ••• ·· N "'<•\ •. I cg • " ./''.ii;-.,\:"'{:: ~ 'I ; .. =· ~J~...:~(i~: Lt1 "'~........_~ .u.c'.lw*t,~.._:t1~t.!f'm:"tf , 11 v~ ;.:; •,.=:;r·:;. ·.~ r, 1',l/!•y~:~._;: .... ~~~-.';· -";·'j· •. {\'J . 1·:~ ···-- .. OOOQ@Q(i·ii~N$~~2.~~;!;~~~~:;{ ~ . . .. .:.. .. . ~3 . , . .·:; .:. . ... . . , " ... ., ... , , . . ·.~ .: . . . ~~~::~1¥. . . ....-. ·, :.... .... :. I : • ' • " • ... , •• .; ~1: ~1';~~:~:%~~N!:~~~%~:~'. \ .. ~\i' .· . •V•\j Ytli . , , )( ·····~" ·· .}!.~K> ~ .~·:.•,i,·. .t. . ,. ;:,. ;t···~;'(." · ; ..:~f~~~"" Ln ·ir~·'..: 4 \;~- "°t: \{'~:·~: (;;IJ 'l'eat Cock 536 ~i,?",\ty./·,\""··.:. ~ i\.~ .i~~, :~i~t: .. ,,,1 ~.1 .... ~.... .~·.r,.. ~, . .·~>~~"~~·: ~ :• In order to provide~ more comp.rebensi'fe int.erp~lation of Ibis pa&jeru' s SCNlA .re.Wts, Albena Diag.oostic,, is iequesWig ~~she\':~/~<<(:. (~~·~·i.'. :. .,!, biolog~ parents of this patiem. Ad~ will perform a IJ.rget analy5U on ~ sampfes foe variant(s) _identified in gene ~~~~~~}Ml ')!~-~ ''.'.\~~.~f~t~~'.·::: -,~ \!~~ we the findings to help iooerpret tbe paUent's SCNlA result{s} al no~ tharp. Please use thl$ form as Cbe rtqOIJiitlQli.©f'~ \J. \.',~:,_;,,;;~;\l);;~: )t '\ l'-~: ~ti~ (In~ patient. Erclose ooe completed fo~ wiib each parent's sattlJ>!e and send to Athena. If you have any qucs~~~~~~e ~}.~(!·~_::,~1;!-:}~~;li:·~?·. -.~ ... p ~ · 1'A:i~~'f·N<~~~l :~~J;,;•;:,,-.~i'f! ~tY fA• \~( J:il sbtppt113 kits, please cotiaet Athena cuseomer servu:e al 1-&10=394-4493.opoon 2.. {L~:J-/~Jf)~.:·tj .,~<· ·.'~ ?:~l ~~:1:r :~~~~i\1//:.~.· _i"!~·t;5 /{'? ;fV~~y ;:.::-.,. :>1;~·1·);,,.~~-~~~:·:.~ ;(~~~- s~ Requlrftnentsi 1 !~veOOa.r tube {8.~ml) 'W~ blood Stunp Corulldons: Rcfd~ Shipping C.oadlUons: Room iemperaw.rc. avoid freezing /f\-;;~ _;S.Y.:'(' '. "~,_:t~.:..,-.=.·!-~i,:;~~·>1';~~. BiolOgical Mother Name: Biological Father Name.: >. ~-i..>'/'i.~'-i·;· ·•. .:·>/N~i-'li~~~.ii li~ t~1/rn~ V . ; ':' .".;'".{ ,.. Date or Birth: l>.ue ol Birth; Address: Address· . . ·~~~\l .~· ~ !~~: \ ;'i lit f ~ {:" ·~ ~~·,. \. ~,' ·t~h ·til ·~" ' :~~,.~·./ . · .. \····, ,_. City,Siate,Zip. )}:X /./ ·,\ C1ly.St11e,Zip. • j m..--· P''""--· .uuu1::. f. :~, ..-uu •...,... S.Pecimcn Collea.ion Dale: • ~~~~~~~~~~~ -n 100.H:adon for Testing: 1'~11@ .>u..t1"riUtial! UPIN: . .•'~:» ...~ ·3~: "::!~~,~~/'1):li·.~~~,,~.;:\}., l ·, ;·fr}.~~~,i~~~'\if:'~iS ~s:;~1 ~~!~tQ)~;:~~f:3:q~1 ·"' '-'°''~· · .· ,1:~.•,,.,, ..1 ....,;, '\'' '• ' ;'•;..\ . \ ' ·~-x! • ' Specimen Colleaioo D~: Medical Practitioner SignalUl'e: . ::~ . . - . ., • ~ • • • •• " •. . i" peoon..., \ ·I • \ . ' 1' ._ .,,;f;.J ~- · -~~ • '-.·~ ~l~::'\.~·j·· 1 ·~. .}, 'i;i \~~?t~\._-;;· I' ,,l .' .l \ • ' l t \ ,,••,. ' 1" ;· ., ';'W!~·;;I '. ~ .· :" f' -.1_< \! 'i '~ .'; ,,,.-;,~"l'.' t i'l\ ' ..~-.i)';~t;;: :' ,.-.-;~, ~'· ;•;" ~· n (IS ~ "Cl ~ n ·.:..~:f:il\~,~~~ ~ ' ti:·,,· ;,"~)'.<•t\ :::J ·~ t,,V :-; l "~ . ...:.\ ., ~.' .~:·.·.~.:v i \~, ·'f l ~ ....~ ~ ~-~t·· i ~ ~-· , ··c":~. - - -·-· ~ '>' r\·:r.'.!-.' .. , , .•. .i : ... I» ~'· ('~.•~. /. 'U'r• ~ .ic. ',f . {~~~t~\~t~·. .. [ ~ -.-~~·.\i ·i . , ,,_ ,o 1Cf)..9 Cudt: 1. Wiirnnt r:bai 1hls !fS is .cillicr._I) ftll' dlt JIW'Pi* of h.~ tlal pcio1 ., s~ tllt- WM.'ITf.lnt. tilt- ~cc~ di..ocasaer:t ""th ltlS ...~ ,,,-td~ccVcirtosdw-dlli:~of~or~tc=•m••o:u1111~~1lf~ttucapo'iiti~ Cl!strc.'o\lltljlt ~~Ill' c:o~_,..cs ~a~ nf - '. ~; ~. • ~ ea lbc.~•--infilnntd •bas tht w1Ua9Jily 111111 ~or filnlltr11mlllg,J:kleG11 ~ aDd ,ca1t11e W'I~ 01 J-fidCll-.kb wnai:. illl'wPai 2128!200G 313/2006 Inpadeo.t 4E Autbtllticeted By: Disdwge S\lmnuny DISCHARGE SUMMAP..Y Medical College ofGcorgja Hl)S}>ilnl & Ctink:i DlSO!ARGB SUMMARY Na1ne of Pooeuf: Medi.cill R~rd #: OOt >8-47 I l Dilte Admitted: 02/2812006 Date: J>iscttar&cd: 03/03/2U06 REASON FOR ADML'>SION: Intnk..-tubk: seizure ehllracteri?.&tion. : .! Hl~'TO.llY Of PRcSb'NT ILLNESS: ia ~ 6-tnoutb-old baby b"ywitb 11 history ofsei:rurcs sirw;e he wa• S 1oolth.$ of 1g~. Ht: is cummtly tllki»s Topiram11te and oxclllb;i7.epiue tilr Iris ~imres. His first setmrc was in 12/0S, and \Va$ dcscrihed as rigbt arm jetting far ts minutes. lie wiu then in a poslklal sta~ fur about 2·112 hours. His 1CC:ood aei~re was 8.tOli1ld '1IC alllllC tit~ but ilwolvcd the kl\ side of bi~ body. Titi11. scizutc: 183ted for 20 n:Unutes aud was C16aOCMted wilh po~ictal vo1niting itlld hemipa.re~s tar 30 minutes. lfe had a third seizure tbat Wll$ described as tigirt-sided jerkiUS f~r alxmt lS niimlC$ aod M$ asaocl8l.td willl postictftl vomiting aod hcmipnrcsi&. He bad m RED oo 12/30/05 tllllt showed bdatenl 1*kgrouud slowirtg. but no epileptifonn activity. ~ alw liac.I a er of th~ head without '°nlrast lhat ahow1:d nsymrn~ic dilallltion of the left teroporul born. ThO seizure' normally occur ob out lwo lo three times pet week. PAS'l' MBDICALHIS'l'ORY: He was boni al 37· ln w;dts by ~olalicouJ vaginal delivery aod hod 110 perinatal or postuaflll complication$. Put Surgka} Hiatocy: No. Mcdkal.i.o11s: 1. 'I'oiwnaic.JO mg b.i.d. 2. Trileplal 2 ml bJ.d. Prin1ed By: C..1\auey, Al~i:1 Priutoo: 4llf20lS . Conndeotlal Inrormu.&n GEO.ROli\. llh'OENTS M.eDICAr~CENTER ~ GfOROl.o\ ROO.ENTS MBDICALASSOC1A.1ES·· CfUl.DlUSN'S HOSPITAt Of' ~...... ~ ~ :i< EXHIBIT _3__ 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 47 of 145 VSCPedbtrb DMIJov of Pediatric Nearelocf nm Lhiapfon, MD FtratNamef. Blrthdate I Date [ _ ___. aosJ ="'9""'1bt . ~----------J] 11J12001j Location ~Debbie.MD ] I Nturol!Jcam I: no .-Mmoo otcnmJal tnmta .,, -.:poar~Ol\llld1q119loofclr..,.;D11e~lll . . . . Ill-..: &wlb911dlltlt,, pocll)'e--. ,..,.. OJ Tel. MD Pt,10 l 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 48 of 145 .. DlqnoMI l 1111 ooneomod allout bb aelrures am ablll(v. I dtsouuod tR.bned aptiom. We mWftcl lho rilb of tmedlealion ~ludla& but !lot limited to. awaloola, tmomme. ~cbanpl, •mll. ~ labbfty, llepatoptdl)t.1nomia, bone mariow euppmsian. 11vero akin tub, Stewa'l-lohmon ~ aepluo/ufollddMlf aad ~ . . . . IDOJDllSl'°" lo Che fbllowtqplaa. ldorlbWft Keppni DOB 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Discharge Summary Page 49 of 145 - R013059682 •Final Report• Result type: Result date: Retult status: Discharge Summaiy 06 July 2007 13:14 Auth (Verified) Resulttftle: Perfonned by: Vertffed by: Encounter Info: contrfbutot system: Discharge Summary Palisln MO, Tenley E on 06 July 2007 13: 14 Amml MO, Jennifer C3 on 23 July 2007 12:45 ~0634900448, Richland, IPR-Inpatient. 12115106 • 12118/06 Softmed · • Final Report * Djacharge Summary (Verified) TWO ATTBNDlNGS - DR. 'Mark Mcdonald and DR . CONSULTS : Jennifer Amrol. Neurology. PR.OCROORES ; Lumbar puncture.. DIAONOsns ~ 1. 2. Sei~ure disorder. Re8piratory distress with hypoxia. reaolved. lL~SS : A 15-montn- old white m.ale with kllown seisure disol:"de:r of unknown etiology prc:.Jented to the ED in !llt.atus ei>ilepticua. Per mom, patient was in usual state of health until that afternoon at dayca~e. wlui!re ·he had 4 20-minute epiaOde of seizure that required Diaetat, with resolution of seizur~. Mani picked patient up at daycare. when arrived $t home, bad another ae~~ure and was given Di~atat, but seizure did not resolve, s o mom brought patient to ll:D for further care. Upon arrival, patient was given 6 mg Ativan. fospbenytoin 15 mg/kg and., phenol:>arbital 22 mg/ kg . Patient contin~ed to S9i~e. ~o he~&& siven rocuroui 'il'lll o . l mg/kg and tbe aeizure stopped . Patient int ubated a.nd given 120-cc bolus normal salint, admitted to flct7 for further care. HISTORY OF PRESENT PAST MtDICAL HISTORY; Significant for first seiz~re at ag~ 4 month$, multiple hospitalizations. 2 PICU ac1missions, no intubation:. Hie last Printed by: Printed on: Gaylord, Sharon 04/22115 08:54 Page 1 of4 (Contlnuec!) 9S :80 S~02 -22 - ?.ldi:I 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Discharge Summary Page 50 of 145 - R013059682 .. Final Report • hospitalization was 12/10/06 tor sei~ure , diacharg~ next day. Ot.h·e 1'11.se, no ho&pi t•li:ation.s . Status: po.s:t adenoidecto.my . FAMILY KlSTORY: Positi ve for &ei:ure d~sorder . SOCIAL KI STORY: Lives with mom, &td. No eibling.11 . Re at.tend.a daycare. No pete. No i;;mokers. Developmer..~lly delayed, 6 lt!Ontb 111otor skilla, 8 month ~Qrba1 skills. Yr/OT/ST involved. RE'Vl:l.!!W OF SYSTEM.Si Posi.Cive for rhinorrhea. 1 congestion, eou9h. No votniting, diarrhe<1, constipation, bleeding, rash, or trauma, otherwiae negative. :PJfYS I.CAL EXAMINJl.TlON : VITAL StGNS; Temp 102, heart rate ~76, reepiratoxy 16, blood preasure 103/42' 11 kg. Q:sNER'.1'L >.P.PEARANCE: The patient iB .eedated, responds eo de:ep 5timula.t.iOD. RBENT1 Normoeephalic, a.trau111atie. Anterior fontanall« not noted. Pupi1s ~qual, rc'.lcd and reactive to ligbe, S•2. Oropharynx· cleBr. ET tube is in place . "J'Ms with tubes . NECK : No masse1:1. LUNGS: Clear nasal diac:ha.i:ge notecl. Clear to auscultation bilaterally. rhoncbi. PA diameter No wbee~es. ra.l•s, or no~al. C'.ARDl:OVJ\SC'CLAR: Rsgul.ar rate and rh!(thm, no lrlUXlllUrS, TWO~plus pulses ," le&li t:han 2-second eap refill . nms or gill lops. 1t.BOOMBN1 Sofc, nondistended, Qo hepaeospleno~eialy. QUi Dcecer.ded eeates, full~ in place. BXTRgMIT:cES: No edema. NEUROLOG7CAL: 9ostictal, 6edated. SKIN; Hem.1ng.t.oma roid abdomen. I.Ar.ORATOR~ PATA• White count l2.g, 14~, po~assium. 3.3, chloride sodium 0 . 3, calciu~ hemoglobin ll.7, plate.14te 353 . lOl, bicarb 2l, BUN 10, creatinine 9.1. glucose 128. ROS"ITAL COORSE: Poatient admitted in status epilepticua ee-conda.ry to v.nderlying sei:ure disorder. WaB st:~le and patient W4a dilseussed with or. Livingeton . Dilantin, J(eppl:'Ol, and Zonegran li:::vele were ch~c)'..ed. aecommendatiOdS per Neurology 1 s dictated note were inetit~~ed. Patient Printed by: Printed on: Gaylord, Sharon 04122116 OB:54 Page 2 of4 (Continued) 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Discharge Summary Page 51 of 145 • RO 13059682 .. Final Rep"Ort • bas re11olution o.f activity at'ter admi.saion. Patient vaa discharged on lteppr;a, .r.lonopin, carba.mazepina, aDd fosphenytoin. He "'U to follow up with Neurology •• ~n outpatient. During his presentation tlo the BO, he wa~ noted to be in respiratory distress with hypoxia and fever. LP ~a& done and n~ted to be Degative. Cultures were negative, ~olieved secondai:y to a v~~~l 11lnesa. During bis ho9pital courae, had reeolutioA of feVel:'s, vith continued URt GYft\Pt.oma, which improved, and patimit ~ weaned from Ol and off o~!Jen :a houre prior to d.isc~e. DISCHARaE IRSTROC'l'IONS: Patie"at was to follow up with Dr . Greenhouse wi.thin l-2 dayt1 of discharge and with Dr. Liviw,rston, with ••urology, on 12/21/06 at lO a.m. aeturn co regular activity ae toler&t~d, witi\ regul.ar diet. r.t symptom& return or worsen. t•n1p1;1ra.ture greater than 1.01., ae1zures that last 1onger than S minute&, ~ parent was to call MI> or go to the l!;D. DISCHARGE MEDICATION; 1- C•roa.111azepine 80 mg by ~outb tw1ce daily. Kep?X• 600 ing every 12 hour9. 2. 3. f<.l,o:lopin 0 .25 mg twice daily. &. S. 6. Albuterol 7. Diaatat as needed for sei2urea. Vita"~n every• hours aQ needed. 2 dropG J times daily times 1 more day. Oi~tmant. ap~ly as directed. nebul~%ers Neo~Synephrine c A DISCJPll' POil Dlh ~,'1'1M •••••..• M$03!t C'OLLa 07/30/2007 10a20 RE<:a 07/30/2007 10~2C PHYia ~lVD1QS'l'*rTIM 9.3 !ND OP RHOM' O?/~t/2011 22t~l These laba appear ok. TSL {4.0-12 •.0J v.g/mJ,, tllm1 · COI'PA\'tllft' C'DNllLM'1'VB 8IMWIY I 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 53 of 145 USC Pedllcrla l>Maton of Pecllatrlc Neurology 11• LMnptost, MD FlratNamt f IHlthdate ( I LaatNllme 200$f LoCatlon c;..~;.;.;._ =~ ~Mf>Jt.MD J Daie :__,J _____ 91171.20071 _ __ _ _ _ ___, ComplafntlHlttior,JPaat fffl~OS ngulafr liuntocal $ins. 2 •fd ICllft>UU-1110 100 mg/5111\ 8 mt bid !onuopt.tn0.5 M& 0.7$ bid l1mfotaI If 10 riboflavin NeuroEum 11: iio tMdcinc»otcnallJ tniur111 and~ pcicr~a.t~fbrqe;10C110Sjblllcs.....,.S t.i ISltLIS: aWlktll'ld ala\ ,ood eya contact, ~I Ml\'C$! n.xn nonu1 •normal 1.Q~ ~ .nl bulk IQ prollkntl 1114Gtll! rnutdo piupt offlo upper ID!f lowcr~lfca lad tom, DOB . OQ5 T8L. MD . . . l 3:16-cv-00972-MBS Date Filed 03/28/16 eiainlllllfon: ·aw. 11""11Ja:no~,DliJI_., tlfn: no no·neunicullMCMd llJlltren lmp,.Ulon1P11n Entry Number 1-1 Page 54 of 145 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Emergency Dept - R013059682 Result type: Result date: Re$Ult Page 55 of 145 Emergency Dept 25 October 2001 02:15 staus.: Auth (VerJlled) Result title: Pe1'fo1Tn«l by: Ven1iecr by: Emergency Dept Shenoy MO, Naren Son 25 October 2007 02:15 Eric A Brown, MO on 26 October 2007 15:44 R0729702096, Rlehland. ERR-Emergency Room •.10124107 -10124107 Encounter info: Contributor syatem: . S~m~ Emargem:y Dept PALM2T1"0 HEALTH RICJIL1'.ND s Richland Medical Park Dri'YQ Colulnbia, SC 29203 (803) tH-7000 PATl:ENr: n DtPAR.nool'r l"R #: Ol·J0-59-68-l Page 2 ot. 2 OAn 05' VISl.TATtON: 10/24/2007 ACCOWT NUMBER; 07.'297020~6 Patient arrives by pr~vat~ transport- ATTENDING RRYSICtAN: ·Eric A. Brown, MD CHIEF COMPLAINT~ Seizure. KISTOR~ OF PRESENT ILLNESSr This ie a 2-year-old whi~e male with a known blatoryof seizures preaCDting vith his. usual petit mal type seizure today . He sei~ed for ia.pproximat$ly 45 minut::os which is 1onger than usual.. Noxiaally, lllOm 9ives him Di•etat at home . Mostly, seizure goes on for S minutea, buc ah~ picked h:im up fro~ school and did tl<)t have Diaetae vith ber, eo he ~ontinuecl to ~ei%e. He did not have &ny a.i.rway compromise while he was saiz1ng. she says c~t rece.ncly be hci.e been :teizing every J days, but she ha$ been keeping at home. She :said t~y he just eaid hi co her and then fell on to the carpec. He did not hit his head. He seized tor approximately 4S ~iAutes, and the aeizure stopped by the time he had got into t.he Eme~ency Department, He was postictal for a short while b~t then bas been hack to his normal active ealf since then. MO~ eaya that he ~As rece~tly 5een DX . Livingston in the la~t l ~eeks, and his Lamic~•l dose was increased. She Printed by: Printed on: Gaylord. Sharon Peg" 1of3 04'22/15 OB:SS (Contt11ued) 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Emergency Dept Page 56 of 145 - R013059682 ~eel& ~h4t haa been ea.uains 1.S probie111 with his sleep, making him sleep less, and she wondering if that is Why he has been having mo·re frcqueJSt. aeizurei;:, She also says that he ha.s b~en having ( I per his phy1o1ical thei:-apiet and &peech therapist that he bas ha~ decrQased trunc&l ~treng,b , and he ha.a be~n using l~se words ov~r the last few months. He w&s diasnos~d with a mitochondrial disorder Within the la•e few months as well. R!V:t2W OF SYSTIMS1 SOCIAL HISTORY; iri daycare. As above, otherwise negative. P1'ST Jiml)ICAL RlSTORY: He does sov Dr. 1.am.ietal, Coenzyme Q•lO, and carnitox. is managed by nr. Li vingstcll . · ALLER.GIIS t He .IMMWI~TIONS: PHYSICAL There are nQ ~et• . He live& with mom, dad. has no kno'llfn Livi~gston. He docs No smokers. Ke is "a i• on Klonopin, Te9rQto1, a mitochondrial defeet t.hat ha"• dru!J allergies . Up to date;. Bl(AHJ:NAT%ON1 ~lIGNS: Te111Perature is 9B. 6 rectally, pulse ia 98, respiratory rate: ia 26 , blood preG911re is L0•/64. Uis p~1~e OJC ia 10Qt on room a ir. He weigh• 12.36 ltg. GEN&llAL APP!A.RANCR: He ;l.i;;. in no apparent dist:rei;s. Be is nontoxic. VITAU HEENT : He is nor1110cephalic, atrilwnal:.ic . MUcoua membranes a.re l'flOii;:t. NECK' Soft., supple, no 1ymphadenopa.thy. LONC.S : Clear to auscult~tion bilaterally. PupiJ.i; are equally ~ound and reactive to light. No wheezes, rales or rhonchi ~ere appreciated . CAADIOVASCOLU: Heart is regular ratte and rhythm . No mul'11l1.lra, rubs or 9allops. ABDOMEN : Soft, nontender, n.ondiatencied. No hepat.osplenOlbegaly. Ile does have a. SINll1 strawberry hemangioma on hie abdomen. BXTftEMITl!S: Ro clubbi~g, cy;inosis or ede111a. Full range ot ~otion. NEtm.OLOGic~ 1 Af;>pearB to he intact; however, he does app~ar to be . aome~hat, m.t~d.1y bypertonio on exam. He inte~acts and makes good e~ cont~ct, but he does no~ speak. · MEDICAL DECISION HAlG:No A.ND EMERGENCY DBl?AATMli:NT COURSE : This is a child with & mitochondrial disorder and a lcno'tln sei~ure disorder tha~ is soen by Pr. Livingston and is well known to rhe Blnergeney Department and to the Pedi•eric Service here at the hospital. Re did have bis usual aei%ure . He did not have any ai~ay conipromis~ of any type. MOU1 just brought him in for precaution. Me did ch•ck a set of electrolytes and a Tegretol level to make sure there was nothing else going on that would have trlgg~red the ~eizure other than his usu~l oeizure ~ctivity . His electrolytes were completely normal tllld his Tegretol level was 7 . 1 ~bich was Printed by: Gaylord. Sharon Printed on: 04/22(1 5 08:55 Page 2 of3 (C¢nllnued) 3:16-cv-00972-MBS Date Filed 03/28/16 Emergency Dept Entry Number 1-1 Page 57 of 145 • R013059682 al~o noElntll • . We did speak ~ith Dr. Livingston of Pediat~ie Neu~ology to oeG if .we needed to increase '1\edi<:at:i.on dose . He Ac:ommended inc:re~sirig the. X.~miC!tt&l, but aft.er explaining to him that aiom was concerned that vas ca.u•.i.ng pr.oblQ.11\8tl!l6l T Job # : cc ; llric A. B~wn.. MO T! io/25/2007 2:15 A 756~02 Doe #: 1103~93 Slgnatul'f Une IU t:c:tronically Signed .r. Vt:ritied on l.0/26/200? lS:tt by :a:ric A Brown, MD Compl•ttd Action List: • Perform by Shenoy MU, Naren s on 25 octobsr 2007 02rl5 • Sign by Eric A Brown, MD on 26 Oct9ber 2007 1S 144 R~que~ted on 25 O<:tober 2007 02~53 • Vlm.IFY Pfinted by: PtinteA Nmoa.stc eumt ftuJl: ~lilllowidlaut ms.nooottmmaa. M.a.l S..: Awab, alert. J\INJUilaaam. CdM. Oula!Ntml: 11- Xlllidlci. IOMl:iact.PDIL M-. DUftMe •notoaSL woac1o ~w1m,..,.amio... ..oaddel. w.-.1111 m..-GCIClldlDadoD for ... l1lvohmllq muvttalall: Ko dion..~ ~ Ollt 11Coae41D...llal"Mlb wU wldaout•........ . ~1.~..--1~ r.,nafollrlu l --11mit Dr. l.Mnpfoa Ttilhtlla £'1a fl'PL Wt dllo'll1ledMRI .wJap ud t. rtik otert'Or ~ ~ modlcll tMdaf. Wt dilalaH4 tt.et madllllt could flrlDa nwdall otMIU !i>PJlMll er MCQ for mfoW'. We dl1CU1Md ...._ tleap,.&alf modioltlou lo~ llD W.~ \Vo ~ mcdlcatlml diana'el and eooddcadoD otdJw+dhp1fq t.euJceel. W. do not NCOn"'"" etoppjq Mian meclbllos1 dile roriP: olwftMtlwal ul=ta. Wo dflcl..- U11 otoloaldl:DI ad we do aotnco11•1N!M lfdl m • caadllCI rilb. We clfeculled Joaa mm diet oa bClllO Miida Iii.ml~! ctllonf«. MOCber aare- •..,. l.aalktalflw:t' ..... ~ ttU). amp to ~ diowablotlbletl. PAa • Wtllb, aooiior ltllOCIUU)'. Tolll tfmo 1pe111.C$ mUiuee., > 50% or c.mu. .-. ,.. 3:16-cv-00972-MBS I Date Filed 03/28/16 Entry Number 1-1 Page 59 of 145 EXHIBIT 4 Articles ~ @ ·:.-1t De-novo mutations of the sodium channel gene SCN1A in alleged vaccine encephalopathy: a..retrospective study SomueJ f 8erftovic, louise Horlcin. focinto M McMohon, Ja• nesT Ptltkono~ SameerM Zuberi, Elaine CWlt'trl!. Deepak SGill Xenia Jona. John CMul/ey, Ingrid f Scheffer Svmmaiy Bac:kground Vaccination, particula1ly fot pertussis. has hffn implicated as a direct cause of an enceplWopathy with o.;•,,. refractory 1cizures and lnteUcctual impairment. We postulated that cases of so-called vacdnc ence phalopathy could J,pol2Q, 201!5 have mutations the neuronal sodium channel al subunit gene (SCNlA) because of a clinical resemblance to severe lon.,I .HhM 8S<. )Hol:h,,.,.MORS. I( St~,oi>a""'ont cf POl4bt,;ca. U..~af' >.clol•idc. A!.>st..U.(l. H••kin~ F,...rofAhnd., .....,.,oideJJus UN.t. loy~I H<>1p;ul(vr Side Child"!\ m myodonic epi.lep11y of infancy (SMID) ror:...bich such mutationB have been icrentified. Methods We retrospectively · studied 14 patients "'ith :iUeged vaccine encephalopailiy in whom di.e first sei:r.ure oc:cuned within 72 h of vaccination. We reviewed the relation to vaccination from source tecords and assessed the specific epilepsy phenotype:. Muhltfons iD SCNJA were identified by PCR amplifiulion and denaturing high performance liquid chromatogr.iphy analysli1, with subsequent sequencing. Parental DNA was eumincd to ascertain the origin of the mutation. · Fi"dlngs SCN1A mut.atio~ were identified in 11 of14. patients with aUegcd vacdoe encephalopathy; a diagnosis ofa specific epilepsy f)'ndrome was made in all 14 cases. FM mutations predictt!d truncation oflhe protein and six were mi11sens:c in conserved regions of the molecule. In all nine cases where parental DNA was available lhe muta tion~ arose d e n ovo. Cliniral-molet:ulilf correl;ition showed mutations in eight of eight c.ues with phenotypes of SMEI, In t.bree of four cases with borderline SMEI. but not in two cases with Lennox-Gast.aut syndrome. lnte'l'retation Qises of alleged vaccine encephalopathy could in fact be a genetialfy detemiined epileptic encephalopatJiy thar arose de novo. The$t findings have important clinical implicatioru for diagoos4 and management or encephalopathy and, if confirmed in other cohorts, major soci2ta.I hnpliations for the general accepW!ce of vaccination. Introduction luting, are chuactcristic and can be associated with fever. Myodonic. absence. tonic:-clonic, and partial regression after v:accination in previously healthy infants sei2.'Ules also occur. The epilepsy is reftactory and OtAl1tW...tmod. and permanent brain d;>.mage.~• In individ·..1al cases, p erccntnge is still debated. Around half the mulatiorui W•S111'ud, lol$11t,AU>trolla YO!lhU,G1'"5. O CI.\ u8tYJ; .,.. D<;1•!tment of hdia1ria. Un;....it, of Molbou-. A ~;~Ch;fti,.n> HoJPit>L Vlctc:i.. Ausmfi' (1£Schtlftt) Corr-t=>ondfnCI '\~. ""'!S.rnu•I f 8111co.i.;. fp~p~ Rtst:.lt chCeot~. AutliOl H.~1;,, we,; 11•;.J.lh«!)o l/it:on• )J81,Avroducts u1both directions on an AB! 3700 seque-ncer (Applied Biosystems. CA, USA). Numbering of each mutafon was taken from the start hHp//nfvrology.!11tlan6), infantile spasms {n-1), tonic (n-1). and unclassified {n~lJ. The first seizure was definitely associated with fever (>Js•q in five patients, six were lfel>rile. and in thrP.e tbe- temperature was not recorded. Status epilepticus (seizures lasting O!:lO min) occurred at presentation in six cases. All cases had severe epilepsy with multiple seizure types and in;ellectual disability. Our review of tile subsequent clinical course led to di..ignosis of SMEI in eight patients, SMEil in four, and Lcnnox-Gastaut syndrome in two. In the two patients with lennox-Gastaut syndrome, spasms and hypsarrhythmia occurren of the piotein in five cases {three frameshift and two non-sense mutations); the other silt were missense mutations (figµre) ."" A dis play of evolutionary conservation of thl! residues where the mutations were found is shown in the wcbfigure. None of the six missen$e mutations were: identifed in the blood donor control population: a suonliro• f~, ....i.~!I".. I 3:16-cv-00972-MBS I 4 5 6 Agutmdy Ag..to•sot 11t>DI {m~ll< I Page 61 of 145 £flllf!l'Sll Fd>m• StaM~ S.U.Wt~ N N H.micll!nlc fn"'*""ft CIJS 1fsX1 JS'l trtT" y N Homidoi1i< :.l'..;•t. II. T. GlCS. SE Ab, Al M. ..... T, CPS ~loll.I 14 SMEI Mi<..nk~~ y 5 lrdTA y v Homidor'i< H, F,GTC5,SE \MEB Fromoshirt1C1077hlli07' No""'"'" ll140lX M"""ot• Ql&iSQ MlncnM £1 !)81l v v ]rd TA N v Hemitlcnic Ab, A~ H, M, GTCS, SMEI u )rd TA N v GC SM~I } 24 l>ITA y y GCS "b, f, M, E, SMEI SMD y y "-'<1hllt NlSC'lfi)USll Vnknown y F, M, lGTCS, 1£ SMl:ll ~-'13966 'r ™"' SMEB MiucnJOY4t:ll'I y Ur>\,_,, II, M. SGTCS. ~l, M..f, .\l.G1CS..lt. NmuuMWJ!4X Urtb>.,·.n c.c: F.M.~TC\Se, IMEI M~....... f40)L y GltS Ab, Al. M. Ip, (.T(S 5M£8 Ha<>e ckt«ttd NA Sp."11> Sp. T. ~•. M, C,.IJ1t,lo..i<.·dont<:Mlzu,~Ct>?™fllh.ddQf'lichQ.vru; I ,, ,ltJ..,"-l; IA..m:-od'oni< "'iNl'tlii AO-abwnt..Jiii At-.: ;"k;Se..nt'h '~l('IA;,PS•""""* •fl.lllgt~~11!$i· ~iidonic,; SGlU_,~~ gtr~ll:)1'c-dan.K !.._-.,. """'clcrl<·.,;l•psyofo1hndtvnc, llA-1" lll'!'liab~ T•W1: Cllniul W•~1i1tla of 14 p•tienb...,..tl> all•geci w&C'Cnt • ....,_ttalopr.thy J !..-----····-··--··-· ··minimum of 130 and maximum of 149 crinb"ol samples were successfully screened for each mutation. In nine of the 11 patients with SCNIA mutations for whom samples from both parents were availai1le, the mutations were absent in parental DNA and thus arosf' de novo. In p~lient six, parenw DNA w;is not available. In patient ten. the mother was tested and did not have the mutation and the father was deceased. This patienr had a deceased brother who was also said to have seizures beginni.Ilg. after vaccination, but medical records we~e destroyed and thi~ could not be verified. Correlation of the clinically diagoosed. phenotype with thE molecular analyses showed that the sodium channel mutations were confined to the cases diagnosed as SMEI (eight of eight ca:c;es) ot SMEB (three offo1.11 cases) and were absent in patient~ who had Lennox·Ga.staut syndrome. '1gvn: Sdu!r.1rn< rt~rt1tc ""lt'1Qtscns01: l lvrtUdw lon~on of the 1;x m~• n:uuUons (gr••~ cirI< tri1"'.)les) 111th~"l1 M Mwilh •il.1•m• "'"t.llion• protdon1l1w1ll'I =vnteedinSMEl. ·• 490 Discussion In this retrospective cohort of w1expb.ined encephalopathies in the first year of life. 14 patients were judged by clinidan.s illld families to have a vaccine eacephiilopathy and had documented seizuTe onset within 72 h of vacdniltion. W1th u1eful elec!roclinical an~ysis. we established lhat the clinical syndrome was SMEI in eighr patients and the relared syndrome SMEB in four. Eleven patients were shown to have mutations in the sodium channel gene SCNIA, which is now a well established finding in SMEI.""" Two of the m:.tlatiom have been reported before in as3ociatioa with SMEI or SMEB {R946H, R1407X} after nomenclature were standardiseout half of SMEI cases with SCNlA mutations.' The other six p•tients had missense mutations. All are likely to be pathogenic as they have not been reported in control populations nor were they found in out controls, and the observed missense mutation!! affect highly COn.'ierved ilmino·acid sites (data not shown), are in regions where SMET mutations have been previously described,• and arose de novo in all cases where b.oth p:ircn!s were tested. There is no satisfactory case definition of the specific neurological pheno~ in vaccine encephalopathy; indeed, even the t~roporal relJ.tion to immunisation is loose with c&ses described with onset of symptoms from less than 1 day to 14 days post vacdmtion.'-'"-'- Although we showed th3t SMEC or SMEn were important ph<:notypes in vacc~ne encephalopathy we were surprised ht1p://n•"•ology.lhtl>ooot.con1 Vol 5 Junt 2006 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 62 of 145 Articles that no less than U of 14 patienta were diagnosed as such with meful pbecotypic analysis. We do not know if this finding ~ represent.rive of cases in other centres. bu1 previous r:ports of sei:cures in SMEI being associated with v.iccination as well ~s fever lend support to our finding$.<"., The multiple seizure types in SMIH and SMES ca..• make diagnosis difficult for ob£ervers unfamiliar with these disordeni; patients can be judged u having an unclassified form of epilepsy and intellectUal disability. The discovery of SCNlA mutations has led to improved awal'Enes11 and diagnosis or these severe infantile cncephalopathies." Scientific and rnedkolegal controversy of v;iccine encephalopaLliy bas spanned seven decades." We suspect !hat the narure of cases has changed because of increasingly sophisticated clinical and neurological diagnoses llld investigations. Some patients bad coma at onset whereas others had seizures with subsequent regr:ession. In the early research, detailed analysis led to the conclusion that some alleged cases were probably due to heterogeneou~ causes, including viral encephalitis and Rcye's syndzome.17 The molecular delineation of genetic encephalo;iathies with phenotypes of SME! and SMEB now seems to be another major piece in !he h~erogeneous diagnostic piozzle of alleged vaccine encephalopathies. The gP.r.-etically determined epilep~ syndromes of SMEI aoc SMEB typically arise in a:osociation with de novo SCNlA mutations, presumably due to mutatiorui in the g3metes or in the very early post-fertiHs~tion ~riod. ~'-"""" Ir. alleged v~cdne encephalopathy the assumption of vaccination as a cause has been reinforced by the absence of a family history ofsevere epilepsy. Now, the rnolec:ilir findings could explain the nature of the encephalopathy .aud the usual lack of family history since around 9S% of mutations in S.Mlll occur de novo.io.t· SME! ofte!l. begins W.th febrile sei?ures and fever is frequently associated w!th seizures early in the clinical course. In the presence of SCNlA mutations, vaccination can still be ;rgued to be a trigger for the encephalopathy, perhaps \-ia fever or an lmmWle mechanism Our experimer.ta! design does not address this issue, but the role o!" vaccination as a significant trigger for the encep~.alopatlty is unlikely for seven! reasons. First, although vacdnation might trigger seizu~s as shown by the increased risk of febrile seizures on the day of triple antigei: or MMR vaccination, there is no evidence of long-:e:m adverse outcomes ...... ' Second, less than half our patien:s hd doa.imented fever with their first seizure, which indicates that fever i6 not essential. Third, our neuroimaging data showed no evidence of an infbmma:ory or destructive process. Finally, truncation and rnissense mutations reported in conserved pam of SCNIAl:iave not !,een foand in many hundreds of healthy patients.'"~.>'l:'.'• Thus. individuals with sucb mutations seem to develop SMEI or SMEB wbether or not they are immu:-Jsed ;n the .first yr.ar of life. We do not think that ;.~oiding vac::ination. as a potential trigger, would prevent I onset of this devastating disorder in patients who already harbour the SCN1A mutation. The mechwisrn by which SCN1A mutations cause SMEi is unknown. Few causative mutations have so far been subjected to functional analysis. ;md the results are inoonsistent: however, these mutations arc presumed to cause abnormal neuronal excitability.1~" Studies of Jess s~re mutations of SC NIA that cause milder phenotypes have also produced conflicting results dependent on the techniques and the model system investigateuiesi• •nd Wl'Ot~ tlte first d:an. Al'>ly.sis at clini<'al J"'-a "''" do11« princip-•lly by l"S. JM I.I, fTP, •ttd Sm. and .i,., by SMZ. !!CW, and DSC. Multc\llat an~!ylit 't':;u 1.1neer1oken by l.H. xr. •nd )CM. ,\Jl ~ulhou critic1lly 1""'S<>d rhe .'i~t drabnd •pPfo'..d lh. fuW manuscript. Confllcbofint.etml ms. artnd Bionomi. /·:MA l'Jll: t01 : 1117- &ll. 2 l(ui<;nlc<.rnpl'T M. Schw4r1>.rn.n JS, 11/ilst>tl J. ;-l('llrolo~cal lic~s of pertuui& inocwlion . Al: ~r au.i,.,..,,. of the llritb..'I ~ioml Citil-SS. C..rm2n•!l.t brain cbrmge a.nd pe:t\l•si• v:>: 199-210. Mtnl<#.s Kinibaur'N! M. Wmkohop on oourclogic c.ompliC1Ht>nt of per t'llni• 11\d pcr.11uio ~•ccinatiou. Nrunt1;0i<>lria 1990; m. 11: UJ-76. 6 7 8 9 Colden GS. f>utu.ssis •acdne and iilh•:Y to the brain.) Pt4i•l1199D; 116: 154-61. C•lt Jt, lhapa PB. Wusil~k SC, Bobo JK, Mendelman PM. ~01 HM. Ris~ of serio11sacute J!ewolojiul ilfo= •!!Pr lmmuni7•rion with dipl'.lheria·l~nu!·pertu.uis •.octiM; a ,..,pub1i1m.U.•.. J """"cnl\hvl ~luJy.j.~M.\ 1~94; 271: 37-41, Botlo•r.· WE. D•vis RL. Clu•cr JW, Cl al. Tue risk of S•i~ •RA!r receipt of..toole-c:eU p•rtu.s•i• or mea$les.mut11ps. aad r~bdb mcine. N Ellf) J Mt4 2001; l4S: 6Sr.-GI. l'erN.·Prn• lt. \ 'actino ro(u,.J ;. cit.,J i11 whnuri!'l~ cuu,;11 om ti.. Swan••• ReJearch Unit of Th• Ror:il Coilejlt of Ce11<11gw~ JR. Hon>il~ SJ, Menk., JH, Sd1v.2rtz JF. Advetse cvtNJ forliug probabiliry of c~uulion, l'tcd with diphtl1~.ria·ltta.Dw· potl'lUi5 .. e• 1991: 91: llS8-6S. /\non. Updai.: v.iccin• side dfects. adverse re-1C!ions, : l-lS. MtAulilfe JS. Wad!wd WC. Pcrtuo.ris v;iccinatJ011. Ans ~aon Pftysirian 19lill; J7: lJl-15. 16 Cowan LD, Griffin Mlt How:on CP.e1:.l.Arute tnceph•lapilhy and chro1tic ne..rotog'.cil oi; m•;e •llct p<.th.iS>i• nu M. Or.a\'tl C, Ceulon I'. T>s.ioari C. Wolf l>. eds Epilcplic Sl1~pht~ns011 &v•,. ; 2002: lil-\Ul. 492 Page 63 of 145 22 lJ 24 25 Couunl,.jon on Ca•ilicalion >i>d T•rminology of tke lntropou l for r...Ued clasr!ficolion of epilt~ and cpilC'plic syndromes. EpilcprU. 1989; 30: 389-99. Clac• t.. D•~l'<>" !ftUl•l1tm• in tho ~udilm1-d1~nm~ SCNIA caute • •Wire m~lonic epilep")' ori!\[ancy. 11"' /Hu'" Gmt12001; 61: ll27- l2. Sug•"':IU T. M•:n.ki·Mi)....l:i li. 1'11kulhiroa K. et •l. Frequent munrions of SCNlA in severe myodonic epilet>sy in inAn'J" Nturo/ag'; 1002; 51: IU2-U Cl~cs I., Q:ulemaos A. A~d•ll•ett D, et 11. De ft()VO SCNIA muulions an: • major cau.. of scure m7odonic tpilcpsy of Wancy. Hwx M'utu 2001; 21: GIS ~21. WaU..co RH. H~ott Ill, Grtntoo BE. et al. Sodium channel alplul ..ubunil mutalious in severe: myocl011k epil"l''l' of inf•nq •11d lnranlilo >'J'U"'" Nc•mifnino 1.lltl.l; '1: 76~\I. N1bbout R, Genn.uo £. Dall• lll!rnanlina 8, et al. Spe~trum of SCNIA murarioM in sevtn: m)">Cloni< epilepo;y ofinfuicy. It<'"" NnuolOiJY 2001; 60: 1961-67. Fujiwan 'l'. Suflo\ ...1'1 T. M:llOdium cn•n~ell111N I ..,ft•g<:·gatod N... ch1M•l 1lpN I St:buni• "'°'SOI IA in cnre - " niyodo.W: •?ilei>SY in infoncy (SMnI} a::d in brud~ine SM UI (SM~B). l!pikpriM 200!; 45: 1'40--4&. tl MW!ey JC. Suunlulon on Cln.itit• lion 1nd Tut?nilt<>~ or tli.: lntcmatiuual l.1-a.l!'Ut .\~•rnri;t Hpa~p,~-. Propqsat for TL"Vi~od di1•ic..d anid ~t'tlro­ oiceph>lugro11hic dmi5tltic>n of~'Pilcptic nizures. Epikpsilll 1981; 21: 489-SOt. 2 T. ti al. Novll ch>ru"ls with 111ui.ti""'' 11( '""'"'" :nyndouic .:pil<'!':brile s~i?~l'<'• pl u... J Nnuopl-5G. 17 Altic<>'. A, lllh!Tllln MM, Miuovi<: N. ~!imann·Hom F. Lctdl, H. A sodium thtnnd mut>t!on u11stng i:pilei>•J in U'lan exhibit• St i1mtiva1ion 011d xti\'iDOOl in vi!Jo. j Pli~ 200~; SZ9: Sl.J.-39. J8 Harkin lA. aow- DK Dibbc11.< LM , d al. ll-wiation of the GABl\,-,.CrplO! yl tub11ait in a f.unilr with ~mera!i:ud epilepsy ,.;th febnlt 1eizt1JCI plu1. A"') H""' c..... 2002; 70: 5.1()...JG. 19 ~mlya 'K. K>nrcla M, Sug•,.ar• 1: el al. A llO"Setue n>t.l>lion ot tLt sodiUJn dtanutl ~·"" SCNV. in• p>ti.:nt witb intract.ble epilepopnd 1nent•I dt'Clioe.j Nwroici 2004·. 2'·. 26%-,8. .CO Oiron C. Marchan~ MC. '1r.w A,eta.I. Stbpe111ot ins... ere myocl<>oi" •"Pil"P'1 ia inf:UJCf'. • r.iufot.~i•"'1 pl~ct-bol. 1.o~n l'. Belmonte A., Kamiusl<~ A, Oulat 0 . i...motr!gi.e.e ind teizun: aggnvario11 ill srvtt'. myodoni~ cpUeps-;. r,.~.11~~ 199&: 19: ~o&-u. 42 Cnp~nh C, l:1Jl<'\i01 C, Mooi:.~ni!li A.•l aJ. TqpinntatP.u •dlk>n drug In IC..,I'<' rnyocionic opiltpsy in infancy- an lulian multiccnler ~" lrtal. F.l 'ilepq R~ain/a·drr,0';2 The spectrum of SCN/A-related infantile epileptic encephalopathie~ Louise A. Harkin.~ 1 Jacinta M. McMahon.3 Xenia Iona.' Leanne Oibbem,1.1 JamesT. Pelekanos,3 Sameer M. Zuber!,.. Lynette G. Sadleir,5 Eva Andermann.'> Deepak Gill.7 Kevin Farrell.' Mary Connolly,8 Thorsten Stanl~5 Michilel Harbord,9 Frederick Andermann,' Jing Wang,10 Sat Dev Batish,'° Jeffrey G. Jones, 0 William K. Seltzer,'° Alison Gardner,1 The Infantile Epileptic Encephalopathy Referral Consortium, Grant Sutherland,1•1 Samuel F. Berkovic,l John C. Mulley1•11 and Ingrid E. Scheffer3· 12• 13 1 0.partment of Genetic; Medicine, Women's and Children's Hosplul, North Adelaide, South Australia, 1 Department of Paediatrics, The University of Adelaide, Adelaide, South Australia, >Department of Medicine and Epilepsy Resea~h Centre, The University of Melbourne, Austin Health, Melbourne, Victoria, Australia, "'4Fraser ol Allander Neurosciencel Unit. Royal Hospital for Sick Children, Yorla rents mildly affected with febrile seizures) where their children have SMEI or SMEB (Depienne er al., 2006; Gennaro et al., 2006; Marini et al. 2006; Morimoto et al., 2006). SMEI or Orn.vet syndrome is a distinctive syndrome with seizure omct in the first year of life, typically beginning with prolonged febrile hemiclooic .seirures or generalized tonic-don:c seizures (Dravet, 1978; Dravet et al., 1982, 2005). The disorder evolves with other seiwre types such as inyoclonic, focal, absence and atonic seizures developing between l and 4 years of age. Development is normal in the first year of life followed by developmental slowing and regreS.lion. Pyramidal signs and ataxia may evolve. U>gnitive outcome .is usu3lly poor and seizures remain refractory fo r those who survive to adulthood (Jansen et al., 2006). The phenotypic spectrum of patients with SCNlA mutations has been extended beyond SME.I. The related syndrome SMEB (Ohmori et al., 2003; Fukuma et al., 2004) refers to children who lack ~veral of the key features of SMEI su.:h as myoclonk seizures or generalized spike-wave activity (Sugama et a/., 1987; Dravet et al., 2005). In two studies, 26% (7/27) and 88% (15/17) of SMEB patients were found to have SCNJA mutations respectively (Olunori et al.. 2003; Fukuma et al., 2004). As with SMEI, these mutations arc spread throughout the gene with a mixture of types of mutation including truncation, missensc: and splice-site changes (Mulley tt al., 2005). A subgroup of SMEB tias been variously described as intractable childhood epilepsy with generalized tonic clonk seizures (ICEGTC, originally ca.lied high voltage slow waves grand mal by Japanese authors) or Severe idiopathic generalized epilepsy . of infancy with generalized tunk-donic seizures. These infants have generalized tonic-clonic seizures beginning in the first year of life without the evolution of other seizure types .and they follow a similarly unfavourable devclopmc11tal course to children with SMEI (Fujiwara et aL, 1992; Kanazawa, 1992, 200l; Sugama l!t al., 1987; Doose tt al, 1998). In one series. 7110 ICRGTC patients had misseru;e mutations in SCNJA (Fujiwara et al, 2003); truncation, mi.ssense and iplice~site mutations were reported in 3/18 patients described as severe idiopathic generalized epilepsy of infancy (Ebach et al.; 2005). We reported the only. case so far ofWe~t syndrome with an SCNlA mutation (Wallace et aL, 2003). Given the overlapping yet heterogeneous clinical features of these epilepsy syndromes, we postulated that SCNlA mutations may be associated with other phenotypes. Here we studied unselected patients wilh severe epileptic encephalopathies (including SMET) with ons~t primarily during the first year of life. Material nod methods Clinical methods P.atiMts with epileptic enceph.alopathies of unknown ca.use were referred by paediatric nl!llrologisti and neurologists from Australia and around the world. Epileptic encephalopathie$ ;ire defi11cd ;u disorders in which there is a temporal relationship between dcterioration in cognitive. sensory and ntulor function and epileptic activity comprising frequent seizures and/or Clltrcmdy frequent "interictal' paroxysmal activity (N~bbout and Dulac, 2003). ~ases wi:re only. included where magnetic rC$Onance imaging was normal or showed non-specific features without a definite art.iology. A subset of 14 patients, induded in this study, with so-e.tUcd 'vaccine en~phalopathy' has been published prtviously (Berkovk d al., 2006). Ekctroclinkal data were ob!ained on all patients with specific emphasis on early seizure history including age of onsd, O(cunencc of 1cacus epileptic:us, ptc$mcc of f~r sensitivity, clinical photic sensitivity and evolution of other sei~rc types. A detailed early developmental history was obtained with attention to acquisition of e:irly milestoneii, timing of plateau or ~on of devek1pmcnt and current functioning. Other impe>rtant details included general and ncorologkal uamioarion, family history of scirurc disorders and results of EEG, video-EEC monitoring and ncuroirruging studies. Rl!1lults of other available investigations such as chromosomal analysis were also obtained. SME.l was dellned according to the following criteria; onset in the first yca.r of life of convulsive seizures which were hemiclonic: or gencrali·tcd; myodonic seiiures; other seirur~ types which could include focal scitures, absence seizures.. atonic · sciz11res, tonic 3:16-cv-00972-MBS Date Filed 03/28/16 seizures; normal developm!!tlt in the Brst yeir of life with subsrqucnt slowing including plateauing or ttgrcssion: gencraliud spike-wive activity and either nonnal MRJ or non-speciflc Entry Number 1-1 Page 66 of 145 .equencer. The final subKt of pat~nu (43) was screened by dirKt sequencing of PCR producu (without prior dHPLC screening) by Athena Diagnostics under dia&nostic condition&. The numbering fuidings. for ea~h mutation is taken Crom the start codon ATG of the S~B full-length SCNIA isofotm sequence (Gcnbank acccuion number AB09JS48). ln cues where an SCNJA mutation wu detected, the appropriate amplicon from irarental DNA (where available) was re$tcd by DNA scqutllcing ro distingwsh. between de fUl'llO ind f.unilial variants. MutatiO!l.$ or rare ,-:ari•nu were distinguished from coding single nucleotide polymocphism.s which have previously bero reported (&cayg ~ aL , 2001). was dMded into subgroups based on tlle absence of specific features that arc regarded as r~uired for the diag1l0li.s of SMEL SMEB-M rcfured to patients who did not have myodonic seilures but otherwise satisfied SM"El criuria. SMEB-SW defined patients "'ho had all the SMEI criteria but had never bad generaliu:c spike-wave activity documented on EEG. SMED-0 refcr:ttd to patients who had Ill.ore than one feature that was not in keepfag with SMEJ; examples indudiiity and wuaUy had normal neuroim013ing. Several individll3ls wetc included whh abnormal neurolmagi.ng that did r:ot account for the clinical presentation such as hydrocepha:US, bilateul pcriventricular leucomalacia, etc. Othe.r syndromes were defined according to the 11.AE dassificatioa (Commission on Cla.ssiilcation and Terminology of the International League Agaiust Epilepsy, 1989). Patients were called 'und a.s.sificd' if we had insufficient evidence to make a syndrome dU!gnosi~ or the patic!lt did not fit into a recognized syndrome despi re ddailed evaluation. The Austin Health Human Research Ethics Ccmmiltte approvtd tl-..is study. Informed conseut was obtained from die partnts or g"Jardians of minors and from adult subfects of normal intellect. lu th( c::i.se of adults with intellectual disability, legal consent ~-as obtained ftom the appropriate government authority or legal gJa:dian. Molecular analysis Molcrolu a:ialysis w-as car ried out on genomic DNA extracted from venous blood. All 26 cxons of SCNJA were amplified by polymerise cltain reaction (PCR) using Ranking intronic pri.mers and stuldard PCR conditions (primers available upon request). PCR fragments were heat denatured at 95' C fur 4 min and slowly cooled to room temperature to form heteroduplex products whi-11 were anal)>sed by denaturing high perfotmance liquid chromato- graphy (dHPLC) on the Ttarugeno mic WAVE 3500HT instrument (dHPLC conditions available upo n request ). Am plicorl5 showing altered dHPLC du·om~togram patterns were scqueruxd in both directions from independent PCR produt"ts, on an ADI 3700 Results Clinical diagnoses One hundred a.n d eighty-eight patients were recruited from Australia (110), Canada (27), United Kingdom (23}, New Zealand (20}, lsra.el (4), USA (3) and Denmark (I) with sehure oo.set in the first 2 yeats of life. The~e included 14 ~ases who were negative for SGNIA mutations on singlestranded conformation analysis in our previous study (Wallace et al., 2003); the eight positive cases and two. who were negative on sequencing, ;ire not included in the data presented !Kre. Our total cohort co11taincd 66 with SMEJ, 36 with SM.EB including the various subcategories, 25 with cryptogenic generaliled epilepsy. 18 with ayptogenic focal epilepsy, 10 with MAE and 12 with ~GS. The remaining cases had a range of other syndromes or were unable to be classjfied (Table I). Table I SCNIA mutations in patienu with epi!eptlc encephalopathies lOtal SMEl SMEa SMEB-0 SMEB-SW 66 36 16 1'4 SHEB·M ICEGTC '4 C,.yptogeni' generalized epilepsy Cryptogenic focal epilepsy MyQclonic-asntk: epilepsy Lennox-Gutaut syndrome West tyndrome ld!<>1>3thic spasms Early m~onlt el'\ce11halopathy Progressive myoclonic epilepsy Alternating hemiple3ia of c:hildlood Unclauified Total 2 lS 18 10 12 s SCNIA mutation 52 25 10 II 3 1 6 4 2 I I I I I 12 168 9() SHE!, severe myodonic epilepsy of infancy; SMEB-SW. SMEJ bOl'derland w!d1ovt generill1ed spike wave; SMEB·M, SMEI bof. derland without myoclonic seizures; SME8-0 , SMEJ borderl:lnd fa.citing more than one feature of SMEI; 1CEG1C, intractable childhood ep.1\epsy wrch generalized tonic- clonic sel:tures. 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 67 of 145 L. ·"" h a: kia et ol. Molecular analysis Of the 188 patients examined, 90 (48%) had SCNJA mutations. Ninety-four sequence variants were identiikd in the '}() mutation positive patients as four children each had two d1rnges. In each child, the putative pathogenic variant was distinguished from the likely non-pathogenic variant; the latter was not included in further analyses (sec later and Supplementary Table). The majority of mutations are novel (72i90, 80%), reinforcing the mutational heterogeneity characteristic of SCNIA. Of the 90 cases, ONA was available from 76 sets of parents and 73/76 {96%) were de n!lvo· mutations. Amino acid alignments of the missense mutations show that thty affect corue.rved domains of the protein in other human alpha channels (SCN2A, SCN3A and SCN8A), chimpanzee, rat, mouse, Fugu and Drc1S0phila consistent with their interpretation as pathogenic mutations (Supplementary Fig. Sl ). Moreover, the probability that the~e mim:nse mutations are pathogenic mutations is .supported by their de r1ovo origin (in 34/37 cases where parents have been examined) and previously publ~hed obmva1ions in SMEI. SMEI Fifty-two of the 66 {79%) of patients with SMEJ had SCNIA mutations (Table 1 ). Forty-four.percent (23/52) of the SMElrdated mutations were non-sen.~e or frameshift mutations re:;ulting in protein tmncation, 39% (20/52) were missense mutations and the remaining 17% (9/52) were intronic splice donor o~ splice acceptor ~ite changes. These mutations were spread throughout the gene with the majority of missense mutations (14/20, 70%) localized to thc transmembrane regions of the protein, in particular the SS-56 loop of domain 1I that forms parr of the ion channel pore (Supplementary Table, fig. lA). ln contrast, 57% (13123) of truncation mutations were positioned in the intracellular loops of the pro tein (Supplementary Table, Fig. IA). Parental DNA was available for testing for 42/52 SME[ p atients who were mutation positive. Analysis of lhe DNA from these parent5 confinne96% sensitivity and specificity (Xiao and Ocfner, 2001 ). Additional direct sequencing was performed in five cases (two negative). fourteen of the remaining negative SMEI cases fr<>m our i;tudy were tested by dHPLC (3 cases) or dire~'t sequencing (I I cases) here. Eight mutations were identified (two by dHPLC and six by sequencing), bringing the mutation rate to 16124 (66%) for those cases reported in our original study (Wallaet er al., 2003). Of our SCNIA mutation negative SMEI cases on dHPLC, 2 of 13 (15%) were subsequently found lo ban whole exon deletions detected by multiple ligase-dependcnt probe amplifii;ation (Mulley et al., 2006). Other SMEJ cases lacking point mutations have been shown to have mkrodelctions includi.r.g the SCNIA gene (Madia et al., 2006; Suls et al., 2006). SMEB We £ou:id 69% of cur SMEB cases had SCNZA mutations. This figure is higher tlun the 26% reported by Fukuma et al. (2004) and more in keeping with the 88% mutation rate of Ohmori et al. (2003 ). The majority of SMEB mut:!tions detected in this study were novel changes (17/25, 68%), with eight mutations being previously reported in patients with SMEI (Claes et 11(., 2001; Ohmori er al., 2002; Sugawara et 111., 2002; Fujiwara et aL. ·2003; Nabbout et al., 2003a; Wallace et al, 2003; Fukuma et al., 2004; Kearney et al., 2006; Mancardi et al., 2006; Marini et al., 2-006). SMF.B i.s distinguished from SMEI by the abseni;e of specific features. The question of whether rnyoclonk seizures are an essential component of a SMEI phenotype remains controversial (Ogino er al., 1988; Commission oo Classification and Terminology of the International League Against Epilepsy, 1989; Ohmori et al., 2003; Fukuma et al., 2004; Draw:t er al., 2005). Dravet and colleagues observed that myoclonic seizures may be segmental or occur immediately prior to convulsiv~ seizures and they postulate that 5ubtle myoclonus may be missed (Dravet er al., 2005). Our data suggest that myodonic seizures are not obligatory as three of four patient~ with an SMD phenotype lacking ooly obvious myoader phenotypes of SCNIA mutations (Table l) The specific generalized epilepsy syndromes of MAE and LGS bad a low yitld of mutations with 2/10 and 1112 positive cases respectively confirming that SCNJA is rarely associa~ with these syndromes (Wallace et al .. 2001; Nabbout er al., 200Jlr, Ebach et al., 2005). The nosological bour:dades between these disorders, SM.EI, SMEB and other cryptogmic gt.>neraJized epilepsies are blurred. Indeed, in the large ·group of patients with cryptogenic generalited epilepsy of early onset where a more specific syodromal diagnosis could not be reached, 6/25 had SCNJA mutations. Two patients had a phenotype with features similar to SMEI but had onset in early infancy with abnormal early development and a more severe course. Others had heterogeneous phenotypes of generalized epilepsy with intellect11al disabilitJ• le.duding those previously recognized in GEFS+ families (Scheffer and Berkovic, 1997i Singh et al., 1~99). ln y.;tients classified as crypto~nk focal epilepsy, we identified a clinical subgroup who presented with a devastating multifocal epileptic encephalopathy. Of the five oises, th:ee had SCNl,A mutations. We designated this group severe infaacik multifocaJ epilepsy (SIMFE) as onset is in the first year of life and mulciple seiiure types occur, with the most prominent being focal seizures. Multiple types of focal seizures occur including complex partial seizures of temporal lobe origin and bemiclonic Table 3 Ep~eptic scir.ures. Video-EEG telemetry showed that the variation in seizure semiology was not due to seizure spread patterns. Focal myoclonus may i>ccur or even be brought out by specific anti-epileptic drugs known to exacerbate myoclonic seizures, such as vigabatrin. Patients may also have convulsive or non-convulsive status epileptkus, tonic seizures with focal features and ·lonic- donic seizures. lnterictal EEGs $how abundant multifocal epileptiform discharges. These individuals do not have generalized spike-wavi: activity on EEG. Their MR! brain scans are normal or show non-specific features. They usually have normal early .development fol!Qwed by cognitive decline, with the refractory seizure disorder cu1minating in intellectual disability. Abnormal neurological signs such as ataxia and spasticity may evolve. The £actor th.at distinguishes these children from SMEl is the absence of generalized absence a~d myodonic seuur~. generalized spike-wave activity OI! EEG, and that their cognitive decline may be later than the second year of life. These children had a severe, progressive and hitherto puvling phenotype, where extensive investigations had been performed searching for an aetiology such as muscle biopsy, lumbar puncture and liver biopsy. · . Similar cases are described in the literature by many authors (Noriega-Sanchez and Markand, 1976; Markand, 1977; Blume, 1978; Malik tt aL, 1989; Ohtsu.ka ~al., 1990, 2000; Bumstine et al., 1991; Oh.tahara et al, 1995; Nabbout and Dulac, 2003; Yamatogi and Ohiahara, 2003). Some clinicians regard this phenotype as being the Iawr evolution of a 'burnt out' symptomatic generalized epilepsy, but these patients never have the EEG signature of generalized spikewave activity, The phenotype could also be regarded as part of 'severe epilepsy with multiple independent spike foci' described by Ohtahara and colleagues where generali~ed minor seiz:ures are also emphasized (Ohtsuka et al.. 1990; Ohtahara ~t al., 1993; Yamatogi and Ohtahara, 2003, 2006). This group incorporates a. heterogeneous array of causes encephalopathie.s with SCNIA mutations SMEI SMEB ti = 36) CGE CFE ~=66) ~=2S) ~ = ll} SIMFE ti= S) Average i,gc seizure ONet {months) S.5 ~ 9.5 8 4 Clinical lea:ures Hemidonlc and/or' generalized convulsions M)'Ocloni; seirurn Always Always Always Often Often Occasional Often Often Often Occasional Always Often Always Occasional Ran: Other fc:.al sei:illres · Other generalited $eizurt1s EEG Genenlized spike wa-ie Mul:ifocal epileptlform activity SCNIA mutation1 Tn.mc~ion Misscr,;e Spk e lit~ Often Often Often Often Often Always Otcuional Oc;casional 52 (79%) 25 (69%) 23 20 10 9 SMEI, 1ev~re myodonlc epilepsy of infancy: SMEB, SMEI SIHFE. sE1ere infantile mllltlfocal epile~ border!~nd; Occ:nion~I 13 2 Often Occasional 6 (24%) s Ra~ No Occasional Always J (60%) I 2 l (8%) I CGE. cryptogenic generaliud epilepsy; CFE, cryptogcnlc focal epilepsy; 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 72 of 145 .... ·... :Jraio (2CC7), f5f;, CsJ- <:52 such ~ tube1ous sclerosis and birth asphyxia. In contrast, STMJE encompasses those patients hitherto without a known c::ause, with 3/5 found to have mutation! of SCNLA. SIMFE is an important ·group of patients with a deva$tating epileptic encephalopathy who are presently difficult to classify. The discovery of SCN1A mutations as the basis of their disorder avoids further potentially invasive inve3tigat;ons for alternative causes and assists in targeting therapy. For aample, anti-epileptic drug' that exacerbate myodonic seizures, such as vigabatrin and tiagabine, shoulc be avoided. This extcruive study of the role of SCNlA mutations in epileptic cncephalopathies beginning in the first year of life has, aot surprisingly, expanded the phenotypii; spectrum. Disorders are initially identified in a 'pure cohort' with a specific group of ~nlial features. M the molecular ba~is is determined, phenotype-genotype correlation result.~ in broadeniiig of the phenotypic spectrum to include mi:der cases c·r seemirigly unrela ted disorders. This is just begino1-ig to be possible in epileptology, as SCNlA. is the first gene shown to have a role in epilepsies ·previously regarded as cryptogenic. An impottant finding is that children with an epileptic encephaloJ?athy with multifocal features in the setting of nonnal MRJ may have SC.VlA rnutatfo:m as may children with cryptogcnic gcncraliu:d epilepsy. A strong indicator for SCNLA analysis is an epileptic mc;ephalopathy with sei1ure on~I before 1 year of age, even if cognitive decline docs not occur for SC\·eral years lhereaftec. The social and economic benefit in making a ddioitive diagnosis in children with epileptic encephalopathies cannot be underestimated. Neurologists continue to perform investigations looking for an aetiology in children with cryptogcnic encephalopathies such that establishing a definitive molecular diagnosis is cost-effective. More importantly, families are very grateful for a specific diagnosis e$pecially with the treatment and genetic q:iunseliing implications lhilt a SCNIA mutation carries. Supplemeritaq· mat~rial Supplementary material is available at Brain Online. Acknowledgemoni:s We thank the patients and their families for participating in this research. Funding was provided by the National Health and MedicaJ ReseaTch Council of Australia, Thyne-Reid Charitable Trwts and Bionomics Ltd. The Infmtile Epileptic Encephalopathy Referral Consortium includes Kim Abbott, Ian Andrews, Barry Appleton, Andrew Ble115el, Neii Buchanan, Christopher Burke, Anne Bye, Carol Camfield, Peter Camfield, Gabriel Chow, K~n Collins, Mack Cook, J. Helen Cross. Yanick Crow, M. Daniela D'Agost:no, Martin Delatycki, Colin Dunkley, Joe Fawke, Colin Ferrie, Michael Geraghty, Gail Gral:am, Padriic Grattan-Smi!h, Elizabeth Hallam, Lorie Hamiwka, Anton Harding. Simon Harvey, Michael Hayman, Ian Hufton, Peter Humphries, Pierre Jacob, Raimond Jacquemard, David Jamison, Philip Jardine, Steve Jones, Daniel Keene, Kent Kelley. David Ketteridge, Andrew Kim, Sara !Civity, Chris . ICneebone, Andrew Kornberg. Chris Lamb, Cecilie lander, Tally I,.mnan-Sagie, Dorit Lev, Richard Leventer, MMk Mackay, Steven Malone, Jim Manson, Ailsa Md.ellan, Philip Moore, Lakshmi Nagarajan, Margot Nash, Marina Nikanorova, Doug Nordli, Mary O'Regan, Robert Ouvrier, }ayesh Patel, Oair Pridmore, Venkat Ramesh, David Reutens, Peter Rowe, Uoyd Shield, Paul Shillito, Lindsay Smith, Claire Spooner, Geoffrey Wallace, Nathan Watemberg. William Whitehowe ~nd EWne Wirrell. Ueren~ Bcaumanoir .\, Blumr WJ'. The wnoit-Gas1aut l)'lldtomo. hi'. Roger ), Bureau !It. Dnvet C, Gcnton P. T:1&sinarl CA, Wolf P, editors. Epileptic syndromu in infancy, childhood ud idolnunc,. Monttouge: John t.ibl>C'y Eurotm Ltd; 2005. p. 125-48. · • - . Betlcovic Sf, Hukin L. McMlihoA JM, Pclelca110s Tf, Zulxri SM, Wit«~ EC. ct al. Dc-noV'O mumions of lhc sodium cban~l gene SCN IA in .Jleg<.-d vm::cine encq>halop•thr. ~ 1etrospectiw allldy. Lani:et Ne-~rnl 2006: 5: 488-92. Blume WT. Oiniul and doctroencep!Wo~phic correlatt"S of the multiplt independent tpllu S, l..mtt RP. Mu!tifoc•I indcpendmt cpileptifurm di~wrg., io cllllJrm: ictal com:Llt•s and ~al tb.ecapy. Nturology 1991: 41: 122>--a. Oacs L, o.:.favero ), Ceilem3CIS B, L.gac L, VAn Bro«khown C, De Jonghe P. ~ novo mumiuns in the sodium-d>aruid gwe SCN IA Cllu~ S!'Ycrc myoclonic epilepsy of infancy. Am I Hum Gtnet 200 I; 68; 1327-32. Commission on Oa~ificaiion and Terminology of tlic lntmuitioncll U....gu• againsr .Epilepsy. Proposal for revised cl9Ssification of cpilcpsia and cpilcpric syndrome~ Epikpsia 1989; ». 389-99. Oepienne ("~ Amma.nogjou A. Trouillanl 0, fcdirlstrae1). Neurology 1989; 19: 185. M~ncardi MM, SlriJoo 1', Gennaro £. Madia F, Par~vidiM R. Scapolan S, et al. familial occuncncc of febrile sciz.urt' and cpile1uy in revere m;-:rlook cpilep;y of i~f.i.ncy (SMEl) pati~nl) with SOI LA mllUtioiu. Epilep•.,, i.006; 47: 162!1-35. Markand ON. Slow &pike-wave activity in EEG and wociuttd clinical featurci: often oilled 'Len nox' or ·~oox-Gll!laut' syndrome. Neurnlogy 1977; 27, 746-57. Marini C, Md D, Cross !H, Guerrini lt Mosa.k SCN IA mutarmn in funiiial s:V\· 2006; 67: 1094-S. Mulley IC, Sdxlf~r IF~ l'elrou S, Dibbens LM, llorkavic Sf, Harkin LA.. SCNIA ma111t:ions lllld epilepsy. Hum Mntat 2005; 25: 53~2. . Nabbout R. Dulac O. Epileptic coccpb.alopathieo: " b1id ornview. J Clin N; S6: 127-33. Noriegn-Sanch'1 A. Mubnd ON. Olnical a.nd decuotncephalo~phic correla!lon of indcptndcnt multifocal spike discharges. Neu:rology 1976; 26; 667-n. Oglno T, Obtsub Y. Amano R. Yarnalosi Y, Ohtahata S. An i.nvr.$l.iglltion on the borderland of scvcrc mrodonic epilq>q in infancy. Jpn J Psychiatr Neural !988; ~2: SS4-S.. Ohmori I, Ohuub Y, 01ic!iida M, Ogfoo T, Maniwa W, Shimizu K, et al. Ls phenotype diffemlce in st\'t'l'I! myoclcmk epilepsy in infancy nlat-&t. Sugoma M. Oguni H, Fukuy:una Y. Clinical and electroeiw:phalognphic study of &eVerc myoclonic cpilep•Y in infancy (Oravd). Jpn j Psychl.atr Ncurol 1987; 41 : 41\3-, , Sugawara T, M:wki·Miraz;W E, Fukushima J(, Shimomurn /, fujiw-.ra T, Ham:.no S, et al. Frequent muutions of SCNIA in ~te mycxlonit epilepsy in inf.ncy. Neurology 2002; S8: ll22-4. S'11s A. Clacyt KG, Goossens D. Harding B, V&11 Luljk R. SchtcrS S, et al. Mkr~dclctions involving th.e SCNIA gene may be common in SCNIAmutation-negative SM£! patiena . Hum Mutat 2006; 27: 914-20. WgJl= R, Hodgso:'I Bl. GrUltun BE, Gardwr RM, Robin.son R, Rodrigucs·CasA DI-DJ/ linker Mfrtema/ Novel - non palhogttnic F 7 lntro11 I c.26S-JG>A IVSl- IG: A N-temii.nal [)e llOKI Novel F 6 Exon2 c.30JC>T RJOIW N-tenninal De no \ID Novel - th is study [SM EB-SW] M s Exun2 c.3020-· A RIOIQ N°-tenninal Denovo fukuma et al., 2004 [SM EB] SMEI f 4 lntron 3 IVS3-13T::-A DISZ ND Novel /nJron 4 c.474-13T>A c.601+JG>A ND Novel - non pa1hoge11ic F 5.5 Ew.on 4 c.495_496ins Novel g• F s lntron 4 c.602-t·IG:- A JVS4+5G>A Tl66fsXl70 IVS4+1G-·A DFSJ SMEI SMEI DISJ De llOllO Fujlwan. et 111.. 2003 (SMCIJ This study [SMEB) 9 SMEI F 3 lntron 7 c.1028+1G:. T IVS7+1G: T DISS-S6 loop V,,11ovo JO SMEI M 3 lntron 7 c.1028+1G>T IVS7+!G~·T Denovo Novel - this study [SMEil Nuvel - this srudy [SM El] II 12• F 2.25 Exon8 Denovo Novel Elt'1n8 o. I048_I 049delAT c.I055_10S6dclTG M350fsX3SS 6 V3S2fsX3SS DISS-S6 loop Denovo 13·" SMEI SMEI SM El DISS-$6 loop DISS-S6 loop M 4 E:con 9 c.!°197C>A Y399X DIS5-S6 loop l)e11ovo Novel Novel 14 SMEI F 4 DenollO No\"el · r ., DIS6 ~ML! c.12071'..-C c 1237T-·-A F40JL 15 Exon 9 b.on9 Y4Uf'I: ~ nol/O 1'11)\·0:I l6 SMEI SMEI F F KS47fsX569 IVS10+21>C IVSIO-IC>C ND M Novel Novel Novel 19 F s Exon 10 lntron 10 Tntron 10 faon II c.1639_1640dclAA SMEI SMEI 3.5 3 9.S 20 SMEI M 4 21 SMEI M 22* SMEI F 23'' SM El F 24 2.5'" SMEI SMEI M F 5 SMEI SMEI SMEI 6 7 3 4 I Pullllshed (phtuotypel I 17"' 18"' c,l6ll7dclC LS6JfsX622 DIM> Dl-Dll linker DI-OJI linker DI-Oil linker DI-Oii linkCI" Oenovo Novel c.2021A;·0 06740 (long isofom'I) DI-DH linkCI" Denol'O Novel c.2J48T:-C L783P DUSI Denovo Novel Elion 14 c.2562delA G8S4fsX876 DllS3-S4 loop Denovo Novel c.2589t3A,-T IVSl4+3A>T DllS4 De110vo Novel 7 rotron 14 Eicon ts c.28JIT>A V944E OllS5-S6 loop Denovo NovcJ 6 Exon IS c.2833P-<:: f94SL OllS5-S6 loop ND Novel 6 Exon II Exon 13 8 4 c.1662+2~C c.1663-IG: C De11ovo Denovo I 3:16-cv-00972-MBS fatic:nt Phenotype Sell 011!\tt l..M.&Uon Date Filed 03/28/16 Nucleotidt rhnni:" Pn:itrin -:tuan:::r Entry Number 1-1 Ptl'.'litlr>n lnheritaarr. Page 75 of 145 PubUs•oo !phcootypel I Noni# (mths) SMEI SMEI SMEI M F Exon 1.5 F.xon IS c.2837G>A R946H DllS.5-S~ loop Denol/O Fukuma d al., 2004 [SMEB] 4 c.28490;-A G950fi DllSS-S6 loop Denovo Novel f 6 Exon 15 c:.2893C T Q96SX DllSS-S6 loop ND Novel M 3.S c.30%delA EI032fsX I045 Dll-Dllf linkef Denovo Novel M 7 l:xon 16 Exon 17 c.3462delT GllS4tsXll63 Dll-Dlll linker Denovo Novel QJ187fsX1215 Dll-Dlll linker DenollO 32 SMEI SMEI SMEI SMEI El238D DlllSl-S2 loop NO No\ el Novel 33 34 SMEI SME! 26 21• 28 29 30 31 2.5 F s Elion 18 M 3 fa.on 19 c.3561_3562delAA c.3714A>C /ntron 14 c.2589+/G>C IYSU+IG>C NoP!!I - no11 pathogenic 7 faon 19 c.3733C>T ND f 7 Exon21 c.4219C T Rl24SX Rl407X DllS4 DUIS 1-S2 loop ND F DlllSS-S6 loop De11ow Nabbout et al., 2003 [2x SMEI] Sug1:1wara et al., 2002 (SMEIJ 6 E)(.(ln 22 c.432IO:C A1441P DlllS.S-$6 loop Deno•'<> Novel Exon24 c.4526delA NIS09fsXISll Diii-DiV linker De nollO F 2 4.5 faon24 0111-DIV linker Denovo F 8.5 Exon24 c.4S47CA c.4573C..-T StS16X RIS2SX DUI-DIV linker NO Novel Sugawara et al., 2002 [2x SMEI] Kcamey c:t al., 2006 [SMEJ) Exon /J c.181 /G~ tf Dl-Dllli11w ND Nov-el - flon pathogenic Diii-DiV link~ NO De110110 Kearney et al., 2006 [SMEil Thf11 study [SMEI) Novel Novel Novel Fukuma ct al., 2004 [SMEI] Novel Fukuma tt al., 2004 fSMEI] 35 SMEI 36 SME! 37• 38'' SMEI SMEI M This study [SMEil 39 SMEI F s Exon24 c.4S73C T R60'H Rl525X 40 41 SMEI F 8 Exon 25 c.4633A:G llS4SV OlVSI Ex1>n 25 c.4794T>A YIS98X DIVS2-SJ loop Deno~ c.48S3-14J;.G IVS2S-14T:·O D!VSJ De1tnl'O c.4933<>T Rl64SX DIVS4 Denol'O c.4934G>A Rl645Q fl707V OIVS4 Denovo DIVSS·S6 loop OIVS5-S6 loop D!VSS-S6 loop ND SMEI M 4 42 SMEI M 9 43 SMEI M 4 44 SM El F 6 45 SMEI 3 46 SMEI M M 47• SMEI M 9 lntron 25 Hxon 26 Exon 26 Exon 26 Exon 26 Exon26 c.5176T: C TlnlR Wl726R 48 SMEI F 4 Exon26 c.S347G>A Al783T 49 so• SMEI SMEI 4 c.SI 19~·G c.Sl62C.G F 6 Exon 26 c.S436G>A p 4 Exun26 c.S656C>T Denovo De11ow Novel Novel Novel Denovo Novc:l - this study [SM EB-SW] Wl812X DIVS6 C-teoninal Denol!O Novel Rl886X C-terminal Denovo Mancardi ct al.. 2006 [SMEIJ 3:16-cv-00972-MBS Pattent Plm1111:ype Sn Onur l.11tation Date Filed 03/28/16 NudMtirtP l!hange Pmtieln ttlt"lfP Entry Number 1-1 PMltfon Irtlterl ta nu SMEI Published [phi:DOCypcl I Nqvef# .(mth.s ) 51c- Page 76 of 145 M 6 Exon 26 c.S710CT QJ904X C-terminal Dcnovo Novel c.S765T. C 11922T C-tem1in11[ ~D c.235G>C D7.9H N-terminal Deno110 Novel Novel 52 SME1 M s 53 SMEB-0 M 3 Exon 26 Exon I 54 SM EB-SW F !! Exon2 c.JOIC'T RlOIW N-tenninal Denol!O No~cl - this study [SMEii 55 SM EB-SW M 7 Exon 4 c.512T>A l171K DIS2 DIS2 DenoV() Novel De novo ND Novel Mancardi et al~ 2006 [SMEI] No\'cl De 1101/0 56 SMEB-0 F 6 E11on 4 c.523a·A Al75T 57 SMEB-0 f 3 Exon4 c.5&0G:A Dl94N SI! SM EB-SW F 7 Exon4 d96C>G Tl99R OJS3 DISJ c.602+1G>A lVS4+lG>A DIS3 59"' SMEB-0 M 4 lntron 4 DefWVO Fujiwara ct al .. 2000 [SMEI] Marini et al. 2006 (SMEI} This study (SMEI) 60 SMF.B-0 f 6 Elion S <:.664C>T R222X DI~ /)e noW> 61 62 SMEB-0 F 6.S .Exon 5 c.677C T T226M DIS4 Denom Novel - this study [CGE] Exon 5 <:.6&0T: G r227S DIS4 ND Nabbout et al., 2003 {Jx SMEJJ c.7150:-A A239T DIS4-SS loop Paternal Novel OIS5-S6 loop ND Novel DllS4 Dll-Dlll linkcr Denovo Novel DeflOvo Novel Clac:i c:t al., 200 I [SM E'I) Nabbout et al., 2003 [2x SMEI] 63 64 SM EB-SW SM EB-SW M M 6 6 Exon 6 SMEB-0 F 6 faon 8 c.ll52G:--A WJ84X M 7 lntron 14 c.258~2T>A IVSl4+2T>A 66 SM EB-SW SM ES-SW M s.s Exon 16 c.30220;T EIOO&X 65 67 SMEB-0 f J Eilon 16 cJ231delA K1077f.X 1079 OU-DUI linker De novo No\el 68 SMEB-M f s Exon 21 c.4062delT Cl3.S4fsXIJS9 DlllSS DenoWJ 69". SMEB-M M 9 Exon 21 Exon 21 Exon 21 c.4168G: A Vl390M DlllSS-S6 loop 0£ nOW> c.41861'"~-0 CJJ96G De novo c.4279CT c.4949_4950insT Ql427X DlllSS-S6 loop DlllS5-S6 loop Novel Ohmori et al .. 2002 [SM EIJ Novel Denovo Novel 11650fsX\672 DIVS4 Denovo Novel Nabbout et el., 2003 [SMEil 70 SM EB-SW F 6 71 SM EB-SW F 6.S 72 SMEB-M F' 4.5 73 SMEB-0 f 4 SM EB-SW F 10 74 75» SM EB-SW F 4 Exon 26 Exon 26 Exon 26 c.53391'...-C c.53470: A Ml780T DIVS6 Denovo Al783T DIVS6 Denovo Novel - this study [SMEil Exon 26 c.S536_5539delAAAC Kl846f&Xl8S6 C-1enninal Denovo Claes et al., 2001 [SMEI] Wallace et al., 2003 (SMEil Kearney et al., 2006 [SMEil 3:16-cv-00972-MBS Paticrtt Phenorype Su Ontet Location Date Filed 03/28/16 Nuelec>tide cbauee Protein ehange Entry Number 1-1 PMftloa lnbu:ltallft {mths) 76 SMEB-0 f 3 Page 77 of 145 Publl•l'led lphenoty!HI I Novfl# Exon 26 C-tenninal Denovo c.5741_5742de!AA Ql914fsX1943 C-terminal De llOVO DJS4 DISS-S6 loop De11ovo Novel - this study [S MEB] Denoi'O No~·el c.5674CT Rl892X Sugawara et al., 2002 (SMEIJ Fukuma ct al., 2004 [2x SMEI] Exon 26 M ExonS c.677CT T226M M 5.S Exon9 c.l 183G>C A39SP M 1.5 Exon9 c.1265T>A V422f 0156 Denoi10 Novel Exun II c.1876A>G Dl-Dll !inker ND c.29l7A>G S626G M97JV DllS6 Paternal Novel Novel ICEGTC F 78 CGE 79 CGE CGE 80 Novel '2 77 81 CGE M 12 82 CGE F 9 Exon IS 83 CGE F 6 lntron IS c..2946+ IG:-T IVSlSHG~·T DllS6 Deno110 Nnvt:l 84 85 CFE (SIMFE) F 7 Exon II c.1724delT F57SfsX622 DenoW> Novel CFE(SIMFE} f 4.5 Exon 25 c.46281'>-C FIS43S DI-OJI linker DIVSI Maternal 86''' CFE (SIMFE) F 5 Exon 2S R\S96C DIVS2-S3 loop De111>>'0 87" CFE M Exon 26 LGS c.4907G>A DIVS4 DIVS4 De 1101/0 EAon 26 Rl6S7H R1 636Q Novel Novel Novel M 18 0.75 c.4786C>T c.4970G>A 88 DIS5-S6 loop t.1177C>T R393C E1.on9 M 8·T Ol480V Exon 24 13 MAE M 90 #Novel mut~tion.. n.:fer to those not previously n:ported, rx>tc that some novel mutations a~ RlC\lmmt in this cohort 4 De110»0 Novel Deno.c Novel De novo Novel " Patumh '>t.Qucm.cd b'f ·\ihena Di~o~t\.$ Mutations in italics were not considered pathogenic, see te111 for explanation, and are not included in figure I. SMEI =Severe My<>clonie Epilepsy of Infancy. SM EB-SW= SMEI Borde:l311d without generalised spilc.e wave. SMEB-M = SMEI Borderland without myoclonic seizures. SM eB-0 ~ SM El Borderland lacking more than I feature of SMEI, ICEGTC = Intractable Childhood Epilepiy with Generalised Tonic Clonic seizul'C$. CGE = Cryp1x>genic G1.'11enilised Epilepsy, 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 78 of 145 Lamotrigine and Seizure Aggravation in Severe Myoclonic Epilepsy Renzo Guerrini, "Charlotte Dravet, •Pierre Genton, Anna Belmonte, t Anna .Kaminska, and tOlivier Dulac 11111ilwu of Child N~logy Olld P11cllilury, Ulfl"Hl"lity of PiStJ. ltvtitute for CJilllcol Ru1arch Si.Ila 11/UU Foundatfrm., Calamlmme. Pisa, Italy; "Cmry Sainz Paul. Maneil/1; aJfd tNttAroptdialrle. HqpitlJl Saillt-V-111CMt-"1-l'aid, Pam. FN11C1, Sunmmr. (S~), flt1Tp01e: [n tcVCl'C Olyocloaic epilepsy of iaflncY multipb: drug-rcaisWll fOCll and general.iud 1ei.zure typea occur. l.lunolriglDe (LTO), fOllDd etr=lve In 111111y Fllmliled &lid pa1ia1 Jeimns, baa bem linle used In NMO cqc iD 1luu, md i.mpro\lcmcnt ha one. Thero wu >.SO'Ji incn!Ue in COl1VUWve .teimra 1n eigbl (~)of 20 patialtl. Myoclotllc edZllm! ""~in .U (33'1) of 18 patients. Of ftve padera .Improving ID It le&St Olle ~ type. four b.lld cla"ldbood epilq>iy ayudromca wi1h muJDple rei%U1e typet. We 1tudied the effects al LTG la SMB. Mr.lwds: Twenty-cioe panenu. with SME. aged 2-18 yean, WCR ftltod with LTG, 20 In add-<111 and one in IJIOnoeherapy. LTG WU swted II 0.2-2.S mg/lc&'day md lncn:aacd to 2.5125 mg/kdday. For each seimn: type, cxolwfulg aiypical absence&, >~ variations corapored wi!h die 2 lll01lth1 pm:mdi.11& Lro were ~&ldind indicawn of reaponse, also taking Into &CCOODt the degn:e of dlaability each leizure lype pnidua:d. lt~sul11: LTO induced worsenlq lo 17 (80'1fi) pad cats, llO concomilant wonming of mme ilavalidlein& teizun:a. Oc:ar-oit ~ appean!!:t within l tllODChs ill mod paiiam but was lltlidi.ous tn IOlllC. LTO was IUlpeDdcd in 19 plliam after IS day!-S yws (mun, 14 ~) WkbcmHequeat improv~ ~vere myoclcnic epilepsy (SME) in i.nfanli (l) i1 one of the most disabling epileptic syndrome•. Seizures begin during the first year of life in previously normal trea1mcnt af many genenliud and partial ICizure types in bolh adults and children (3-5). Although LTG is currently used in various childhood epilepsy syndromes (4, 6,7), coru:lusive data on itt efficacy in seven: epilepsies with multiple aeizure types are scanty. Add-on LTG in 18. Condiuion.t: The ~ seiz;&n detaiaration dUdDJ LTO lrealmenl 'MU not amibutllble to the mitumJ ooorse of die diseue md could be a d1rcct ct'lcct of lbl:nipeutic LTG do&el. LTG lre&Dmut sccma iDappropriate Jn SME. Jtey WOldl~ La111.0trlsiJie-Seven: m.yodcmic epilqisy-&liure wonening. children as genuafued or unilaQ:i:al attacks. facilitated by fever, and often occurring in the fonn of &talus epl- management of Lennox-Gutaut syndrome and nonspe- Jcpticus. Such seiz.uces are followed larer, between ages l and 4 years, by m.yoclonua, atypical absence&, and ccmplcx partial seizures, accornpe.nled ·in some children by clinfcaJ photosensitivity. Often coinciding with tbe 0111et of myocloxuu. there is a slowing in psychomotor development., patients being variably m:atally retarded from school '8C on. AU seizure types are extremely ceuatant to drug titatment. Although SME i• ~~ only in -1% of patients with epilepsy (2). the managerumt of these patients is particularly tin;ie demanding and costly, as they undergo multiple periods of hospitalization and antiepilepcic d.rug (AED) trials in which almost all combinations of available drUgs arc tried. Lamotriginc (LTG) bas proven to be effective in the cific funns of symptomatic generafued epilepsies bu been evalllated. with several open studies (7-10) and om conbelled stndy (11). Results appear to be favorable, as ~ in reduction of aiaoic, tonic, md atypical abteoce seimres. No data on the efficacy of LTG in SME are .vailable to date. A&r ptetiminary obeervationa of seizure awavalian in four patients (12), we &xamlned the nsu1ts of LTG tmitihcnt in 21 pati~ with SME, the majority of wbwn had ht.en auted with add-on in the framework of p~ tipective studies including children affected by different types of severe epilepsies. PATJENTS AND MEmODs ~..cd Ian111ry 6, 1998. Aderels -~ and l'ttJrillt t(.ll~ to Dr. R. Chic.zrinl ae lnstinllit of Child ~logy &ad Psyclliaay. V\a dei Gia:iot!. 2. 560\ 8 Cllammne, Pisa, fwy. Dau. were co11ected in three centers. Twenty-one pa· tieots with SME, aged 2-18 years (mean, 9 years 1 508 EXHIBIT 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 79 of 145 "" LTG AND SEIZC,'RE AGGRA VAT/ON IN SME wu enrolled iD a prospective Crial of LTO monodll::npy that was continued for 1 year. S~teen patiems were ineluded in prospective m.tdica of add-on LTG ~ Data for the rcmainia, four patients were collected ~t· rospecti-Yely. All paricata Wlderwmt EBO during wake.fulneu and sleep while ~ving LTO ~Hottever, only in 12 of the .21 pasie.nts wu one EBO performed within lhe 2 months preceding LTO ~ and anadler, designed to be comparable, durina treatmmt. 'Jbroughoot the period of LTG cnatmem, patien" were seen regularly every 1-3 months in the clink far evaluation of clinical. efficacy of the drugs md any ad· vem effects, duough geo«al questioning of~ and cliaical eumjnatioa. Seiz:u?e$ ~ teeOrded diuly in cal· endan by the patients' ~lativu. Treatment WU coutin· ued for u long •• it wu thoo.ght either to improve lei· zures or 10 have beneficial effects on patient well-being. LtG was disconlinued by re®ciDg the mainceaance dose lllOlllb) were treated with LTG, 20 in add-on and one in IDOllCthempy. All patients bad poorly controlled epi_lepsy. Ni~tecn had two or m~ types of seizure&, and two had C)!1C eeizure type only (Table 1). All paiients hAd been~ wilh various antiqilleptic dNgs (AE08), aingly or in various combinations. which had failed to achieve seizure l:OOl?Ol. LTG 'NU added to the pnicxisticg drug reamen. ataning with a daily dosage of 0.2-2.S mg/kg (tt.e smaller sm:ning dosages wm used to minimiz.e the risk of skin rubes, especially in VPA·tn:ated . pdi.enh) and increased to a maximum dose of 2.5-IO mg/kg/day according to type of comed.ication and clinical response. A twice-daily dosing mgimen wu used io all patients. ABDs wed at the start of LTG treatment are thou in Table 1. Concurrent AEDs were adjuatM de-. pending c,.n patient&' l'C8pOIUe, but on aa:ount of the lack of posith·e clinical response, in most panenu previous mcdicatic.n c:ciuld not be tapered. One patient (patient 12) TABLE L Mal" clinical JWJln1s of 21 polleNs wilh severe myoclolJic ~pilqsy Olld ~«ta of LTG tr~nt ... ht!lo. Aeaa: lit~ of!.10 11' 6 )'!S 2IM 2 yr 8 111.o 3/F .,,.,. - fol~ s.i.... tnicl bel\Q t:ro 4.2 Ho -()Q No Nyocl No 2YFI- ~ VPA. 'u N~ SP, No OTC 5mo ·l)'l'llllO ~ VPA.C2P 10 No Myoc:I No s mo 111' ~ VPA.CZI 2., No o~ No 1)'(1 ... 1 - ~ VPA. l!SM. 3.3 No oa No 2mo ~ 10 Ho OTC Ko 7mo ' CiTC. Ma t.fylx.l.Jll. I :r.M,00, M)"l<"I C".O.SP, CP. 2yr hr GCI, Myocl, T VPA.~. w · ~ llM 61f31DO ™ J :Y' j')""' 7 yr l mo UCl,Cl.M SP. Myocl (1J'C, M 6/P 3 yr IOll)t) 7/P IO)TIC•mo 12 :rr J!l;L ' ,, 6 JllO so VPA.OA JIQB !yr MJocl SP,Myocl, AA.mt: SP,30,M oo.orc. M.uLTG dcM ~~ ~ ~ No \ICl !'lo 1 ll'O -_ 6mo ~ 4mo .. 21'6lllO ~ Wotxllt4 My~ c::ZP ~ Ohc., ~ Dlncioll olLTO !Jr s r1 7 yr VCI. S(J, AA. 9lM 12 yr JS 11 me. M,oc~ llW ) Y" i "'" !yr,_ No No llbad,' No l Jy. l JT Ho oa l.l OTC ~ 1.4 a lll)w1, No ,,, Vl'A, CV', PGB 4 No t111il No 31110 avo.CZP. a.a 4.4 00. Ho No :2yr31llO Sdll lal:!ag 11.3 No No No s:rr•.,., No VPA,BSM cm:•.M)'OCI. 11111' 9 yr JO mo 17yr GTC. CP. GCl. VPA. 0-a PttT,CU VPA. OVO VPA. CLB. POll VPA. C2P Myect All ~SP 4 YT 6 mo OTC. M)'OCI. 00.M. U1il ... 711<1 O.S mo 1,,.6mo lyr 3 II» M1ocl No 4 ,)'T ~ Mrxt T_. AaP-'1111<111 No lTJM DI A .....¥11iaG i yr er 6yr 6mo 11.yr 1.,,1- Myocl VPA.Cl.8, Pft.01/G ~ 13 Y'I lllo No 7.S N)'Dd 00 00. MJOCI OCI. ore. 1911' 1.:ro .m.s No 4 Yr 9 .... 10 172. mo 4yr lW o.-11 T, M1oc\ llP 14'1' P..114.-q tftt.rLTG ~ ·l!W 12 Yr3 mo l4!1f6 mo l.C.~ WI' s yr 10:-r'- AA, .MJOC1, PB.C'D' ore, Myocl No me OTC No Na No No No N&• Ep/Jq1i4. Vol 39. No. .I, 1994 3:16-cv-00972-MBS Date Filed 03/28/16 510 Entry Number 1-1 Page 80 of 145 R. GUERRINT ET AL by 2S tr.glweek or lo 50% for 2 weeks and Chen to 25% for a further 2 weeks. To usess the effects of LOT, seizure frequency wu detem\ined for the 2 moolhs Jm!Cedill& LTO introduction and was compared with the frequency during LTG trtatmem. Variati.om >SO% were taken as indicators of improvement or wonening. Becauae epilepsy syndromes with multiple seizure types may show different degrees of diEability and varying respoasc to treatment. we usesaed !he efficacy of LTO relative to each seizure type, excluding atypicahbsences. and expressed a gk>bal impresrion of seizure.reW.,d disability. In geneml. convulsive seizure$ were considered m~ severe lhan myoclonic seiz~. which in tum were mote seven: than complex partial 9CiZ\U'CS. To estimale llei1ute-n:lat.ed dis-ability, we also~ the 1pecific acizure c:haraeteristics of each patient into 11X0W1t, became enensive ixttra- and interindi.vidwd \lariation wu ob!lernd in any given c.tegory. for .eumple, prolonged clooic teimres followed by protracted p:iweizure sedation were· found lo be far more diaabling than briel IOl'lio-clonic sei'ZllreS occming during sleep, although both are convulsive seU.ures. Because clinical detection of subde aeii:ures such as atypical ahsestces ls arbitxary, especially in mentally retarded children,' for the latter. we i:nuely requested parent& to pro'fide us a global impression of the modification in total quantity of absences. RF.sULTS Results an:: 1ummarizd in Table L L TG treatment proof the e,pilepric syndrome in 11 (809&) patienu, resulted no substantial change in three and in improvemel\l in one. Table 2 shows the culJllllative effect oo the main seizure·types. Then: was appearance of new seim'e types in thru patients. Analysis of the -distributio11. of the variOWJ drugs admioi&tered as comedicatioo in patienu who showed no aeiz.ure eucecbation compami wi!h tbose wilb worsening suggested that the aggravation w~ oot attributable to a particular ass.ociation with other du~ wonening m A£1>&. TABLE 2. Cwrwladv11 lljfectt of LTG cm tM lfl4in selt.!AtY The most important finding WU the >SO'll> increase in lhc freqaeney of convulsive aeizutt& (unilateral, generalized ctonic. and general.ired tonie) of 18 patients, ill one of whom a first epiaodc of myoclomc status cxcumd after LTG administration. Althoo&h an improvement in at leut one ieii.ure type wu roaru:t in five patieuta {pUicll.t'!l 4, 9, 17, 18, and 20), four of them were considered to have had no improvement because there wu a eoncomitaot worsenin,g of m bad improved er unchanged &eizmei claimed to have noticed an improvement in their child's behivior and al.mness (better contact. kn irri1&ble). For Ibis reason, trcalment was con-tinucd in JOIDCof !be WlChangcdpatieota (14, .,, 1.11d 21) at their parenis' request, even after a lack of effieacy on seizures had been obaened. Of the 12 patients who underwent EEG in the 2 mootbl before and during LTO tbeclpy, din:e (patients 6, 1, and l7) showed increUe in iaterictal paroxysmal EEG abnormalltiea. two (patienrs 1 l!ld 16), a moden.te alowing in bukgrmmd. EBG activity; aix (patienu 8-13) s~ed no change, md on.c, an improvement, with awbd reduction of interiaal paroxysmal activity (patient 7.0). ~· (21 palielffs) No cbln1e Myoclonic Absaice Cea cLciGl.c Gell TC CP SP ua Ill 12 10 12 6 0 3 S 3 I ' 0 1 ' 2 10 0 1:2 l 3 6 6 (l 4 .J ·1 4 1 Oc11, gea.etali7Ad; TC, taGic-edence can provide any reliable in-' formation ~ lbe cffcccs of LTO ao dlis type of seizure in SME. Although reslllts of medical tl'eatnlent an: in general disappointing ln SMB (34), VPA aJUi B7Da are p~fer­ ablc to other drugs. Jn these palicnll, PITT often no obvious advantage and may produce llXlnl Kvere side effecca trum PB (1.2). CBZ may wonen myoclonu1 and atypical absence aeizlRs (3~.36). ESM may be hc'lpful in reducing myoclonus. Amoqg the n.cw AEDs, VGB rqay lead to interesting result&, teducina <:0nvulsive seizures, but only in older patients in whom myoclonus is no longer 1 prominent symptom. (37). The poor zesults obtained, with a JDlllbd u:ndency toward scimrc aggravation, suggeat lhat use of LTO is inappropriate io SME. REFEUNCES 1.• Dm.t C, B~n:aa M, Guurilli 0, Giilud N, 'Roger J, Sev~ m~ cloalc qiiJepty ID inl'anu. lJt: Roiret I, Blll\llll M, Dnwt C, Dnifuss P81 Pmc\ A. WoU P. eds. E]JSlqtlc t:y"4ro1J1111 in Mf-c:y. c1U141JttJotl a"'1 tldok.rclftCil. 2:rid ed. Lond011: Jolla Libbey, 199'2: 7~8. 2. Guc.nkti R. Dnvet C Seven. epiJcplic cnCCflll&lcpallliu f1f infmioy•. Olhef llllO Well '~· Jn: Bop\ l. Pl:dky TA. cdr. EiJ'~~: a ccmpnha.Uu ~Pl>ook.. Philldci,llla: LippllllcouRave., 1997:221>~ l. Ooe n., llms SR. OWp P. ~e: • n:Yiew of ill phiu11191:0\~ p.ropertici .xill~efficecy in cpiltpy. D111g1 1993: . 46:1Sl-~. 4. lea& FMC, Wallat0 SJ', Dulac 0, Alvina J, Spelll:Cl' SC.~ G. l..alnotzi&ine fur lbo trea!DWat of epUqMy ill cbil dhood.. I l'.diatr 199,:121:991-7. 5. Butel\ A, Clucrrilti R. Belmallle A. Alc111Dad MG, Cltlti G. J'o. NCC& E. 111e inRPc-of doeqe. _,e, ud ccmedictt!oti en *8dyltale plllala .laJnotri&ine ~11111 ill q>ilepL!c childml: a · pnMpective lllldy with prdim.lnary Qt6"Ulmt of CllfM!atio1111 wi1h elin""1 respOQIC. T,..r Driq MHll 1997:19:100-7,. 6. Ve111oui P, ~ C. Rex fl. Dul* 0. Lamatrlgi.iM in il)famik spe411li. Ullu:tt 1994;344;1375~. 7. Schllltllbtrpr £.Chavez F, Palaciol . L. Rey f.. P•j~ N, Oll1ac 0 . 3:16-cv-00972-MBS j/2 Date Filed 03/28/16 ~ 1994;3S:l~. · 8. Oller LPV, ~ti A. n.unlla 1.. Lllmolligice ill I..ennm-Oattlllt S)~ F.pllqrla 1~1;31(.i:uppl !):SI. 9. Tlmmiap l't. Rlcbea.. A. LlmilC1igiJte u an add-oa dlaS iii !ho ~iw.trt af l.au!wc..O..taut S)'l)dronM:. F.tu HatT11 1991;32: JOS-7. M~lleu L, OalllgMr J, Mcwco P. for The IAo»dai Lana1.· 0-WU SllMfy Gnmp.. Imfl'wed neute!lO&ieal fwledoa 11CC0111418aicll e:f&ictlvc C01111'-bll.ad, pllr:tbo'1111\bOll.t c\lahlalioa at dw tafcty Mid efficacy of ~lie (Lamic1al) far ~ lz'l:IUDent at patiartt with a clinical diagnoeil of :t.c.iwil-Our.un syndtomr.. l!pilqJ1ia 19'J6;l7(suppl 4):92. 11 Gcmon P, Dmoet C, BU!Uu N, Fannoe& F, Mes4jl.an £. Aggra..a\i.cm of avore myoclonic: .p!cpay of illt'auts by lamcltiPe· a.o. 22. Ftme CD. ltolrlnocm Jtnctt C. Puayioqloulos CP. t.ro u add-oo d!ua in !ypic:lll ~ 11:izo!w. Acra Hurol Scaled 199-6: 91:200-2. 23. Itm!er WO. ~ It Clininl and maropllbolcgical findiila• lnacll.90 ollllVCft ~c ~)' afimuc;y. ~ 1991); 31:217...gl. . 24. Pl:rlaica B. The new ~11 cl lllllepileplio ckup: advatagcs mid &advucagu. Br J Clin PftarMacq/ 15'96;4i:~31-~. 25, 0111& Bernardina B, C«povllla B, OWllli G, oi 111. Bpilep&ie ~ ~ 27, 11. .a- J. ~ dlOclg of antic:plleptic dro.p: 'IV'litfi. Aaa ~ SoaNct 1'96~:.367-77. t•. l'enlcca B. C1nm L, Avam.tni l.. Cazbamat.ephle~ cpile{l&y lo cbildrD 11\d ~ P'41<#r N.ivol 1986;l:340-$. 16. Wlbi S. llG N, !ucob. ti, tt.-.mOlo Y, Rayma R, Cb.Iba S. Scvwe m, t .l.t~· 1 1 OE.PAR rMf. N r o~ ?ATHCLQG•t .5 R1C.l"4LANL1 M::O!CAL PARK COU.JMBIA SOiJTH CAROl.iNA .2920J RE.PORT !JF POSTMORiEM f:.1.AM!NAilON ·A.mended· AUTOPSY J:: AiH ! :; CHART SEX: t.1 ;.;l :~. ·-~ : ::::· ·· :·.. ~:.. t-.~.-...~· .t';_:•. ;3~ :.: f:·:~~·~ · ·.:·:.;; :" ;·; :.~:f;: .~. 1 ~i ·: .. ,.~.:~ :·~; .:···:· ~EIZW!\.!;: :t: . ~ ;~~:.z.:.::~~·.~::: ~·,::·l: ...·:~,f:.:.,.;.:. ·;··(;::~:: -:,;· .. r :' T·:) .. ~·:,· 1 r~·:.:·:; :~,r. C•Ut T;°;') Cf.i:\"?t 1(;A ( iO~S Of Ml~ or:H()N(ll~iAL (TYJ:ie'. NO! SPf:C!F'lt!.i'.'.!;. ttiSOR:!:1E~. r.: :'. .' • ~· . ~· .~ , ·•.' . - .......... ...,.... . . ... ----- ......... . ............... . . ........ . ~ w _, ~:i < EXHIBIT 'l 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 84 of 145 : ' . i. ' . : l'AlMETH~lEALTH )I ~lUILANt> PA!..METTO HEAL TH R.iC HLAND OEP.ARrMENT OF PATHOLOGY S R;CHLAND MEDICAL PARK COLUMBiA SC1W1'H CAROLINA 29203 REPORT OF POSTMORTEM EXAMINATION NAME: OOB: AUTOPSY# : A08-10 RACE: Ca~cas•an 12005 !Age- 2; SEX:M HOSP# : 999A08C ·.o DATE OF AUTOPSY : 1i6..-?v')':: DATE OF DEATH :i.:5i200d PROVISIONAL REPORTEO: i/7i:.!Ov8 REQUEST OR: G.ARY M WATTS PROSECTOR : CLAY f!... NICHOLS MD ...r :s ;.~JP.··· i~ ; r c~ r;.., r ~' ~ :)t t \..~ ;~\'Li.;c; :; :_is;;~:.c:·: t: n ~; t i"~ :. ::-~ ~ · t: '7i ~()P. ·· ;,.: ~: ·\ t .;~~ '-~::. ~ i... r:. F:·:;~~ ~j ~ 11..U~~.:. <;; :,; E::;.;_:. ~.::::/. ;..~ ·:· ~ ·:) ~.·= ;·r ...·-;.(~ 1..:: Nr·~::~i;.·. ~}i$C~'-:D~.~··: ~Y~f. M:JT s~fc ; F1F.; D .. £.~~f OE ~ Tlj. '3C..:u:..:E. t;.<.;t: ro C•lS()R::ER ~iY~~E . ............ - . CQ1.l?~:c.:; NQ7 h.1.:::r.'i ::~. : :.~ri'OC.HO~·mRi;.\. 5~~c1r1~r: , ... .............. • i :01,;:, ();: ;'.:~.s 7 - ............- ··--···--·-·--····..,-., .. ...... .. ......._..... :: 1,:,:· \ . -.:. ., . !. ~. 3:16-cv-00972-MBS Date Filed 03/28/16 ..:, ···. "' . ... ·.·· .... ~ ..... A•.n t:'1.\~·e<."(J · P.~r1s rn! . " ..... ·. ·: ·\.'.ii:".· . . .... ,, .. · ... .·. ...:,:' ·1· ~ 'i"" ~ · ~ •: -.~r. "':~~· ~ ~;,.:'7. J·'.'i~ V·t.H~~ J;;g~t)Ut L~.llC- : : ... : R~· ..~"»r.·n · r:.·.·: . t:.... . t P1.::-·;\)u:;. Si~1rn,,t . .; 4~ ~ . ·~ • • ;~! : .. C.ttP.: :: '. .: ..·: Entry Number 1-1 Page 85 of 145 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 j:)ALMETiO HEAL TH R~C HLAND DE?AR TMEN'! OP. FATHQLOCY I .HI 5 RlCHt.4ND MEDIC.AL P.C.RK COLUMBIA, SOUTH CAROLINA 29.203 REPORT or POST'MORTEM E XAMINATION • Ame !i<.1& i !.::.: t;i:.:.;;..:. OF MlT-:.·;:-H.CiNDR~At 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 87 of 145 Af.J 'P'. ··" ·· :._ : .. :-.. • ! - ·.. < .. ., ·:•. ' . ·· Am(? ''cl. "1......~!,tS ... ... ··-····· ····-·"' •" __., , , 1-'\ ry"\t t'\'SC•:t. ~.l' J~Cr. , ..... . ~ ·., ·-- · ·····- ·· --- --~ · -·· - · ·· --·-·--.----- ;. : J. ; ::~ ~ ::·:- . .... ·.:: ~ ·,· :' •• I ... " ~; <. ,., f-~iC'V i.~l.i!t Si g ~f.1 \J~ t},) ~ C : ~ ~.· : ·~t .:.. :. ' .' . .. -·· ··-.. ·-. - .. ~ ;,; 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 88 of 145 '-· 'Pf·i..Mt fl"O Hf."'\!. Hf R/r,~H !..ANO Of.PAf•!lMENf O F PATHOLO GY H 5 RiC H .AND M.EOlCAl PARK Ht.\:"{) COLUMB IA. SOU"!'H CA.RCi.iNA 29103 RE.PORT OF POSTMORTEM E.XAM!NAitON l'.·U.MLTH~ILALI )I :uc ·CHART~: REQUESTOH; c.·,\RY M v:,·~.TTS :;,.~ !,:.g._GT..R !'.·~I:i 5 F.tL \;R ~: Otif'. f4:r ,:;1:1,'\M:;.1Cl\ 1'iON S o··~C:r!~·f. R. .- .. ( '! 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Page 91 of 145 3:16-cv-00972-MBS Date Filed 03/28/16 STATE OF SOUTH CAROLINA COUNTY OF RICHLAND Entry Number 1-1 Page 92 of 145 ) ) ) In the Matter of the Estate for Amy Elizabeth Williams, Personal Representative. ) ) ) ) ) ) AFFIDAVIT OF MAX WIZNITZER. M.D. ) Personally appeared before me, the undersigned notary public, Max Wiznitzer, M.D. who being first duly sworn deposes and states as follows: 1. I am a pediatric neurologist at the Rainbow Babies & Children's Hospital, board-certified by the American Board of Pediatrics in Pediatrics and board-certified by the American Board of Psychiatry and Neurology both in Neurology, with special qualification in Child Neurology, and in Ncurodevelopmental Disabilities. In clinical practice, I commonly treat patients with seizure disorders, including Dravet Syndrome. In addition, I am a Professor of Pediatrics & Neurology at Case Western Reserve University. 2. I have received and reviewed the SCNlA DNA sequencing diagnostic report issued by Athena Diagnostics, Inc. ori June 30, 2007 (Exhibit 1), along with a second revised report issued on January 30, 2015 (Exhibit 2). Additionally, I have received and reviewed the pertinent medical records pertaining to the decedent, The Decedent Suffered From SMEI: 3. clinical history is consistent with the diagnosis of severe myoclonic epilepsy of infancy (SMEI or Dravet's syndrome) and clearly details the presence of the clinical evolution of his seizures. 4. In agreement with the revised SCNIA diagnostic report, issued by Athena Diagnostics, Inc. on January 30, 2015, the variant 123 7T>~ Y413N is a disease~causing mutation, causally related to a clinical diagnosis ofSMBI. 5. Specifically, the decedent's DNA mutation (1237T>A, Y413N) in the SCNlA gene not only possessed the characteristics expected of a disease-causing alteration, but it had also been correlated with a clinical presentation of SMEI in the medical literature. (Exhibit 3) Y4 l 3N = SMEl (Table t - Patient #9) [2006] Berkovi<: SF, Harkin L, McMahon JM, Pelekanos IT, Zuberi SM, Wirrell EC, Gill DS, Iona X, Mulley JC, Sclteffer IE. De-nova mutations of the sodium channel gene SCN IA in alleged vaccine encephalopathy. a PLAINTIFF'S EXHIBIT ·0 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 93 of 145 retrospective study. The Lancet Neurology. 2006;5(6):488-92. Epub 2006/05123. doi: 10.1016/sl4744422(()6)70446-x. PubMed PMID: 16713920. (Exhibit4) Y413N .. SMEI (Supplement Table 2 - Patient #l!S) [2007] . Hamn LA, McMahon SM, Iona X, Dibbcns L, Pelekanos JT, Zuberi SM. Sadlelr LG, And.ermann E, Gill 0, Famll K, Connolly M, Stanley T, Harbord M, Andcnnann F, Wang J, Balish SD, Jones 10, SeltwWK, Gardner A, Sutherland G, Berkovic SF, Mulley JC, Scheffer IE. The spectrum ofSCNIA-related infantile epileptic encephalopathies. Brain : A Journal ofNcuro\ogy. 2007;130(Pt 3):843-52. Epub 2007/03/10. dol: 10.1093/brain/awrn002. PubMed PMID: 17347258. 5. It is my opinion, to a reasonable degree of medical certainty, the decedent suffered from SMEI secondary to a mutation in his SCN IA gene. This was the sole cause of his epilepsy condition. Negligent Failure to Properly Diagnose SMEJ And Treat Appropriately: 7. An individual with Dravet Syndrome has a significant chance of surviving into adulthood. 8. Sodium channel blocking medications, such as Lamotrigine (Lamictal) and Carbamaz.epine (Tegretol), have been reported in publications to worsen seizures (pronounced seizure deterioration not attributable to the natural course of the disease) in patients with Dravct Syndrome/SMEI. Specifica11y noting, that "once a diagnosis of SME (SMEI) has been established, CBZ (Carbamazepine) should not be administered." These publications include reference #11 on the decedent's SCNlA DNA sequencing diagnostic report issued by Athena Diagnostics, Inc (Exhibit 1). {Exbibit5) [1998J Guerrini .R. Dravet C, Genton P, Beb;nonte A, Kaminska A, Dulac 0. Larootrigine and seizure aggravation in severe myoclonic epilepsy. Epilepsia. 1998;39(5):508-12. Epub 1998/05/22. PubMed PMID: 9596203. (Exlu'bit 6) [1986] Hom CS, Ater SB, Hurst DL. Carbamazepine-exacetbated epilepsy in children and adolesccnu. PediatrNeurol 1986;2 :340-5. PubMed PMID: 3508708. (Exhibit 7) [19961 Wakai S, UO N, Sucoka H, Kawamoto Y, Hayasa H, ChibaS. Severe myoclonic epilepsy in infancy and carbamazepine. Eur J Pediatr 1996;155:724. PubMed PMID: 8839737 9. The decedent's medical records reflect treatment with increasing doses of sodium channel blocking medications, including Carbamazepine (fegretol), through the end of the child's life. The seizure patterns of the decedent, while being treated with sodium 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 94 of 145 channel blocking medications, were consistent with the conclusions detailed in Exhibits 5, 6 and 7. 10. The decedent lost his life on January 5, 2008; the cause of death was a seizure (Exhibit 8). 11. It is my opinion, to a reasonable degree of medical certainty, that if the decedent's SMEI condition had been properly diagnosed and had he received appropriate care for the treatment and management of SMEI, he would not have suffered the fatal seizure on January 5, 2008. t~~ "3 , 2016. - Swom to before me this Day of F<.-b _9.~~~ ~ic ~ ~ta.te of Ohio My Commission Expires: 2. \ 23 lllp ""3-d-1-(J.0 I~ 3:16-cv-00972-MBS Analtiagoosta -"- ....&!. Pi!ialll /2005 HI fflB DNA 1estCUQr,q Atqi.;:~i;y~· :M: ···· .. __. ..... -. · .... __ - rnn~'" - ------ - ---·-·· ·--·-·· -· · John Shoffner. :MD ~····· ···· --····-------·· ··--···---··-- - - -- --·-··- ·· - - - - - - - - -·· ... - .... • .......... ~250 Atlanrit, GA 303"38 ·i.iiiilr<:;arZl;fl'...1:1111: ·- - - - - -· - -·-· - ·- I ~ 'IhiJ indivi&lai pvssesses a DNA sequeoce variant or c:ooiliinaliOi.1 of variaib in the SC..VJA. gem: whose sig.aifk:wce is m:i::nown {Ir~1s~ vru.im>.t £?f lm.kncWD sig;_..YJ(eswee). ·r~ of th.: b~~ad 1lftrez1is fl ~·m.NA V1'.riaot l; Nucleotide Position: Tr.wsversion T 1237 O:ldon: 413 Amino Acid CJ::.aoge; Tyrosioe Variam Tyy.i: > >A Asp&~ Varlaut of\..'fll;nown ~ (he!eroz.ygous) Ho oth:::r cl1nonoal DNA scque.aa Yammts We:'C ~fled in tbe remaitvJer of~ «.ding sequ.ena: :md imroale::wn jw:i.ction. ·C"mmenis , J ~ r ..' . R!ml:: w..~!t'niie. . Pa-----·· Date ----- ----------- - --·-···- ···...... -.-·-·- NO C~l Oii.i - ------- - · ·- -··-·- --· ·-- .fot·eq,n~tatfou 07025148 000000000 . One 0-;.tnWwdy P'Mk __ _... _ .. ···- ··-- ·- · Pagel of 6 OiannC1sis Senriee Report · ···· ... R:;iii'lii' .··- - -·· - ·- · ·--- -·- ··· -· - ..... .. .. tll/ititt.ll .ms. (800) 394-4400- (5iJ8) 756·288S SCN~ ?~-~-~ng ____Ti_est _;_ _ __ ..... ..... ~'T.lf 06lllOslleSirtnOrB~Ga111r Widiynw6: m !fiatS1nlei. -Z-Aln ·· $iii:lll Se:u~ l'iamb•J Ti!t· ~~isld . Page 95 of 145 J~h. lfAllt7S2 ·- .. ·- - ........ ·-.·····-·· Diagnostic (Symptotmltic) Entry Number 1-1 www.AthenaOfagnostics.com -se. ~!)llSil!JI Date Filed 03/28/16 l.'.iilim& ~!ltd in be3ign polymotphisnb:, the n.ahlt~ of this variation pnrlmles dear intttpretafioo. Tuere DNA seciv.ence •,rari.mrs Jl19¥ or may not alte.r the ...... ·····•· -· 05/03f}J)fj1 ·- · - - - · -·· - -·- - - - - -·--------- --- P.r.p!ll\D:o'= 06/30/2007 - - -- - - -··-·- ··-·- prom tinr;tioo.rd a:!lf?tdS of the SCNIA gen:: atd /or. ia :vroducL While smthodologically NlCOD11r:, Ole resu:u of l1Us mlt'l)'Sis cannot be defiailive.ly interpreled due to the absem:e of published ltlldies correbit:iug these v.uiallt(s) with clinical J>4~ 8l'ldfor pdolozy. Therefure. based on ads !liBgle 2.D.81j'ais. it ?s not poeaible to conclude with any reasonable degtet of dinical ~ at um tim! whdher or not ens W«imt is 8llOciat.ed wirh uted awl i1 it •,i:ery m!i};dy tfu1 Ibis m>!.atlon is !t!¢.onsible 1:br clinical S}111Jl0ms or ~ risk ot disea1c. Arra:t.00 willl JfSS ievete GJ!d!'S + ~ epil~y with febnle seizures plus} - Ille varitmt is au ~~d pa:hologlc muiation tb31 does not C3USe SMm. but may l.ie associm:t wit:1 less ..-ere cliDi.cal s~oms. Affected with SMEI~ 1bl1: variant is an UDiepOIU:d patbotogic · mntatian and is therefore~ widl the dise:He. Odler wuiaJda of kn sJgnif'~ This amlysis may II.so have ~ ocher types of •qoeoce variana u li*'1 .in the 'rcdmical .~its section,. n common ~ tor an amlys.is of thiS ~ However, in the CODfl:x.t ofresults teported, the pmicore of addidonal aequieuce variants ii ~Y of Mduced ai.grWic:ance sod does nct modify dJC fma1 ~retdion of the test iaultz. Beoign p::tlymotp~lll3, if idr.a:ified. are C01'.lsid.ered noJ:IJlll aDCI are rot reported m tile Technical Rar'Jts sa;tiou 01~ this report,. but are available upon requ«:$t. i>feas ; 5 - ·- - •......... ·-··· ····------ -· ·····- ·.......• - ·03m.t.0,_ 0iiltlo,...,.•ll. ~!C,.ADIWJl! t\"21i'l4 ···----------- -· ~ < C) ~ w ~ ID :J ... EXHIBIT _L__ 3:16-cv-00972-MBS . A F.iiiiAf' ..• - --·.······- - ·-·" f2005 ·s.n.i Scc11!\:t /b 1.-.v M --. - -- -- · --- -~s1lliliiiiii~-· -·· l""'llQl1fD ------ -- ·--------- John Shoffner, MD Sui!e2.50 Dqnostic (Sympromatic) --- ·-- .. ..... .•.. TiSI flecp.~d SCN1A DNA Sequ.eocing Test '• -·· ·-· ·---- Ailii.ma, GA 30338 ----- ------------- - __________________ .. ...... . ,. Patcn!ru wstmg and c:het ful!ow lJl> m:omm.cmdadom: T~ of tbe biological pi!IC::D is ~y ~.d (!or w tdditiomd charge) to hi!l? rcsn.'ve die UDCC'.t".ain1y of Chia seqtt...mce vnri:mt'• p.athugenicity ~ tilt; llllCCrtaimy of 1he predi:ced p~. Mis.Yemc mocatiom causi::;g the se'Vl!tt. Jlll.enotypes a&'IOCiai.t.d with SCN1A 11'111tstiomi (SMBI C'l' SMEB) ~ US1lally (>g.J%) de novo. ~DI UW. llle mutllioo Ill'<* in tile atfectOO individual, mi is Dot detec:lld in lb~ bio1ogf.cal paim:B.10 Millscnme ~ US'.>cillld wi~ th: mi!t1~ p!len.,;~ (GBPS+) are usually (>9S~) i.nberitcd from one of the biclogiet:l ~DJs . ]() Copsnlttcri ;.Jith Atben:1.'s rat ootmselcr {!~3~-493) is ree~ded !Jrirx ro ~tal testing. j .., °SC<".sose SCHlA m;Utions can ~ icilcr.itcd, tbi:! inaividml•s fim:fily members may be at ris.t fur ~':.!Sing or mheriting lhese lDt'ZllOm'I.. Careful reooncili::tbou of rbfs rmT~C'Jlar do '!;ith thls iOOividl!al's -:-.Ji!lical m:.1 family hi.st.oi:y is hiJP.?ly .n::co1IBT1!.BLlcd. A!heca re:comm!Dds g:Cnclic counseling tor :I.bis iildr»kt:W and lds or her JBnilly memiJei·s., 2nd ccas:idcntia.11 of pJRUt:al ~- !>?ell~ contict Atl:cna! Clie'!Jt Services at 1-800-39-1-4493 or· visit -ww~·~~.C-,); ,.,! l{,f~ Date Filed 03/28/16 F..11111.tlllll 06/3012007 Badcground i:of'orm.atioo: SCN'lA enco;fes for the n\!Ul'OOI •:ollag<>-1~ K'diurn chaur.lr.l alph.""S l mbaoit pro-~ Ml;tatton:s in th SCNlA ~ bavB been nsaccla2rd "°ith aevet'll!. O\"Crl.apping epilq>~ sy--~ wiging from XVC!'e ID mild pl.ltMtjpeS (SMBI. SMlm. m GE1lS ·1-). 1-lO l b l!CYete pbeno~~ ..inctucte SMEE, SeYC1:e Myodou: .Epilq>ey of !8fiuley or Drll";et !)l!ldro.l:m. N:'d SMEa (SMEJ. border1ioe with KJl1IC. bbl llOt all. of the dusical fea~ af S'MEI. GEFS+ Gcmraliied Epilepsy with Febrile Seizures Phls. ~ a nmgc o p.limot};t8 from febrile seizures ro mild gmer..&.ec! rommm • includes aeYere ·cpilt{Kj.c eocqJbal~. 'es, mdlesa SMP1 ball t pt:i-:1! propmit. indwling ~ dela.y md l'l:fncioi:y ll'Cimres. PmtbC:mlorc, n lr~1acni QJ:llfit·f ll>'!il fliugnolis c'f SM:m ·~ ~6.1 pid ·rl«Whln&. u SCN t.>~ mntatioos t'ill broall.Jy intD tr-10 p.JPS- MO Tr~ malalios Hmt BCYCrdy disrupt tli= gcv.; ate ususlly assocjarcd with ~ ~ u:h u s:t.mI. M:isscm~ 11BJl211iOB& are ~ widl . r~ af p~ !icJm mild to Je'TC..'1:~ Molt mbrioDll .dm! cans Sl!rlEi arc dG oovo. « spora:W; ~ in ~ ~ irdividual ntthc lball bellJ8 ioberitr:d)3.S,10 BD ~pattern that am b~ ~ 1.Y testing ot pan::olL Pawilial mutaliGr..s . ~ us:Wly a:sociad Widl mil ~ but can be aer:n in SMID. It is nocewonby that !l011~ mnrnnon carrk:n IUi variable e.'CpteSliao of a:flhctal c:a:rricn have bP'A obtcNed in these symdtwns in ~ &mili.es. This ~ tru modify.log faclOD inftueaoe dae e.xpmrsion of diseese, eod .IDdiada 1lt£ lflC mnlccWa: analym ant be cacctlally teOOllciled w1Cb die c!Dd pn:acneation and family bistmy. __________. . _____. _...... ___,," ' ...... . .... - ...........- - --- 3:16-cv-00972-MBS A ;, diagoostir.s {800} 394~9! • (5ll8) 75&-288G 9 M ~-r.iCTir'ii<·i)f; ·- ·- - Dl-lA -:t..aut1 m'""s~ . -=r=nr.~:-.1CI:=:'SI ----------- - --SCl-l - -·--&:>cnJ -.-s,~;u:-~ ~tlCf'l-ttl1~ 1~ .~JSrunld my ~ clifil-.;3!1~ simiiar to !:!:le.~ ~~c! t::k1t.:t1~ i;:o: t.."li~ SCNlA gene. Allllo~gh f~ c.JIU'CSll " ' ~11~ di~'r4.!i!JI. m!}' Vlity, patim:.s wit!\ a ;,y· -· ,.._ ..• ·- ·--·- - NODare · Aet.1-0CI" ""' - .. ·- ---- -8-tlla· ------------·----·- a~rtOII13a':d ~ °?«G~/~~~J 1.hllrlllill 05103!1£{)1 ~~-iii: J);m;t.,fi(llKls et Mirr!. . . ..=.A {ltr.;2 ··-··· ·--··- - - - - - O:'li. Entry Number 1-1 www.AthenaDlagilostics.com ....&:~ ;;;::r,:;-,-'. - Date Filed 03/28/16 05/30f.l001 seositivit.." 11pproadling99%. All.teat. nisub are reviewed, inteq.trea:d, imCl ~ by ABM'G certified Cliaical Molecula.r Gemticisls. Nucle-Otides aD-1 miino acids are numbered tbllowing the inttmatjonaJly a:-.::cepted. ~:!Jlll:e su torth by 1he Ac.I .H~ ~ on Mutation Nomer..zbtme. Tb&'! initiamr ClOdon, ~. is dcsign;ed as codon llWlil;er J in fle cDN>.. Thi! "A"' f1f tho • ATG'' !oitiat.oI oodon is designated as noc:teotide + 1. A.bbm!iation.r rssed: . Im'gressive myocluaos epil-:psy sh.are isome smill.u f!atmes to syodron\:lS cmised :,y SCN'lA. matnfons incb::dirg Iil)'t'clooi.c and tonio-do:!'-:C ~in;.!$, ~..ili, 1..".IC aboc'1T'..J8.J ~~<¢y;;ltot.:i-~1l ""-"'·ef.opmer.t. l'.:bel1:L offeu t ...sring-fc: :!hr« l~ -:>f pt\•grt...,Q\:·e :inyo~lnnc.:.~ epilepsy, E'Ph-f!, W'.>t'a ui:r:.·s~. :mi! MBRR.t-:-. t(~ .:.;&11 fuither assist t?Je di~s of Y(lllJt paticm's symptoms. SCN!I! f:r,~:v1.7Flal -,,;;11lUft!·:taA'.1.tif:J frt:t't.'" lf&{)(.·flmi<" q•i.fl!J.>$>' af ilifW>1.J); ,<;W,8 f!Jtwdtrlhil. SMJ:.'TJ; (:KFS f (g0$:•.J"li!jlJ"(! tpiiept,) Kith fe'1,.;.ft> '!l!i.~ pktrJ: l\fethods ~.k m .f.r~vsis of ?he SC/ti.A gene was 11cr.."auned by PCA ampllilcation cf hi,gl:Jy pa.r~..cd gmomic Di'U.. fu!IO'Mld by ~ tmi..directiooal .DtM ~.;:g of !b.:-. 26 <:.'\:Cir-~ of Ch~ SCNJ.A. gcoe, im:ltXlina th~ hi;;ruy rotl~ni.'!d euJt1-iumm ~·~ janctio..tl$ (e.g. C'l'•... AG) ~ · :iU l•:i ~~it.I~ ev>ns. ; A.it ~&.·1'.'JIW seqw:nce vaiian:; were ~ by oi-ci;T\'~twml ~~iJcudog -.:- atn::cw.~lar. ~cqUM"llCin~ ~.._.. arr ~ a.t a.'1 ove:rall ___________ . .... ....... ... .... ~~-~.;.- ~..:.~-· Sturues m Ibis sma!yne ··· --..•···· ............____ ONA {lil'.in-.i ;1'JU:atiom, OODSC'ltiC n:uwio:illS. a:nli &tel~ or duplJutlor.$ 1>! entire e;u30$. Cttm:nt Jllet:\tnre ir.--di~ ht n,.;A ~nt;~ Vl'.nau'-'S ,;•f tll!s t}'J"~ ~ msociabld with di.o:aae. Jl"w~:::r, . Jue t*'1 ~ch. ol' un!.'1'1m".at .:;:igsdfi.'.!'<NA seqaet:ce 't'1.ri3r.l!! UMt1 are ~kll.ttd ·~~l\:ibl}. be:. hr.Ye nm ~ CCJmhiaid with d 1wail 1m:~.nrllfioo aoc¥.1)( pafll~o.!t' i!\ :tre .:-.;..::rent ii1Lr4twe, da they rewlt in .'l ~-' p:"cll~·\'l'Jed tt Ile' ft•WJd ill MlY a.:ie .....~,~ nf • ~...;)Ii. ta~ ~owism tn;.· r1~f.~t" .:.! t•.1t: d i~ . Hcw.e \:tt. r. i.~ a.;~ ~l~m!: tu t.a~e mare t:i.aa 7 ~\'i) ~)~ ~"!' JJNA ~ v.xria~i; da"..l;:led ir. ! ~~. Li Y-O!jf>D, 1f;·~ ~l11:1a.l ;;j~. o ;· ir.divifkJ!. \'~l t).-pe.$ c!ffm w;.C!eJl. 'Tfu: l>.NA uri.l."li fy~-c :o!"..d 11\ii.:i!icna! t.e.n~~· utllift in .!~; CtU!t '..bt 'fedm:i!!.lll ~St'df'i 0>00 c.>no-,,:urJ. :f!c-cfam !. Kam Mot f M;.:f.ui<>'t. updat<., ~uhJ:I:ia.:.d) ) J. C.Ul:n-lu P. :!t·aJ \ J.9'J~) l:i;:>il~~in 3'l: 51.r.i-S 11 T -··· ·- · J..' ~ a1 1"J(J04) P{'ih.-p!!i-3 .;5·. i41)...f.t8 1;ujhv~. Kanai, K --- - - . - - - - -- Page~·af ~ 0"101.5148 - · ·- ~ D1agnostic (Sy.mptJ.llDlttic) ~. JidrH1rrtfj(Jn mu-~~ .s.~ Jclm Sltofl!tt•.MD . ·-r Page 98 of 145 ~93 - (508} 756-2885 M Testj{jqllssled ... - -··- ·- w-.,.. lilrtmflf lisz1 Milrt01i_1 \ 1lA l!m2. ~·~····---··-·---­ J)r\'r\ Entry Number 1-1 www.AlhenaOiagnortics;com _,&,___ 2Cl05 Date Filed 03/28/16 :uruCtifdl'I are t-Xpc!(:"~~"bly;~ l ~cc varilWS 1lult 1:.i:"YC nat bcal. eom:laml with cliDicaJ pr$t.:uliun ~c!/l'f paltolu~)' iu. ~ Cun'ttlt ih:r:inn~. ~ du tbc.y rMU!t in a radily pr~ rt'fe~ :upon pnlf~:n IUU~~ .:t.nd Nur.tiQn. Typi;:;aI e."l;ntples !Wu.de Amite .r:or.itntilfe cbmges in the codiog or DOD- :1 ij 'I it (j ------- ---- - · - -···· ·-- ........·-··- --··-·--- ···---· ----·--- .---·--·..·- - · - - lli~ OaJllt-- ......... h>.--G:Z- ··---·-·--··- ··----·· - ---··-·-·- - .······ -··· ·- ··-.- · . ---·--. 3:16-cv-00972-MBS Date Filed 03/28/16 l~ll,Ml.0!7.52 · 'Si;.·· - .• --- -~l ~H~ 3nC~S M S--,,..x:i-.,n ~---- - •.•. DNA :uhlll .. ·· - ---- ··- - Dia.gnostic (Symptomatic) . . . .... ......... SCNlA. DNA Sequencing Test ............................... ;-·~ ol ~l ~ ~ ·'°·~ <1l ·= ~' .~; ~· ·• ~. ii i) :r :1 ·-- - - - ·-- - - ··· - . ·- ···- ··-···-··...... ~~C:.~\\~ Paik ·i I) 'Pa'"iil~·-· . ___ _... __·---- - - - - - - - - W{Jll~l ~lP!li1l!llC ·- - .-- - --- .. . .. . oooooocioo ~.ii~Ddl-, ..... -"-Dlc~Olll ·-·········· · - ·-··- · - ·----------·... .. ·. --. 05103/2001 •rr.itUelt - ---- · ·······-··-.... -·--------- . --- ···----------··-· 7. Daaign ,0·1ymoll~lia:lu ~ -- 06/30/2007 - • •• ,.,•.•• ,,.,., _ _ _ _ _ _ ~hC'.lW•~· n~A ac~.:~ to be pre~!it ~n ,~ftect~ ·.xmuot ~Jee?s, "'- ' :"** FlNAL B.RPOR1' ~.:£:._ u J)!oJ: ;,i;; .,~_. ·~61' il:f ~'-~ ~tDl/q c~•~ PJ' ~· !J<1,1~ 1....-. I• ~ _ ... trM t*"'lt.' ,.,,. '''FP·~ w i.'j * ~f. S. '"°""'..., n....~ A:t'ffilfi;r..~ .... C""-.,,..,._ fts,( ... ~ .::~4·~ .:r~8tiWll i1 .,._.~~'· · n.h ii ~J.~, •.!P-iQI/ ~~,.-:~~ ~ dH1d:J ft,;: .~ 5. ~.noone:..°'l'l'.tF.i:Ye tist. resulrs ~ tl!ase una!Jle to be i:l:requmx) s.tr eilher ugatl-.e or positive due !O a tecbnical problem in tlle iway-, 8!Jd dim cm "1}e qnt nei.t3:a the pret~-:.e nor ~ of ab!lormafities in these ~­ Inconcrosivc results ai..11 typkally P..sol~~ by ~"Sis of a :oi:peat sr~- T'~ will be l!.O ~ foT' lbe lefJe& amtysis. l-=-tcuc i.w:iica:le ·~BAT SPBCl!Y.Jili ~ a!oog wit!J. the ~,re l~tm::m Accraion l"tilmber on the rer.W~ If Ibis t=t is port of a promc and a p-::>n~ result v.'ZS oUtainCd fur ilt:lotlv:r gme. the ~ of a repea! 'V..*': I-~-~~·.,,_,._,,,~,,_."";,~ i~,U::_~f ...· ·,'!;.,-:'411~· fll• (,,,.[...Z, ld ..., 111po.~ ............. #If 19'8 (a.IA) .la6,;. """'-' i.m pul....--. Rl~Akfl .........,. d&iim{ ,,,_.'3JJllla......·~ ..itil.alliDo...,., -'"- 4nslt/pltl C:. loOo''"'"' ~.;a1i.,.m·•a.i..:1;,,:,,;.:;z:.j .. _ . _ _ . . , ~-~r'~ llGrzdoc llf-., <».-'ft•'"' Oir.:r.J~ ~ (l((XT,SJ. Lal....:>rltory .n:solla and snbmillOO dil!ii:al informatiM reriewed by. wmmett. Sat Dev &lish. P~. PACMG Olili:f Dixcctor. Oeoclies 6. fao~ui.11:.'-!.e- le8t :esull:s. while ~:bc-iologically ~te. .m ll:>I.. clinicruly ;neaningful &Je to the .b lck of pub.ii&hed ciink'..al sS!mie!: corrc::atmg ~ results in this rpcciiic c:a:egory wi1h clinical p~ lrJd/Clr paltology. D!IC ID b la.ck of flualished i1Jldhl.g$. tiJ£ae i.c.L Nm:m11han N DL"'ector, ~ PhD. ABMG .Tlm Zhu. PhD, ABMU :D.irec:tnr. Geuctics I..~ ov=igbl proYidcd b)' Joiir.phI. Hig~Jl!_~., F..A.A.N., li~ bolder, AJbma Dbgno!tb (CUA 8X1IX>..~IPJJ CUA Tm6og pcrfarmricl It: Meua~ Pour BiOUJ:.b Parl~ m l?lant:ltion St Woroeslel" MA 01605 -------···...... ..... - - - - - ············· ···----······-········ ···-·- · - -·- OJilOQSA1t,1"'1ntv- ti<: Nllf.OIZC>lll!OI• , ., wrlllllts that ln\-e been and are comidmld '1:-enign" \JJOO-petboJCIJiC} scquCflCt •tarianls. If idmz:;fied, these are coosiden:lll noimd vz:Dtions Gld ue not m>ortl:c! in the Technical Resulla 8Cction of tbi.s report, ·aut arc ivai'llblo upon ~ « re:sults canoot be ioletpre:t?ll1 as eirm- v:onc.'1 or :iboomr.11. 1J:tdctmnin3.!e reeults an: ge.Det'2lly caused by tat resnl%s elm!" '.!all cumdc of the es!Wlimed inteipreLnrc ~ lmletermimd: 1l:St 1-esule& ~ not resolvro b)' aoa1yaJ3 Of a repeal .specimen.. ·- NO:De Atlmla, GA 30338 ____________ - - .. fttlllJllUllWl~Nitiiw- --- - - - - - -- - · - · ·--· · - - - - - - -----..- --· .. ;; Ct 0} ~Jilll~ll' 07025148 cod~ legiuns of the get!O thnL am SC!.lmti."00$ lal;ded ~~ •mutt· mP! -- · ·-· - Tsit~~ Page5 of 6 \Woerwd':NflltlllW9~0Dcar~~ Slll'IU:s. 2111 fGlat ~. ?'" tl:ior _L -A!. (800) 394...;1&;. (:i08) 756-?i!BS -Jl3!iw.- t - - - - --·· .. ~..- - - - ~~f'll;"!_9_1'1¥51~~~~~~ . '&,(~1iiiill" Entry Number 1-1 \lislr 01N 'l1fi1sit;J k.r"m.11t ~711 azcur~ llsti'lf S!Dk:I$. ~iii··--· ,._ Date Filed 03/28/16 &x -- .... lioJiiiifii>--·- -~~•;11illr.&.~ lvl SDai:il!~e--"----····· ~'l'illdet Iohn ShofrDct....MD ,.....,.. , .......... .... ' .• ~-···••·····._ .;,.,,,~·······-···--------~ --···-····-·---~-· ···•"···•··•······--·-·· Sliite~O NO C~e Atlanta. GA 30338 OS/03/20f1'1 .... OC-0000000 -~IUl!lCli-~ca·-·-···· - --- --··-·-·~tltlsitk.n <:- ~ -~ ~ (;) .C -~ 'liiT~f- .. 06/30IW01 ·------·~·-···----------- foi:- P'.;1re11M T~til•& - T&>i' Coi:'re 536 Tu order ·:o !Jl'O'fide :t m:.>re ~ensi'-'e }ll!e!prei~~ of tilis 9l'!!ient'a SCN'lA ~. Athena Diagnnsrie.<1 is requesting samples from the ~!l1Jo_?;;.~ p:•.\"er's.t.' of ;t;i< p.."ttienr.. A c:hc.u will ~rfotm a a.rie:. anal}"~i!! en ~h~ ~es fur variant(s) identffie4 in gene SO~L\ f!JJ..'y Piil u;;e lht: ~ ~ hel~ '°~~l I.he ~m.'t S~ 1A raNlt(s) ~' DO ~uJl!ltl.oual ~mrge. ~WC USO Sbis 6:JmUS the :.-.mbioo, for }>'aI1:o'Ctal i;;:sri.cg uo. r~ p-adi."nl .. Di\.'\.:>,.;g vru: C.ddl"en: ---·-········-.-·-·· _ _ City,Stnc.ZiIY. Oty,!:'tate,.Zip: - - - - . l-800-394-4493.option 2. Spocfo.icn RelJJi.rero.t-..17.l\~ z ~ecd:u" m!>e (8.5::n1) ·whole blooo Stor..tge C(lndltious: Rtftigerate ::;!J~ing Corat!1lons: :Rwm. i'CJnpe:re.tn:r:e, :>.W.d f.tuz?nt 8:-.-,1r1&;~ ;.f?t!:cr ~~:.:. --·-·-···· . Riologicaj P!.tlwr Name:--·-·" ····Date of rlirth: ::!! .... · · · · - · - - - -- ..----.. -- -~-- ----···- P.ilot\C: ........ --·------·--·-·........ ---- ···········--- -----------··· S~«imen CQllection Da~: - - - - Specimen Collecdon D.axe: .....-~-­ ~c ;_!1 lnilicatiol' fur Te.!!tiQg: __ ...... . Medical Fmc!itioner Signature: __ •;r T~': /.;t;::-..>ri.:.i~ d .( ·~ '."'I ... ,; ~"' (5 ~"' i!. •U tQ --- :-~riOda Atldiiortal l'lllilD115 to: ,,........ ~ila111l!U Diagnostic (Symptomatic) Sqf.?~DNA Seqt!!mciog Test ,::"j ..... :;J fiirrJlt-tiam~.,,,....,..-N~1111 ts - O~pwrwoody Pa.1k,__ Ttsl~ N 0102..51"18 ONA l8$1 cau:13c,1y --·------·· ···-- ·--······- - - - - · UPll'?: ----- ---···"······--- iC~·:I :.)>di:.; l t\'.itr--"'tl.lllt it111 :.:.si !1 z-"11;.-r. 1: ~,, ,•.: ;."ll"l":-••f ~.;...,~.,.. !lo:C:ttil\;t..::; ~ Ji.,;:;a.'11:, itba........_ ~~-• .:}-:~:'c' :lii.c: llff'"fl'ian: •·n:-~ v.•~- 'J'lli:i Tdll'!l~·~·wi: i.-•~'.r:!-:Hs·.;nn,. t..i:s ,:..,,c;.T., ~· c:.i.:::s.::it.. :>\~'10.l;;. ~,.Ir~ t~~ '-~:·.:1 ~ ~Cl'.<'.'1". ;,,:· :'.':• ~n-_..m\ ~ ii>-'.:1t-"-" •}:; ~::.rdyi' t:.. f{JJli~l.'. ~ l'.::.,.;:;;:«;".r.; ....:~: 1:.~,-: -:,! 11 ~.;.i;~iw: ·;It'.$ l!: ~~ G1C Clfl"'..S:":I f3r.la. ::;," t4V!rlllo~ •""'~"" <'!JV,Gf.O;'~ l\'UQ -:.-;.., ~';:\' iJ''l:llJi:lli.'i· •:rJ....,.,.. ~!!~ ~~ Ill:: ~ill:.f af l)''.~Ci¥~ # N;t.C~11 !.<:;S ~·I&!~: k•o:i i.; ((~ Cl.I 0 -~·'C ·~• :•.~ ~"- lkii'. di~ ·~• ;u~ · - • .a " t;..,,;~-Ax :it ;;z::JJ ~~ t;~ 'I !l!:,r.~.;on ~ :!a: 111:c~ f11;4110n •*.t ,•,i».-~: tb);.;' ii.it 'M'Atil>l'I a::J i'llr.en...::c. \of . im111;r1~. p::yi~~u. ~~~·zfrn·:,1.d ?""~:IC :..;;i,.,r.,;:;t".';_, Jl.\!tl".)Y~:i~;.;&:> tlmllllllt 1~:.,11!:Jll:~1 ks,~1lJ~"l!tlt- ~ ~ ~<1<1t1.;... -.;;:-1..._f-CC.~-.-:':s>ez•!""·.•.~:O.o~~~J-r;""" ,w:,.,;,, •• )l"!!.::itEPOrt!f # ~- A Nuciootlde Posit.ion: 1237 Codon: 413 Am!Jlo Acid ~ange: Tfrostne > ~gine • Vana_m Type. D~1a1ed mwao.oo ~zygous) /_;;!:~- ,.. .,:~ 1*• ,l in02s1~ ·>:1)1!~il' ~ .. . . . • : .· . .. . , . . . , .......: : . t~o(, !('"t':. t~t·~.°'·?i~:J , \, ,l-,.:ca ·:;:) ~~;j{j:~~n-t)$f ':~ ~ --~, . ...---~ ' "r;:,;;..;;-~~J.:'.~tA'f(< ~().:If~~-~~{~'~.i%l:~}'.··~~J;;,~!:~'.':~ i .. . . . . . _ . ' "l .· . ... ~'~ :~:..: .~.,yt.t.i.o•-'\ ,,· · ·~ ~ .: . .. -: . :·:; .:~ . ~ OS ' . . ,~/Jf:.~ ~~k;t.r" ·: ~)~ t.~~ ~ ~~~;f.H'i~~~~~~~·~NJ~~XI~: ~ <" ·. ~ ~~~@~,\·i-''{'.<. ;_.~\?~..;·f~'.·~-· ~ ·;1Yi.{1f/~f ~!-i!P{O!r;;A~:~'.~~~~<~ No~ abnormal DNA se~uence variants wer~~~~~ -fri~~;:~~=.:·}5'.<~~~\:':: ~ remainder of tbe ctW.tg S.:_1 !.S:l'f / '/i.\'.·:Ml.•,\}'\ /-;~{f@ft ~·s;~!/~;~·;~.. ~'t..;:(:':: '~~\•:~?~:i~\~5·: .~ ~·\--t?{·'. /,.;.-.\.~~~;·,:, ~ )C-.'i"··:\.:;\\~'.~~'...;\:·: ;~~,i~:;·;x~·J:{f:it~~~ Mo.u Sia,nlficas.t rauft: Aoafysfs of ..UiW~ :. 1viilint's $:;f:it(f.'..:'M·~,':'-:.;..~~ ideruifioo a DNA ence variant d\al ltit~~~ ~t{ie'liter~f~·,r-~ •-be·~· ...... Wll.U ~SMEt or S~ .. "~n ..i<.::.' ..~:.· ~\ ....i:..,...,_.~·, ·ll!ISOC1a~· .· .. -.·~·!-:''} ..,,,. ......oc-:....u..:u ~~·~re ..,......~ "" , .. Comments with SCNJA MJtadons:1.10 (~~irtatioa ; jJl.ti - ~1~~1.~~t: \ result ill consistcDt wid' a diag.noris of{t!(a·p1~$poeition·f9,4#'~1~tr:~-\-~\ SMElorSME'Bl-M> .:· ?.(• \t-' l' .-. >·:\,'.p.'.'~ ·,_-, ,.~~i -1 --~ ...!) :u.i • l .- . ·.:,.,.:-;,;)'}.!.:;~ ~~~!·~-:~\~ Otha- •ariams of le8 ai~,·T~iS analysis niaY(~:~~~~-~h;. detected 001er t'YIJCS of sequence·iv~~s as listed .in''di~\!~!1\:\~~ Resulcs sa:tion, a c.ormN>n ~ for an analyss ~~~ .~!t:~~~~l/~) However, Ul ~ c~l of te5Ults ~!led• .~ eresence:~~, -~~ifx \i f sequence variants JS generally of-.~ed sigruficance a'¢ll.'d®~ :tibl, \ {\ rn "'"°'-~':"°' ....... ,....""'"'"""''»~ ·-. . ..... :.~-- , ... , , ., ' . · modify the fmal imer.precttlm Of (be lat resulL~. Benign pclyrq~~;, ·~ .,· .)' .+ ff' identified~ are to~dettd nonn.al ~ 2l'e !10l ret)Ortt.d ln ~'t~t~J ~ ~ ;. .Results ~too uf lbl'S report. but .are available upon req_~sti\~e,( ·! 2!. ~.osul! ~ Gtoswy f?t a detailed c~n,of "DNA Vari._)'~~.!~: ·;·' '!:2 mdk:ated m tbe Technical Results rectJOO of this report. ?.::~l. :(\·~·.y .>\ !, Parental tfStblg odler follow ap l'fOOIDlllerutatiem: Te£fiik?Jt"~·~· r;·· bialogi:al parews (!or no additional charge) may help lderuifyi'~jh~\· ., this ~uea:~ var~l ~ ~ fl"PO. or inhtthed. Because SCNJA mu~ \'f '" can be 1oherked. ttus indrvidwl s Canuly members may be st "5k.~fO$SeSStS a DNA sequence variant in If)! SCNIA gef.lf • i'.:.1._•, tbal is a prevrously I~ dlsea~ted ma\lltlon.l·M> This tesl result is cun.~t with a di~ -0f~ or a predispositi~ to devel~ing. tile severe phenotypes associated widl. SCNJ.4 fR,1.tatJOOS, SMEf or SM~B.t-Jo ~lease refer t.o the. Tecbn~al Results .an.d Commeats scchons of 1his repon for fllttb!r infonnauon. \\,;,,~)', ~f . . · • • . ·. . .\f:~W Interpretation lr'V»H -· , . ... .• _ ~ ·:'·'~'. ..,See Attached OrigiMl Report ·~~ I • • ·:,:)).! ~e var.t.ant of unknown _dm-:at s1gn1ficance ~oosly reporu:d · ; {;~~ Jn the SCNJA gene of chis paoent bas~ classified as a ~.t~\ disease~using ~utatioo: Pl~ see the Technical Resuhs .sectlon ·,_:)\ 1 below for more informauon. ;:,,-1\,) ·.-.-:J.~ ... ,, \ • *.' ,:, ·. -...--... Page 1of6 ·...~\~'.)·,'!(' \ :s •:,t-.;.'.\'·'I ··~Sentt 1 " \ill-~ .. • • • • ' • •"' •,. ·. , .. . . . . • ·.- ------·.. . . . · . . .. -..· ·: ...... ; -. . : ..• · -. .. f~?~N'~· . ~~,\'f)t.J.it ~ • ' • • •. ·'. · •·• · ...~...·-~ -"')".!, \::.. ,.. m · · · _.,,\~~,:~~·i;:;:>'.i=~:.,.;-';\~~~~· •• ... . . ' . . ' •-. , • . . . ' . . >' ~';ij \"'"' ·""\\'<' fat • · ~-.· •, ~.-.- -..:· •" :· .. :: . ·..: • ·: ·-~.•".~. 'It. ·. ·~ "• - - -~~!itr~~:~~.~~i.~~).IQ~ •· " .. • • . .. Ff.:;,._~~)t"ltUi1 .......t.~i&·~~~.: te1¥)f.i!l(.;.{-.fsi'(~1~~e. ~}~~- ~iagno~ic (Symptomatic) . _. ·frlt -~1';~· --------- .:- >;, , : .' ~~ , ,.,,> ' :,.-~ ;·, ,>;~. .-;:··};;': .:,_'.',.4.11.? ..u;~ ,•.,,); ,A ., -ljj .. ;'1.~-..~ .. .1t..~i1·· •·. ' ·~t. ...,~,~~~~'3t! -. '. · · : Page 101 of 145 . . .. · ' ··· .. . " . . ... · ~·· ~ i:! v.I :1 ~. .. fi' EXHIBIT z & DI C'Q ~ l'5 3:16-cv-00972-MBS ---- ·-···.....................---·-··· --·--.. ·-· ,,_ -· --· --------- A \(~~ •\~·;;·::, ·~--~·~{;~ - ,-y(~~.1; , ~~··.·.c-: '.i;~~~:.u~~ .-'"S:- i::_-:15:.' ···\.!~· ,i ';io..;· I:~ir~ mt~~i~1!.r~ .,~~~,·~· ~ .OOS · o;~s~1c (Symptomatic} .... J·k ", .: •:-. SCNfi(DNA Sequencing Tes~. . .. . :J~1t . ·... · ·..... .-.· :-" · " '. ·. ... . .. · · !' ~ · :ii-~<~! :\~\ ·~·~\-.; l .__, :_. .... , _ , .... . ' ; • : ; •• . " .- " ~ilepttc encepbalopathie!. n ~ 11,•.), . A!- comm:oed diagnosis of SMEI may signficantly guide tnatmeat decisioos. 11 SCNlA JTWta~_ fall broodty fnlO cwo groupu.te !cunc.ation mutadom llw ~verefy dw-upt the ge.ne are usually .asSQC!ated with $eve:l'e pbeootype.5 such as SMEI. Misserue mutations an: ~ wttb a range ofpbeoot:ypes from mild to severe. Mosc mutations that ca.use DH -.;:,;~~'"'~f~"''... ------ SMEI bas a poor prognosis. including dcvel~ delay and refract6ry ser.rures. -~J~ .\< furthermore, .;, ; · ' : ·. ' 'I• t' 1 • '..:··.t;;. ~ ";.;. • .N ' ~, i · . ....~.., ....... ·>:\~~\if< ~ ....... ~...····•t\' t Page2of6 .. -·--·~··-·- - ~····· " · · ·. · : : " "" _. : · · . . · · "' ' ... ... . · .. , : . ~~\'(:v)t ~ f~~- ~~t.:'.l'.\e N .• ·~:$t; , -. · . · '· !·(;., ,:'. m ' ..... : .I '> . .:·..•. :_ . . • .' ) .., '. . ~ . . . _. . >' ' • ' " • "· ' ts _No.: .....~~~~t~%~.;;..,~{ir:1·'.·";~~~t>~ i . >'.:.':- ··.·.··. ~~ . . ' ~-z~\~fi~l~:ftW1·:t~P ~ ~o.·:.;1 1,,.~;(.f,?:t>.·{·~!'1\'r~-~· · · · , :" ....,.:.·: ·k;.>~~~:~~~~~?{~.~'.:t; _ .. . . . . ... . . . 1 ~· . · .. · · .. · ·.. · _.... . . .y~::} \\'WW.athenadi~~c~.oon,> for fu~ inf~tion on pare~t ~ing. ~' ~t\ The a~bed. reqwsmon ~mis WtU • fac~te £:t:c sub1JUS.S1011 and ':\\~;i p~SJng of parental ~unens for this ttsung servcce. ~;:r._J· :'}~\, ·-,·. :, '· · · .. : · - " · ".- · , • One Dllll.woody Part- n;concilia~ o_f this m.ol.ecutar data 'Wltb this md.ividuat•s clmical am family bistocy is highly ~meru:led•. Athena rtooll\.alCO(ls gentiic ~llilg fQr Ibis >OOi.Yiduaf a.ad his or her family 1!1emben._and COOS!dera.Uoo of pare?f:tl :trn: :,.,\ _ ;··~.J ,-;. . . · .. · ·. ·,··.- ---. _·: · -~ --~: . , . .. , , . .. .. · • .. .- _. ., , , .·. : · · ..... : . :. ..·.· ..:..•. ·:· :·~i ;,;. ; ·:",;J .... ~ .. :- . . ~c..: >.:.:,<:' poss.essing or i~ri~ ~~. muWi~s: Careful ,., ,,,,.. Wt)f!t<:t:..>.ts;,;...i.°' .... .,.~,«'J.JJ•1'-1f41 '1'.~-~um ~.. w :.:·~,'" ! • .. ·x ... ~... .. ·-··----- 07025148" . .. ({~~;sr ~ . ~ ..... 't&$(~~--. i\tiit~" , ':-- :·.":'·.·:_,.,.. ,·. ·.-:.'"'.~--,-. :c·--~-- -.·::.:....... ft~&jaz:.,;Wutthlii\#1 ..,\··;;··.:,~Y~~ .... i.1 · ·· · · -. - · · · · · .. · .. · .. · · ·. · · ~ · · · · · .,... .. .··-= 1 ~ ~:i...... ~ m 1\'1 • -. · · · · " · · · · John Shoffner MD · .\~-·.:>'.'\'~),.,·...;-.~..,,,~,:._•,~\ •• ~T~ii~1 •'.7t~': :.~". "'"-~ " : :.~ ·,:·< \;, ;:-:-_ · ,_ "·': ·. DNA . ~ ~:" Page 102 of 145 ·~~-~~~~~~"~~--~·~ 1~·~~><5(j3\~ea · !<'!'If: .. ' ."".'°•\ ,'J •· ' -. ~.. :- ,- • {, _' : · ~11if~ ' ..~,~:: ·:::tr; ·~·· . .- .... : . · · . , . . ._ .;·.-~,\~; Entry Number 1-1 ·- ·-----·-·---· .. __,,_____.. _._..,,_·-----... - ... - .- -..- ·- .. · .. : •4?,f;,N;·t~·!"I,....~"-~ 'i:~· · ~'~ ' · " · · · ~- .. '."'. ~ . . •.. .:_..:....:.._ "· ::.:~ . (\,\ - Date Filed 03/28/16 ·-· J "~'''"'·'•'·''' ...., , . ~ OS ." ... -~rt'.~~~~~-~:·:;t~~~~f~~ zt.: 1 ~~ii" ""1~·;•;<'i.!":< ""''"· W7~~~~t~i'~ ! SMEJ ife 1 /~d Wl.~{~. :~M~~/} presentauon a.lid family lusrory. : ;.i'.;· JSf / ... , -· t ,.'" .,.LI Ai\$'-'~-: Umltatlons of aulyllis: Muwlons op}{~/by lhis'~~Y~W~~t~'.: =~1 include large del~l\S and l~rge i~~...~rlhennore, lh&-f.~~-.·~~~~~.i :~;:{ 001 derect fl(l(cnllat palhogemc muta~9Q~"i4• w_ promot~•·;·~~~ ~~t;}~·} umramlared •• 3• u~ared ant! ~~#ei:ited introok r~ ,<)f;J.ti~.1/~?.~ geae. Mutauom 1a ~ie.ms ~ ~m may not ,.~::~~~~~:t\·;+~ byautomated~11eru:1ng~f:V ".-;.i!\•::~~'Hi~ ~~-~~«: :·~ ~ . l} ~;t.~i ~'~\~ 1 V rs ;~/ ,\t1!H~~{~\ ~ \·1 r,i. :·~ :~ :':') l\feth~ \'i Anafysu of !he SCNJA g4SC' was ~onned by PCR ~if'!Ca\W_1V.«>f' r\ ·i Cf highly _purified genomic DNA l'obowed by auro.mated uni~~.; i ~ ;;· DNA. sequencing of the 26 of- the SCNIA 8tne, i~~ ~er} '§ higbly C~l'\'ed ~on-.ilmon SJ)l~ junctions (e.~. GT....AG)~ ~~\ 1 &'! nons all 26 codins WJM.1 All abnormal sequence v.ar~ wen conf~ ~' ~· bi-directional sequencing or alremative ~g cbemis \'j' - - . A .. .......a .... ' . ·' ., A ..._ A n!----~?-- Y-- '-'"'---·- ..... - · c+ 'SstW'" .... ,_}:J.,! ~- ,.,.,,_~ · U ~ l . ' ... ,. . . . . It~~~~:L " " 3:16-cv-00972-MBS .\.>~ ;-~\;:~~~. ·:.:·i,/'.1' •·v,.i: .,, •., " jb'··•.th· /;<.<" ':· · ·· · · · ··· · :;i,nf.'.M- ~ •· · • · :;1i~ Entry Number 1-1 Page 103 of 145 ~ttl . · . N'.iM ~nt.. .. • • · · · · . ~~'~"-~~ i,;..;,~·»""•6*;. '!'l!'~,y·~ ·~~ ~}? ·' . \'·'-5·, c... Pa J of 6 <-:~\·~.~~~'.·\ ; ge "'""'"-:·~·;;;1·«.'; ~ .. ,., . . ,.w ·iltaet•. S.n!f· ~'t · ~.~~~· ~.Piltl!F> .. • . · · ' . · .. . · ·. •· ." .. · .. • ;_ · · ·, ._ .. ::::,.::,.. -"""\5 un·~ . ..· ~ ...·.... · > .· .... • ·., ·., '·\ ·~ · • . . • , . • .. ·.• \ :.\.•~·~. 'l J!.&;'N· .. .·. · lohnShoffher• MD.. , ' t . , , , . . . . . ... . . , 1 :-.;~.y !i1~·~11Jr\, ··~\<··' ... · ... ·...... · · "'-\~ , .~ · · · . . . ·. ·:: · · ·.' . . .· ·. · ··, · · : :-':.rv DNA· ·... One Ounwoody Parle • .. · ·· ;::if~; . ... ...... . ..... .. ... ...... .. . .. . .--.. ··-·------ ~·;;,-=-· /\-S,. ..~ ),.. '!-~ • • • ',... .. :, t.'t SCNlA DNA.Sequencmg T~t .. :.. ':·~·'i1 · · · · · " ;~10~ . "\\ ,. · : ---·-o··-- - - , ,· · .. < itliitfu',~lllit · · . ;._:! !{1i SCNJA (rreuron11l vol~ge-qated s(}d!um c1ta"rlMI alpha I st""=mtt }: . ~-\.i X» SMEI (seveu mYVtU/'U!}. 71Jis tt:f(/148 WYkti fs JWl'{fJmt(:d ~ .,,...,, R~ ~:~ '-· !~ ,! ~·.- • '·) ::_;~\' ,.,, ·\ 1 .:itJ\i 1 \ {:\ · 1 ~ .~~ ?~.:; . JO a I'CR sn~MS. Inc. liutti.:i~ . 11 l'J'l'ttllfl!fft " " !lof.1"' {, ·'·..,.' ,• · · · • '<._;. ~ .... Muil~4llr · ' .· ,~ ·. ~ ,_.,_,,.i = ·. · -. · .. · • · 3. Claes; Let al (2001) Am J Hum Gent.( 68: 1327-1332 4. Wallace. RH et .al (2003} Neurology 61: 76.S·769 ~. LeuJ (2003) ffum J>.!m 21: 61~1 6. f~!-Wara. T er al (2003) ~ 126: S31-546 7. FUJ1w1.1r.t, T et a1 (2004) Eptlepsla 4S: 14~ 143 ~ ~ .. ·· .... , .. '... .... ;)}':} ...... 'l.... ... .. ... . .. . .. ~".!\V~~~/~~?:i~\(~h~:: -. .o.~~:(-,{··'1;·:«:..-):Fi'."', • • \ ' . .. A5·~ f'i . v J~ .,,_ /·~~~\~\~~::~ i · ·<~:~"\:l\lp) . - , ...,\,••, .. ,.,. •...... ··: . .J•il''/i«•j·rj,'~$ "(.'{'' • ·;;fl · N~·.,:- t·f \.>'f•.t ' · ~ ' ~ ~~~f~:.\}~m~~~ ~ 'i· . . . ., [l .:--.~-:\ . ·,. ~.~..~~·;,~i:.·. --.a 1:n t...l 1 v sequence or tlle pe(s} being -~~;1~~~·-:a~~~.diSof4~\~/:.~_.· mutations must be rouoo in only one ill.8e.l5ffa:·'gene ti>'; ~rm>.~~~ "~· p~ of the disease. However. It..~)¥,-'·~ : ~)-~~~~~:,-h~t than tw() types -Of DNA ~uence. :-~~-dee~ io' a :~~{ :})~i.:_{i\ addition the clinical sigoilicimce 'd'-·idd.ivi"dual vanant·l~l',ci;~.~VH~ widely. 'n.e DNA valian.t typeS an~f~(bonal tamino~, ~-~.~~i~~~S I.be rcpon arc. explained below. {~~ I.be Tcdm~~;i~\.~~~;~,Z~.; Comr:uenss secuonoftbts report to ~~me if aft)' of !fl.cs/~~~~~.,:.-.:.._ ~ ~"'Y to this individual.) -j·r I} ! ;'.;,\ ':\[~l •;\1~ '\ V rt ," \t," ; !.. < "~ !.·:'l \t '... M ,··t ·.; ., ~\.*\~.. \~:. ~ ~ )" ,. "~:.:I · 1·~~ ;..": : t ,- .... :._ ....,> ,..~ _.,, . ... :~ " 11. , ,,.;,\""<."': ~, .. .. ...., .• {np\, .. y .:.:;: ... u 't ;. ir->- '. ·. f· \ \ ''" ., .. . L Known disease-asseciattd mutaiiOns (doo1inaat) are ~t#~al/:} the lliera£Ure (D be a.uociaetd witb diseases .inherited in a- ~~~~·~ ' man.oer. The individual is likely ID be a.ff~ wilb. M ~ ~f~· developing. a dominant. gent:f.ic disease. . ._:, '1 ~ ~ff1k? ·~·r ~ .i.V.•i\ n' ., 2. ~ diseue-&'!80tlated mntaliom are expected ~.. ~~tjft\,· ~ sign;tlcast alte.rati-On of me suvcrure and function of the procmn ;'(~ . ; ; ~ ,.,I .v :,_ ' ~v·. :~ . ii a . . i;~~~:~~ ~ «\! )* \.•..., : . •.. "' ..,·· ·'--' . ...... '..",. ''- S ':~.-: • "'1'1-' \~:-0'!."1"3'1"\'j'-'J: -·~ • "< • " •. ..ll~ . All\,~:.:.,·:i\•·{~:!~~-~~~;•'. :; ,;·•.;..~z:-:-<~-::.,::.r ·.;~;;• ...., •• ..~_i. '~·'·;p,t;··l~-:\·~:\·. !4.;r ~ • . · •• i;~-"* &. Kanai. X ~al (2004) Neuro'logy 63: 329-=33~ :{i'M,. ' .i:p:.:•1'. ~:~.>}-:-~('\:;-. .>.;.(:-$_.~.:~ 9 r~.• Bbr-M et l r11'1nd) Pediarr ...:..t:. .. 5-:..L4: \ -~' ·. '..Y: :'~\· . ·, ! .. \.A;U\cma:ns,, .£U ~ ~~ I~.~ ..,,. •. ·'-'· ·· ~ ' ·~:· ·\.:'.~.~~~;~ .'~ 10. Mul.ley,_JC et.al (DCQdfng)_Hun:t Mut (M~ ,):1~te,;;~~~~~W~~\:{;! 1 J. Guerrlm R et al (1998) Epdepsi.a 39: ~1~l';$~,~~'\ ~N~:; ..~·'·'~~..·~·it~·(;.: ·'.· ' I~ .,·\').•• ·i,) \ ~·<". . " :\-1\ · · . GLOSSARY ~ . ~.;'-: '..;.. '.··:··~.'.,' !.'.;,\"'.:'.,'; ..:-.fo!r;:\:• :,: t·, ,,-;l :lh;~' ·\· ~ , ~.::··:~:.~;.\~·.}'. ':,~;\"_; pi,o: ~""!-t,.,\,r· .-:.,~'<·~ <-i:r~t·1;.;·" t \' ,.,:......, y • ••, 't:' ~~;.;J:: .. ...... DNA sequence variants are deviarioM::.~Jillef/nonnit'i~ti~~~~J.~o.;(l·V· QI.MU.A. 1. Bcayg, A~ al (2000) Nat. Gen 24: 34~34.5 2. Wallace, JW et al (2001) Am. J Hum Genet 68: 859-86S '.lV':. :· .. - ----~------. --- - . v..........lTVl'lt'<•· e,erences \ \\ s. ~w;J~~ l -~~: ---• ·'" ·.:. ·:: .: :'\}}'J t}W AbbN!iwtions used: ';\.~, '~·; r) . . .. ~lama. GA~~~- . .· ; ' .·. ... ., ... : .. . :. ;· ; ' .. .' ., : ·, ;. ' . .. . . . · ·" ·- , -.... ·;.:::·::; and rl"l'Vlf"ted ·' -' ABMG certified CUnkal Molecular Genedclsts. .... ·. . -r~· v' . ·\·\~.: . • " • ,{ ,,,,: .Nucteotides and am.i.oo acids are numbered followJng I.be internatiooally _., -::~~.. acllP>nted Nomenclature set forlh by die Ad Hoc Commiuee oo Mut.atl-011 ~J' • 1'..r.... a.:~ • • ,a • •....I ~~ ': \,.;:-., ,y N'omeoclature. 1be iniuator codon, •"1X.'Uuvnme. IS v.es•gna~ as \.Ul,lon ,_,,;, .. _...,. J l .a.- DNA. ..,..._ ~A" ,..,,, th "ATG" ;.,;.-~......... c-.L..- is :_. .._,·,~ nu.n.Ul'O'r n u;K; l c tide . 1us: v• e ........cuvt uu:ui' ' : ··:.' • ~.:::':'J dcsig.nakd as D.UCleo. + · ;;Y.t 1 :. ·.. '~, : . ~'.' ?·: ~;, ' .: .<. ·. : ' ,· ; .-. '. :. t;s.1:··::i~1i~:·~ .::~~·1~i .. ~:-· f: ',''' '< -.' -~"·~~~!'-~~ta...~·.~~u .'~'Jii ·· .. · f,;;· ~a'iiftif -diti:'1 · ., · · · · ·. · ·........~~ ·~- ·... ·..-. .. ~-~-~ · A·. ·· ·, ·: )·i:: Date Filed 03/28/16 ': . .. .. ·<;',~·'\'\: · JJf?StN . 3:16-cv-00972-MBS ~~~~~! ·~·:·'-.~;~f~~ «'\:.Y .· 3~*;~ ~~ ·\:~;! ..;;{ ~ ~~ I> (( .... : .~~ -~: (~ tl ~~; ~. ~: .. \{ ... • ;*: '.;: t°! .: ~ ~·:' . .~~=::~~·: ··<:_ -~>·' _, ,d/:_,i; '-'.·': ''t;· •• • •• M, ,:.·-:. :. ·. := . .· < · ~· ~ •· .-;· '· .' .. : :. .. .... . .. . •. . !¥-~~r~: .. · . . : -: . _.:.. :.. ·.. . . . i)i;~¥1!~o;-- D1agnosuc {Sxmprom.anc) . . . . . . . . fiil~ • . '"· . • ·.· ~CNtA DNA_Sequeo:ing Test.. . . .. . . . Jotm Shoffner. MD o? .. .Park • • • bti~~ood .. · - ~ . Suite 250 _ . ·. ., .,.,. ,_,. ·"' - ~-~ {:tir't'C'\ .• . ?zt' t •• . . ' . .. ' • . • • ·.·c:: ' .. ,. . ~ta.•. GA_ ~38 ._· ... ;.'-, .· ." . 1 . ... •. : , •. ;, •• -~ . • ·. •• ' • . . . . . . .. . . . .. ·; ' . I.•• • • • . . :. . . .... .. .. . ~---. . .. . . . .. • :. ; = ·- " •. . ., : by the dominant gene. 'Typical example$ include frame shift mwariona, 3J)licing mutations. nooscnse 1mt.ations, and d.cleti\>m or duplic.adons of entire c~oo.s.. Current Jilerature indkate$ thaL DNA sequence variams of mis ty~ are assocl3ted wKJt disease. However, due to the .abs~ of established genotype-phenotype COlt'elations fur trus specific DNA sequence vanant, dli&. result should be auefully recondled with this individual's clinical ancl family l~. : : . , --~-#~~~~lf!~?.1J?E;~r;;~~: NO.'~J?;1/>\.,.•i~ --;1-.:;/>'~···''~~.:, \.' i ··:~' · ":~l··--·~~ ~:::·..~~··~!.t\:JJ{:t~ · .. • + OSfQ.J, '.-tHt~~M:;~~·~;~1t~') ~ 3. Amino acid dlaagu of unknown llignifkance are DNA seqae.rtCC variants that are detectoo reproducibly. but have not been correlated with clinical preselllation and/or pathofogy in the runent liiera.ture, nor do they result In a :readily predictable ~l upon protein strUCture and function. The an1ino acid change is predicted based on 3irnple interptttatiom of the genetic code. However. these same types of alterations ma}' sometimes alter oon:nal gene spliciug and processing. and thereby cause more sig1.lificant and unpredkr.abte elTCCIS. Shice lbese types of sequence variants are similar to &hose observed in ~as.e~ associated. mutatioos and benign potymoq>hlstn$. the nature of this variation prohibits defmitive inteq>retadon, axe ~led reproducibly. W.t have OOl beeJl oonelated with cl.ioic~l presenzation imd/or pathology in the cu.rttnt Uteiacure, nor do they n:sult . in a readily prcdictal>le effect upon protein Sttucl'ilre and function. Typical eumples indude single nueleolide manges in. rhe Cflding or noncoding regions of the gene that are sometimes laheled as "slleu · ., or •:w._. • ..,,..r .....&.::......, " Th eSO'~~·"''"ad~i'~"11 ·I~.'» '"~"..:'t" ··,~::J,,;:o:-.;.'.:.l.'.:..i:.;-' "i ...S mutattons u~.,ruc l""vmo·~· ui1,~:~K :-· . ..,.. have no etrea.. but may· soJDL"titneg altt.c ~;~~f&iic:~~~.::~ ~:;·; ~ processin~. ~illte these lypes of~ v·{~k siJ ~.. ···:;.~~ ~~H} 1 00served 1n di~iat.ed rm.uaoons at14·~ti+Je~t~~~··•Mt:.·N > v _... - .~ ...... .....,..,,.: ...·... "'""UJU\'Olu~•y.~",-~• .A.J:..:~ -~~~.. . '-'·;:.'.·•~~:~-...: ,.....,.n= 0 f•'-' u.IS van3uvu l:"''"'u;ol.., •.~'·i''::· 1 . .,, _.. , ... ,~ . .., .. , ·~;~f..'-:(:\(l~fr/l';\~ • S. Jnoondosive ~l results are I.hose unaj,.(~-_ -r.~~s.~,.-,wJ6~&;~•~P*11:tr,.-.11r~ ' . ·. . . . ···. . . .. '• ·.. :-; ' .. '· . .• . · ·. . : •. • . . . .. . .. --- -·--------- . . . • . 0 '~i\,~!~~:~~-;i~-~~~~t~i~~y)~ ·"~'-~feip~~:~:...e1U~i;ii\\ii':·".;,.. negatheor po$itivedue to a tedmical lK9.. . Jff~ ass.a :•iiiid.111\ii~},:~-~\-­ rule out neither d\e presence nor ~-~a§J:l9'.uiialities~ ~·~~{:.' ;~· lntonclusive resuks are typtcally r~~Xbf·ana1ysts.. qt-..,~~·~';~;:.~.':~ s ilrK:tl. There will be no c~~~:'d'ie.. t · ariil ·~\ ~~~-:~ \~~­ 'REPEAT SPEctMEW ataQ't'4'iih'lhb ~:~~~'ij:~~;.~i(. Number on the tt.qulsili-On. If this ~ );~ of a fi1¢·~Al>.~~ii~~ A~ ~.., t..•-=--.:1 If'. --.L.- '. ''• ;t.;_ ...._~ • ·b .. ··.'· ~).!'"·." \ t1AJW.t VfaS OUYJn<:11.l 1or aiiuwg· ge~,;. ·us; B••m•ISS~ · ;·_()t>(..~~ .'.~~~:'~:}\ ' t""_._.. • .. •· ,1, I , .... ... l Spe<:IO\en may no U'W wamhUN\I. .>{ti .• :?/U !~ ~'~~;.);:Y,\:· ;: i:fca1e aW: ~, ·.·;~:\ ~ .··':"·.:'lll~\'lt~:: !~t ·\'.: •·. ·'° resulls ~allll(l( he &ll1erp.reted as either normal or .~~~t~ r·,·' a ~ Indecenruoate re$Ults ~generally~ by ~.rew.!1.S that ia{t~c~ii~·:}. of the established imerpi:etive crilef'ia. Indeterminate ltsl res\lff.5. ~~\: ~:~: tesofved by analysis ofa repeat ipecimen. · .:-Yi :·m·~ ·i~''. ';! \ .-.,:,> .'I\ . .. \. ,.,q;,,i~.··i \.. 1. Benign pal,morphisms .are D,NA ~nee variants that Jia~r~rtif . . . . ' . . · · ~ ~­ ~ ·l ;·~:;\. : ~ ~ ., ••· ••=.'! " I. ca i . . · . .,. . . 'i . . /]~i;~~};~~~ ct ~~I,;~(\. ~ 'f'\ \~_,t~"i't' '!\~; ~ ·' 1;..:-1,)~.'.\ ' !\l~-~~-..!~'!:.r::' - ----- - -- ·--...................... ... . c whihi~'~togically. ~~;-~!~\ V cli.nicalt;y meaningful ~ Uk: ~ of. ~shed•.clinl~-~~r.~u '~) .. comlatmg tesi results m tins ~1ric.C&1egory wub cl1mcal· ,;~ .i \~ i t:# and!« pathology. D!;lC to the lad ~ pttnished finding!i i¥.(~'(iii;~ ) ' ;· 6. looeaennhlaie iesr resu.irs . 1ji' :· " ····., ·, ·. · · ·. ,.·, · · ··· ··. ·.-~ •: · .··' :,'r.~· ·· . -~ . · : .: ·.... ···. ·. :. ·· · ,-. 1i«i~W!&;r;ttlflti~ '' ..' . ~JI' 4. VariantB -ot wdmmm signifka.D.C!e are DNA sequence varianis mat ; ,.'! • " l \'4Ww;·~fb.aQ'fa~~·•m ·.·· -~~~ ;: : . ·~ ...... -. -~~~~~-~~ -~ :\:· ...::. \~ }\ Page 104 of 145 ·., . . .. . . . . .. . -~ · =~~~ f.J~~t ~~1: Entry Number 1-1 ·- -- ........ -·-·--··"·-·-··--------- ·-···----- - ---·-----------------------· .........--·----······-· _:~~t;{~? -$--:~~ -~ Date Filed 03/28/16 3:16-cv-00972-MBS ~;~\f. ... .~ ;;~~ 1::rn FifJi!./' ! • • '.. .... . D.. , : . ; · ~·· t ·; • I ' t • • ! •. . . ·. .·. . ' • • • •••• • • • •• • • • • ' ; · • • • • • t ;it~ SCNi~(bNA.Seque~ Test . ,... . . . . . • ... : : . ·.. .. . . .' . ..· .. , • • • • • · • i .'' ·.. • • • • : • •·. • • .. ..... .. !'. ·.• • .• ' ~~ t • • •• • .. .. .. ·. ·. ' : ,· '· ~ ',. . !'' .... '~~, 11 ~..·q.,;•;• l,\•f~i' {i'·"-- ~ {:'~ t~JJ.\V}:i}~~,J~:fr~~>t~\ki~~· x ~J.,:~i"'\~·.",r; :~3(::~!:.~·5'-'('.~i~\\:,.-. ~ . , .,.,, . &11 ..... :\.-·." t\"' ·.l ii. \..\pz· \'::,? .. .............\,.... ·~·~.' .. "\ .... ~...... 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J}..:;~t/ \ ' ~~...\ I! ,, /,=~·i\. i i ... &J ' ' • ' t i . \ ' i . .... I ' • •• ' ? • • • • • 1 .... ...,.. R. ~ "a 'f · :.•. 1 'l:. I, SIJ '; ? ·:· i " ;i ~1;'{,) II ."f.~} 1"t¥-:t/~ • ' .. 1 .r }\~; r,~ ~">il";.f{. " <'"'''' \'t,' LalM>mtOJY oversight provided by Josepb.J. Higgim, M.D., F.A.A..N., CUA lloen5e bolder. Adlena Dlqnosub (Cf.IA lJ 22D0069126) ' ~ ·:r \\ ~:.~~ ~'~)~' ' ,~ "' ·'·'"'i :;.\ \"~\ , ~ i \ ..+ ,~~it ~1 ·~/?_ _ ' -: .. ···) ''t ,,-vi.;~ - ~~( ....\ .... :<:~i~Y / ,.- ;~t ·;r:J v .. ·: ,·:t.., .. , .. :.~ '::t,\· I ~.~)''i~·:.: ... <:i'...:-:.'{~.:~·1/;,~ ;U I t -~~1..-,. ./:.-:.-.: ~·~.•.;;}.~"!\~: .t.. ~·.~J~;Ni?m'.~~\~{~-~ ;.1·:- ,,l>.V t\:;.~11,•::":..!.} ~·"t.;' Director, Genetics w r((',~"?~:··~:/ . .;~:~'t ~ :.~>·~~~,~~: ~ . : ·~\'.';" ;~· · :~ 1 ~·.~,..::,·:·~i·~~t;r~~:-.. '" \· ..... , , it ~''"'.I'~"··• 1 ,.~ ,. "' • ) ,• •p I'\\~.' t_~,•~·';:,'; ,';l• I \ ·.. , : ·<;{:/~. ~ftl ?='~"~'t •\\~ ~·/l..•:'i, .:~;~~ ,.. ., l::f ( ,\ ,.... 1 i,.:; .,~) -~. ~ ! i ~'·!. • \.' l• I ~ '•'; Na.-asimban Na~an. PhD, ABMG Director. GenetJ.CS x{··~:·, ~·~ :. 1'~ '!-::,·~·\. >r! ..\:~.... ~---ii ~ .. ·~~-~:'; :~'. I •,~ ... ~t; : .•°' •" :<.·~,~~ ,·)., t , .., 1.:f..~!; . ·( 1.:~·~·~f / (1.:0. . . : .;: :"'~'x'• Hui Zhu. PhD, ABMG ~~ ! I) :,",[ ~\:?; °t\ '(t)'(};,/ ' ••• 'o;-~~',t ·\'.·~' . • li ?,_, . . ~·l!•/ ..~ .- ! \ { i •'" .. ~::~{ ({..,' ~ i.·.~-t;~~ ;:~ 1~l .. .•• ·t ~)·t •• =~"' " " ~~u6t.~,~~~·'.f{:.~·~g~f~i~~~; ~ . Laboratory r~ and submiilcd clinical infonnation xeviewed by, ~\;j :"l"' ....... , \'· ,t. ,'". \ . ....... .. . lm/INJ!rl~ Mit~ #[ 19& (Q.JitJ to tiitfWrl ~gli ~:tky c/ilfJMJ Mw>a Di4(.11,,,t]a II/IS rwrfo~.....,,. ·11aJidoti011.iftrt(;n - ' 7lm klttf~4 lo lo~ ~ llN1 ~g MKtdlJlfl fn ~' tlilA Uf'#I# iH lf~~Jkld ontf in «rMbttt k'itlt J/~ .ittwtl\»m Df mt NatlttMl c.o-utrff "'' Gltrfcat I~ ~(.\'CCLI'). ~\,.'.~ :;.-; '• £,ubo,at¥Ilk U.S. T(IOll v.lfll Pnq NtlllliJf(lln:l/rJrJ. Tk~ l'Jl.of.lltls ~ •kt sueJi dftlmHtr or o~ i3 ilol ~, 1Ns ll!lf l.s 41S"1j(lr d/Jil.UJ fJf1fPOfet 41td Mollll.IllOr II. ritanW al f.mftfgr.11Cr.Hiat or /Dr r#J>ttfTd i>iflJ. AJ&41tt1 Dfagmmtrs If litM.Utt lllrdt.r Ill# CRa!all ·1~1~1 P ;--.,,i :I . .;. t.fi~~.......... tr~··1-::::·.'\~.\~1~· llfl ... ~t-i,,~~·i·"'. . . ,... • ***REVISED REPORT •••v er u (ff~ '~~~- 07025148." . .... . . . . ... . •: ..... t . · : : ·. · • . ", .'• : .'. •;. • . ~::·:..~~-~; shown to be present in unafiectod ~-Onlrol subject&. and are e-00$ldered . ~...."\~~: ·~ign" (non-palhoget\k) sequence variants. If identified, UJtsc m Wll$ldered normal variations and ~ rot ttported in the Tuclm.ical Ri:sulrs section of this report, but arc available upD&. n!(JICst. '.i:~1 ···!!\.>~, .,. :!~ 3'r¥t~i~· :v~'.~ ~ At1am' a. GA.JOlJS · · ·•..·' ·.·.... : \ ' .·.....' .' :>.' ·• .· ; : . '.~I '!~,R~~~: ~· " ' .· ·:: <" . '""" .-·~"•"""-'f-'( . ....... ,~ . ' :("'f ;ii.~i!i ~t~' tii ,. • ,•'Ir/• .... ~\.: !~:_,: I~, " 1;, ·-, '\\1 : ' Uih,-J'·~·· c~·~ M ,, ~· . r ~ • 4 ·~ ~ 11.; .. .. --: • . ' , : , . ·.. ... , . 'lo •• ~,s ~: . .. r:h" •\, . n~~F~~::~~{~r:,t:..t:\~i~ ~ ,.c ~~l.:~ 1 )_~\ ~ ~ ei . o~it1. ; f;-\"vi'~ &\\~.~.,?,~· ~... ··~ ~ ....\ ~, ~ ~~~\rJ.~n-r~%~~~;~~·:;~;~~~~~~\~. )( ~! \i~.:'t{\~'*f .: ~;~(~1· .. :l.l;::~~~~~i,~·~·> t-. '-'; Ruiaisitlon fer Pam.da1 T~ - Tm Cock 536 \ -.J .· ._. \~{~:;:-;-.~·~:;,\~A~:~~:;·· f:!] .··~v... •. ' \ ·· \ :\ ,t-~}.,~Y/•,1 i · .. ~·x· ., ~i·t·;~;f', ,. 1,1 r~--~·~\ ;~ '-~~-:(~~~: In order to provide a more c:-0mpreheusive interprelatioo of lbis palient's SCNIA 1esulls, Alhena. Diagn~~ ~ ~ucstin& s!)~~~ ~~..~,:::-·:,(~?;!.\~:~« ~', ,!, biological parents mis pallenl Athena wiJ1 perform a carget analySis on d~e SUtpk! for var.1ant(s) 1denf.1ficd m gene S~li ·~1~~~d ,t).:l('··_. -.1. ~ '.~~·:>·:. use the findinp a> help i.nt:erpnuhe patieot's SCNl A result{s) at no additional dlarge. ~ use lhis funn as dle reqi.~~~ .Jf.~otal '..,.,~~ :.:\;~~~·;!J!S,'. ~( ~i~ on !f»s patietll. Enclt>se one comp~ ~ widt eacb parent's ~e and send ui Aehena. If you ha~ any ~~~~ft~e :,..~~-;·\),.[;:'.Mfu.o.;~:~~­ shippiog kW, ple&!le CODW:L Ar.ltena cu.!J(OOll."f' service at 1-800-394-4493,opaon Z. {;~-{"~~~'t -~~:,/ . 1\~ $' ~.._.})~~~. 't,.\ }5..{!{if~j.~;1 .{! . ·:·.l ·\~::·:·. ~t"t·i }~~~\.:-~·;:}·· Spedmt"Jl Requlmne.ts: l tavendar t11bc (8.~mf) w~ole blood Stonp Conditloos: R.efrlg~ ,! ,~·,/· ;/!J;,·'.! . '~':· . :. >.-Jtlf~i..';:~'.~ :~: a..! Ing ""11111UH "--~on... R~ t..............,h, .... avoid f'ree:zWl....:.:· \" .. ', .'.:-.·:··1.' ..,' . ". :.:::;".j·:·:·.',':,_··:· .. .. City,State,Zip: ~~;;':;· . -t . . . . . . . . . . .. . . . . . . . . . . . .. C1ty,Sttte,Zip: ....... \. ... \ \... - • Address· !:' J. t " · ·..· . " ,,· :, '··'. : . DiueOfBinh= Address: w\~ :, ' 111111, . .. ..... , . .. . , . . . · . , , ' •. ,~· ~~::~:.~i~;:!~·~k;\::'~-;,;. ,, ·C._, ..(,_y.:.,·. •··:.~.• v.'. ,.. ..... ·. •, . . . . . . . . . . 'Cll"!l: . ·~, \t:l~t',.• •.:• One Dunwoody ParlC.· . . . . ·• ·. . . . . .• ·. · : ..' . = ~~~·:::w:~:~·:·?1Iit::. ~ .. . . . . . . . . . . . . . . . T.;(ij~"(f ' . ._._ ~ ~Qo/::·,._ ....~·.', :">". ·:."·.:•.:. '.:: J~hnShoffner. ~ ... .·,. . ~·;\~". ... : '. '.·: ·.. · ·. ~.· .. ... 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I '(·~.:i:M~~~ }~·N ~j;:i;~::. m 3:16-cv-00972-MBS I Date Filed 03/28/16 Entry Number 1-1 Page 107 of 145 EXHIBIT Articles ~ @ +~ De-nova mutations of the sodium channel gene SCNlA in -alleged vaccine encephalopathy: a retrospective study 5omu•I F Berlcovic. Louise Hafkiri,Jaci11ta MMcMal>M,)ama TP~lekano~ Sameer M Zuberi. ElaineCWirr~IL Dnpak SGifl, Xenia Iona, John CMulley, Ingrid f Sc~er Summary IA- 1'ttwo/ ZC06; S: 488-'32 1'1;!1£i~td Onlino Ap~l 20. 2006 !>OI :10.l Ol61Sl~74-4411(~l 70446-X hckground Vaccination., particularly for pertu.slljs, has betn Implicated as a direct cau.se of an encephalopathy with 1e&actory seizurta and intelledtlal impairment We postubteii that cases of so-called vaccine en~phalopalhy could have mutations in the neuronal wdium channel a1 subunit gene (SCNIA) becawe of a clinic;il resemblance to severe myoclonic epileplly of infancy (SMEI) for which such mutations have been identified. >«•lhl~•l'' of !llolbou"'•· perfonnance liquid chromatognphy aiulysis, with subsequent sequencing. Parental DNA was examined to asceTtain Aintln Hoolth, !idclelbo'll the origin of the mutation. WtJ~ Vlcl:arlo,A""""la (> FB•:lre Haspl~ ..iWolcic, Austnolia ;I. li.utin MS<. X :on11Jip'l;o.....:so. l CMulloy P~:l): l>.>p1,...,1'1t ...,( h'4Attiu, Ul'iwnity of A.W.idt, ""1a1piWforSldi Cloihl,.n. Yotllhil, Gl..9ow, Ult findings SCNlA mutations were identified in 110£14 patients with illeged v.icdne encephalopathy; a diagnosis or a specific epilepsy syndrOme W3S made In all 14 Cl!Ses. Five rnutatioos predicte'). c.i•aiy, Al bella (0 S C.il i R~CP); School or however. the perception of causality cnn be difficult to Mol• il)o of and has led to successful litigation. Public interest in this lr.• Otp•,.....,,1 gf issue is high with a vocal minority u rging _avoidance of l'•tdo.t.•co. Uol••rsity of vaccination.• with the grave consequenc.e of a potential Md>Ollm~ Rot-.! Childf11n'J resurgence of preventable serious childhood illnesses ." tiospltil. Vldoda,Austnll• This i&ue is difficult to clarify largei) because the llE!chtfle<) diagnostic features of vaccine encephalopathy have never Co :'lU?Oi:.d'itnn ta: been defined. Reported cases have an apparent temporal • rJISl....,.I; &Ht(.n1,..1w11•• relation to vaccirution {varying from ~' develop.c:nen1al urest or regression.<•.:•·1 ~·, J.berkovk=urilmfl:t.ed.v~v There are various causes of seirures and developmental regression in iufaoc.-y, some of which h ave been pteviously misdiagnosed as vaccine encephalopathy Q A particular epilepsy syndrome, severe myoclonic epilepsy of infa ncy (SMEl), h as beco~ increasingly recognised. SMEI begins in the first year of life in pteviotL~ly healthy children. Hcmiclo1tic seizmcs, which may be long (S M 2'1:1.,iJ ~CV): D"l>'U1mtl'l of P.dlrnlu and 488 lasting, are characteristic and can be associated with fever. Myoclonic, absence, tonk --clonk. and partial seizures also occuc. The epilepsy is refractory and developmental regression ensues.•,,. The syridrome is associa ted with mote than lOO different mutations in the n euronal sodiurn channel tll subu nit gene SCN1A. Most cases of SMEI have such mut.>tions, although the exact percentage is still dehated. Around half the mutations truncate the protein and about 95% are de m>":o.' '"" We noted a similari.ty between the clinical pattern of SMEI and alleged cases of vaccine encephalopathy.1hus, we postulated that SCNIA mutations might u nderlie such cases where the physician or family believed that vaccination was causal. Th.is finding would imply that the encephalopathy was oot fundam~ntally caused by vaccination, but was due to a genetically determined, age· specific, epileptic encephalopathy. M~thilds Patients This retrospective study of pos:-vaccination cases was nested within a larger study of96 patients with unexpla ined encephalopathies and seizures beginning in d ie firs t y~.ar of life. We recruite d !»tticipants from child neurologists around Australia and New Zt:ala.."ld during 2002 and 2003 fot whom clinical details and DN'A were obtainable and other causes of epileptic encephafopathies {perinatal, hllµ://n11;roktr:t l com Vol ~ June 100 6 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 108 of 145 Articles post-tr~urr.atic, post-infectious, metabolic, and structural, etc) were excluded by appropriate metabolic and imaging studies. A few rcforr.ih were also accepted from outside Australasia. The study was approved by the Hmnan Resea:dl Ethics Committee of Austin Health. Written inforoi.ed consent was obtained from parents. gua:rdians, or the 1.pproprhle government authority. Cases were systematically classified on the basis of an ex.luustive ~e\iew of medical records from child neuroiogists, paediatricians, hospitals, and other treating doctors. Source records from initial medical presentations were sought to determine the p~ecise onset details relative .to vaccination. No specific neurological phenotype has been described fay v;iccine encephalopathy; so all cases were coded as vaccine encephalopathy when a relation to vaccination had been previously Claimed and O\ll' review showed that the first seizure occurred within 72 h of vacciruition. The time interval has no agreed de.finition, but on the basis of the published work we selected the time fnme of documented sei7'U1e onset within 72 h nf vaccination."" 11·' 0 ' All patients had epacptic encephalopathy (refractory seizurts .ir.d developmental slowing); febrile seizures and other benign epilepsies were excluded. Epileptic seizures and ep1epsy syndrome were diagnosed according to the Intemalional League Against Epilepsy dass.itications.'"" For this ~tuleofthe funding source The spoosors of the study had no role in study design, data collection. d&ta analysis. data interpretation, or writing of the report. The cortespondi~g author had full access to al.I the data in the study and had final reponsibility for the decision to submit for publication. R~uh;:; 14 patients were identified for whom vaccination had been judged as causative of the epileptic encephalopathy and our review confirmed seizure oru:el within 72 b of vaccination. The patients were ;i.ged 2 · H7 years at the time of study (mean 12 years [SD 11]). They ~re 2-11 months old (S·-4- months (2· 6)) at the onset of the illness, which followed vaccination by 1--13 h (12 h [15 hl). The vaccines included pertussis in all cases (t4ble). The· first sei7.n£e was described as hemklonic (n=S), generalised clonic or tonk-donic (n-61, infantile spasms (nnl), tonic (n-1), and unclassified (ng l). Th first seizi.;.re was definitely associated with fever (>18"C) in five patients, six wen~ afebrile, and ln three the temperature was not recorded. Status epilepticu.s ~seizures lasting ~JO min) occuned at presentation in silt cases. All cases h;;d severe epilepsy with multiple seiwre type~ and intellectual disability. Our review of the subsequent clinical course led to diagnos is of SMEI in ~ght patients, SMEB in four, and Lennox-Gasl patients with unnox-Gastaut syndrome, spasms ~ hypsauhythmia occurred early. represe:iting fae known evolution from Wei1t syndrome. MRI showed no foe~ lesions and no evidence of destructive or infiamrnatoty processes; scans in all cases were ~ther normal (n=8) or showt!d varying degrees of diffuse atrophy md delayed myelination (n..Q). Molecuhr genetic ilJlalysis showed heterozygous mutations of SCNlA in 11 ofl4 cases. 'T!icse mutations we:e predicted to lead to truncation of the protein in five c.ases (three frameshi.fl and two non-sense mutations); the other six were missense mutations (figure}.1'" A display of evolutionary conservation of the residues where the mutations were found is show::'.I in foe web.fig·..irc. None of the six misseose mutatioM were identifed in the blood donor control population; a 0 ic~Ont•,.fo•·-1tbfigv1e I 3:16-cv-00972-MBS I 1r~~) AiOllttt (....trths) s.i.u~ • .....t~- V>ed•• 11'1'• 8 74 lodTll H 2·S ;, 14 litTA " )rt-11'""' mutation Sttiw op'-?11<•1 Stizvro- ktmiiclon•t: Hemidoni( Ab,>., ~Mil F,.m.iJ,;ft<13Hf>lCl079 " Ab,!>:,11.M.-'TCS, !Mii - Jntr;, " ~mldoni( GC ~b, lll'EI M l~,,, .~164St' y ll!TA v G<...i ti, M. GPV y v Mtll\idonO: Mlf..,,.1Y4\]N y 11H" Unlm°""" Vn""'-' Unlrn""" l\M.SGTf.S 'iE. At, F, M. ::;r. Unkn""''~ IJ 16-S 11 14 )rdll\ y l) us 7 ~rdT" Uidrnown ..,. 14 145 H 1"TA N H ... fA111tJi,U .,,ti9an (dip~'\eiA. ~'~uis.. ttbn1}:· PV..,,..,~t vitt.:1rt<. ~~thw1A. p.:fb.nV,., uwi.i), i"l(hnc.d po~o, andhMmo'.()hihr,):GT\'S··gt~nr:~rltoft<-dGntt s:N\lrtS;G( ~rMIW'd dotiic. t';ll'Vi".$." CC -~ ~lwd tt.:'1""5.iot. lV'lOted rtructu1'! of SCJlllA protein Tho prot.lo ·.orn?::oos fQ.,, homolo3ousdomains (l·IV)• .,,h ,.ilh six trar.sm• mora.,. segment>. S<•tion of Ille six misKn>e rr.ut>.tions (green ) •nd l\w 1nuution~ pass;bly cavs;f\g pro!e!ll trunation (pinl< 1rl•n9I01) In th< U cm1wil~ alltgedvac~ioe en~tjlh•lop~thy ., . >hown. Th• >11l,.,e1\le1nulat:onsp"do1i1i1>lotlycxc\Jtlorl In the •"°"' :odin3 for the p<>r• lormiog iegmcnu, 11 pr•vio1J1ly .Wcribed inSM~I. 490 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 110 of 145 Articles that no less than 12of14 patienni were diagnosed as such with caref..tl phenotypic analysis. We do not know if this findi."lg is representative of cases in other centres, but previous reports of seizures in SMEI being associated with vacciD.ation as .well as fever lend support to our findings.''"" The multiple seizure types in SMEI and SMEB can ma.Ice diagnosis difficult for obsenoers unfamiliar with these dillordets; patients can be judged as having ;.n undusified form of epilepsy and intellectual disabi\ity. The discovery of SCN1A mutations has led to improved aware.n ess and diagnosi.~ of these severe infantiie encephilopath:ies." Scier.tific and medicolcgal controversy of vaccine encephalopathy has spar.ned seven·decades.vwe suspect th;it the natute of ci.Ses has changed because of increas!ngly sopbistiated clinical and· neurological diagnoses and investigations. Some patients had coma at or.set whereas others h:id seizures with subsequent regttss'.on. In the early :esearch, detailed analysis led to the conclusion that some alreged cases were probably due to heterogeneol.IS causes, including viral encephalitis and Reye's syndzome." The :nolecular delineation of genetic encephalopathies with phenotypes of SMEI .and SMEB now stems to be another major piece in the heterogeneous diagnostic puzzle of alleged vaccine encephaiopatbies. The genetically determined epilep!if synd!omes of SMEI an lwl.1t In alleged vaccine encephalopathy the assumption of vaccination as a cause has I.teen reinforced by the absence of a family history of severe epilepsy. Now, the molecular findings could explain the nature of the er.cephlopathy and the usual lack of family history since around 95% of mutations in SMEi occur de novo. i>--: SME! often begins with febrile seizures and fever is frequently associated with seizures early in the clinical couue. In the presence of SCN1A mutations, vaccination can still be :u-gued to be a trigger for the encephalop.ithy, perhaps vfa fever or an immune mechanism. Our expe~'ntal design doe-; not add!ess this issue, but the. role o: vaccination as a significant trigger for the encepb1Jopathy is unli'kely for several reasons. First, although vaccination might trigger sei'zurcs as shown by the increased risk of febrile seizures on the day of triple ~ntigen or MMR vaccbarion. there is no evidence of long-term adverse outcomes.'-' Second, less than halfour patients b.aC. documented fever with their first seizure, which i:ndicates that fever is not essential. Third, our neuro:rnaglng data showed no evidence of an inflam~mtory or destructive process. Finally, truncation and missense mutations reported in conserved parts of SCNl.A have not br.e11 found in many hillldreds ofbcalthy patier.ts.""')"""" Thus, individuals with such mutations seem to develop SME! or SMEB whether or not they are immunised in the first yeac of life. We do not think that avo.idir:g vaccination. as a potential trigger, would prevent onset of this devastating disorder in p~.tients who alrea~y ha:bour the SCN!A mutation. The mechanism by which SCNlA mutations cause SMEI is unknowti. Few causative mutations have so far be~n subjected to fimctional analysis, and the results are inconsistent; however, these mutations a.re presumed to caase abnormal neuronal exdlability." 'i Studies of less severe mutations of SCN1.A that cause milder phenotypes have also produced.conflicting results dependent on the techniques and the model system investigated."~ Definitive data. from neuronal systems have yet to emerge. Moreover. because many of the mutiltions associated with SM£! cause truncation of the pcotein, these proteins are urJilcely to be expre1sed at the cell surface; thu~ poorly UJ1den;tood changu to sodiumarticular child should finally put to rest the case for va~cination being the primary cause. O>nfirm;atioo of our finding-s by others would be of value in determining their generalisability and the broad societal implications. Cases of va ccine encephalopathy should be carefully a~essed di nir.ally for characrerisitcs of SMEI or SMEB, and testing for SCN1A mutations should be considered. Correct diagnosis will reassuTe the family as to the true cause, remove the blame of having vaccinated the child, dkect appropriate treatment. and allow realistic planning for prognosis. Specific treatment regimens for seizures in SM.EI arc emerging with ccntrolled data showing the effectiveness of stiripeorol." and uncontrolled open studies suggesting avoidance of lamotrigine~ and probable benefit of topiramate:~ Medical aod societal er.ergies that have focused on the alleged association with v;iccination need to be redirected to\lrards the care of these seveiely handicapped individuals and tcwards novel approaches to treat and ultim.ttely preYent these er.ccph~lopathies. I 3:16-cv-00972-MBS I Date Filed 03/28/16 Entry Number 1-1 Page 111 of 145 Articles Comnbvton SB dc«e!oped dte hypoth.si4 and <•'?Oil: the first dr.!\. A.~alysi.s o! clir.iul Jal• d<>r;•• princip•lly by ll'S, )MM, JTl',:iml Sl'll, and •I."' by SM?., £C\'i, and DSC. Molecular>nzl,.:s W3l 1Jd•rtakrn by LH. Xl. •nd JC:\!:. All authors criticaUy :evi$Cd rhe lirsl dnt\ •nd approvtd the &n.rl manusctipt. w" (onflktsof i11teru1 SB, IES. •nd ICM h•·:·; rct<:i•1ed rro'31gnwtic n~sl (or SCNIA mmtions. Alt'J!.;&n. ;rnJ l~n A•d•~I: and Ali!011 Gardner, who ~ld th• amino-.:ic aii!l"rn.,nts. Th~ li!udy was supported by grant! from the HHMllC ad 8ionomics lid and 1 donabon from th.e Th)"l.,.lleid Ch>ritabk Tru.:s. RtMninst ""1oe>ping cough. JAMA 19Jl; 101; 187-llS. Kul~~•l«ination: is lht end of ~'it '"I!" in sight? V.iaittr 1989: 'l; l9~llrain. J Ptdi~lr 1990; 116: 4>+-61. C:•~00.;.>>:<.>-<0ntrol .•Ludr.JAM.l 19'i-I; 211: J7-"'11. S Barlow WI:, D~.;, RL. <:.!..;er JW. et al. Tbt risi. of tei2utet afltr toceipt of wltolt-cell Fetus.sis m•asles. rnu.tr.p>. and rnbelia vac the Swans.a lksearch 1.;nit o!Tltc Royal CoUeg~.orc.ueral Pr"cririonen. B•Mtdj (Cli• R" Ed) 19g1; 19 Commi1sion on Clauilication and Tenniuology of lbe lnttrnationil lngue Apinst Epikpsy. Pmpo.ul !or re'f\scd dus!lie>tirm of epilepsies ~nd epileptic sy11rlromes. !!pil.,,.io 1'389: JO: 38'>-99. 20 Cla,'$ l, Dcl·l':tvcto I. C.....lcnuo• ll. t..ag'.:c.- L. V.u1 8ro~ck1.J.,vc11 C. 0<' fo11t(lic !'. O.. """" m\lt.tiur>• in Li1c 1C.Jium-d1~ntu•l 11n"' SCN IA cau5e se>t caut< <){ :evm mroclonic epilepsy of lnfollC)'. MiUai 2003: 21: 61S-2l 2) W:all•c.. RH, Hodgson Ill. Grinton 8E. et al. SOUr.i•. 2• l.~ ~~I um chao~l •lpha sllbunit tYl"'-1 (SCNIJ\) in iwacnbk childho00 •pileps~s •mh frequent gtillfl.¥ of ne...,ooal volcase-;atcd Nat di;uu1el alpha l sub11nit gtne SCNIA in core se1cre myaclo4; 4S: l:l'HS. 27 M;zlley JC. Schelftr IE. Prltou S. Dibbens 1.M, 8erkovlc SF, futl follo.,fog im'"uni.ution: •s.ening prob3bitity or ausa1io11. Pulicw Neurol 1989; S: lg]...90. Fartinnton P. Pugh S. CoMll• al. A nrfitld P, Cl1erry JD. St•led "'ith dip!tOmia-tttatlUSpertund precaution': recotnr.teno•tiOl\S of die Arl>isoryCornmilteeon lmwwii:.ta\ion l'l'3dtet {ACJP). MMWR Re;:om'" R:p 19%; •S' 1-)S. McAulitre IS. Wadla1td WC. Per!ussi< .acciu•. lllc..i11e 199); U.: 1)71-79. Ste':ph1·n~n JB. /\ nr:uro10~11~ 1•->ks :tl 11t~un·f~it";.tl d\S&•L.._l~ l<,.nrm•lly rd:l1· DTP irnn1u11ir.1tiou. 'r•kai) f:rp din MtJl l9l!S: lJ (suppl): 15'7-04. Ora• tt C. Bureau M. Oi:uui H. Fu~u,•m• Y. Olkat 0. $ infaney. childhood and adolcsctnt;, 3rd edn. ~a~lleigh. UK: John Libbey ti: Cu. 2002: ~1-!UJ. anJ infanti!o Hc»r~ 2001; 61: 76~?. Nabbout It C.::t>nito E. Dalla 8mmdin~ &, •I d. Spe.:ttwn of SCHIA mutatlaM id >tvtce myodonic cpilA!psy of infancy. NturolOff 2003; 60: 1%1-67. Fujiwar• T. SU&aWl."' 'T. l\4a>.akl·Miyauki It ~I al. Mu1>1hms nf JS 36 )7 la 39 40 41 42 lS: 'i35-42. Co:wru),.riou on CIJ!j:tif&otiuu ·.md T<~m1ihology of lhc fut~rn•lional IJ·.1¢>~ ~~inn r.pncp.•~· PtoJlis.:d dinicd and dcctro..r.aplt•logr:iphic clmificotion of epileptic sri?utcs. 11pilep•ili 19Sl 22' 4&9-SOI. C;ttterail WA. fu>m ioflic cuni:t11s to molend fwtdon of ¥<1112ge-g•led wclium channels. l'll\!l'OK 2000: 16: H-2S. l(on•i l<. Hirose S. Ogu11i Ii. t't al. Effect ofl<>nli1ation ofm!Herue mulalioM in SCNIA<111 <; D: 321)-14. Stepbrulels in,• .,,.., myoclonic •?ilepsy ofinC.uc;·. Proc N
t I. Culdin Al. lueteased 1te-ilr<>nal firing in t<)mputu :.Unulations of !odium channtl mutalioiu lhat wist g•11enliiod tpilepcy with f•.br'J.¥ ~ci1:11rcs plu•. JNm-ophysioJ 200<\; g1.: 2G4G-St>. A!ckoY A., R•llm>n MM, Mitro\ic N. :.dunann·H~rn f. Lercl1e H. A •odium channel mutation causi:lg epilwaJa T. ~t al. A nonr<~~•• 1nu121ion of the sodiuO'I 'lurutel 3c~ SCN2A in a puicnl wim intr•ctabl: epilepsy •nd tn•·n1>) d•cliM. j lo/;mwci 2004: 14; 2690-~3. Ch\nl11 C. Marchaud MC, 'Ihm A, et ol. S1iriper.tol in •ev~r~ myoclonic epilepsy ill in(anC): a r•11'10111i•cd pl:rtd»con1tulk..J .< 0. umo\rigine •nd $CiZll.tc aggr:iv~lion ill severe In ·nctouic epi:ep>y. F.piltpli4 tq9S; 19: 'iOS-U. ' Coppola C. Capov!ll• C. Mor.Ll!lnini A, P.I ~l. 'foplmn•t~ '" •dd..,n drug ln "'""'' lt'.yodor.ic epilepsy in infanty: an Italian muhii:entcr open rr;•J. f.pilepsy Iii< 1001; 49; 4'i-43. '"''"1' 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 112 of 145 doi:IO.i09J/brainfa· -1mOO~ The spectrum of SCN/A-relate.d infantile epileptic encephalopathies Louise A. Harkin,0 Jacinta M. McMahon,3 Xenia lona,1 Leanne Dibbens..u James T. Pelekanos,3 Sameer M. Zuberi,4 Lynette G. Sadleir,5 Eva Andermann,6 Deepak Glll,7 Kevin Farrell,8 Mary Connolly,8 Thorsten Stanl,s Michael Harbord,9 Frederick Andermann,6 Jing Wang,10 Sat Dev Batish,10 Jeffrey G. Jones, 0 William K. Seltzer,10 Alison Gardner,1 The Infantile Epileptic Encephalopathy Referral Consortium, Grant Sutherland,1•2 Samuel F. Berkovic,J John C. Mulley1' 11 and Ingrid E. Schefferl. 12• 13 'Department of Genetic Medicine, Women's and Children's Ho1pital, North Adelalde, South Australia, 2 Department of Paediatrics, The University of Adelaide, Adelaide. South Australia, 3 Department of Medicine and Epil1!9sy Research Centre, The University of Melbourne, Austin Health, Melbourne, Victoria, Australla, 4 Fraser of Allander Neurosdences Unit, Royal ·Hospital for Sick Children, Yorkhil1. Glasgow, UK. 5 Departments of Paediatrics, Capita I Coast Health and University of Ota&o. Wellington, New Zeal:i.nd, 6 Neurogenetics Unit, Montn!al Neurological Institute :i.nd Hospital, and Departments of 7 Neurology. Neurosurgery and Human Genetics, Mc:Gill University. Hontre~I. Canada, TY Nelson Department of Neurolog~ The Children's Hospital at Westmead, WeStmead, Atrstn.lla, 8 Department of Neurology. B~itish Columbia Children's Hospital. University of British Columbia, Vancouver, Canada. 9~partment of Paediatrics and Child Health. Flinders Medical Centre, Adelaide, South Australia, Australia, 10Athena Diagnostics Inc., Worcester, MD, USA, 11School of MoleOJlar and Biorm:dical Sciences, The University of Adelaide. South Australi~ Doepartment of Paediatrics, The University of Melbourne, Austin He1lth and Royal Children's Hospital, Melbourne, Vcctoria and BDepartrnent of Neuroscience.s, Monuh Medic.al Centre, Melbourne, Victoria, Australia Correspondence to: Prof. Ingrid Scheffer, Epilepsy Research Centre, Neuroscience Building, Heidelberg Repatriation Hospital, Banksia Street, West Heidelberg, Victoria 3081, Australia. E-mail: $Cheffer@unimelb.edu.au The rehl.tlonship between severe myoclonk: epilepsy of Infancy (SMEI or Dravet syndrome) and the related syndrome SMEt-borderland (SMEB) with mutations In the sodium channel alpha I subunit 1ene SCNIA Is well established. To exptore the phenotypic varlabllity a.uodated with SCNIA mutations, 188 patients with a range of epileptic enc:ephalopathies were examined for SCNIA sequence variations by denaturing high performance liquld chromatography and sequencing. All patients had seizure onset within the first 2 years of life. A higher pt"Oportion of mutduetioo SCNlA, the geo.e encoding the sodium channel alpha I subwiit, has emerged as the n:iost important of the epilepsy genes cutrently known (Mulley et aL, 2005). SCNJA mutations underlie more than 700A> . of patients wilh the epileptic encephalopathy severe myodonic epilepsy of infancy (SMEI or Dravet syndrome) (Dravet er al., 1982; Claes et al., 2001; Mulley et al., 2005). More than 170 documented mutations are associated with SMEl and th, related syndrome of borderland SMEl, known as SMEB. Truncation mutations account for nearly 50% of mutations found in SMEI, with the remainlificd by polymerase chain n:aaion (PCR) using flanlcing intronic pri:ners wd standard PCR conditions (primers available upon request). PCR fragments were h~at denatured at 95°C for 4 min and sle>wly cooled tC• room temperature to form hcteroduplC)( products which were anal~cd by dcncturing high performance liquid chromatography (dHPLC) on "the T.ransgenomic WAVE 3SOOHT instrui.1cot (dH.?LC ce>nditioos available upon request). Amplicons shl!wing altered clHPLC 'hromatogram patterns were sequenctd in lioth directions fnlrn independent PCR products, on an A.Bl 3700 Page 114 of 145 8roin (2007}, i::o. 8-B-352 $tQuencer. The final subset of patients ( 43) was scruned by direct sequencing of ?CR products (without prior dHPlC screening) by Athena Diagnostics under diagnostic conditions. The numbering for each mutation is Wle.n from the Jtart codon ATG of the full-length SCNIA isofonn sequence (Gftibank accession number A0093548). In cases where an SCNIA mutation was detected, the appropriate :vnplicon from parental DNA (where avaibble) was tested by DNA sequencing to distinguish between de nova and familial variants. Mutations or .rue variants wu-e distinguished from coding single nucleotide polymorphisms which have previously been reported (Escayg er Ill., 2001). Results Clinical d.i agnoses One hundred and eighty-eight patients were rccrui~d from Au.stralia (110), Canada (27), United Kingdom (23), N~ ZcaJ;md (20J, Israel ( 4), USA (3) and Derunark (1) with seizure onset in the first 2 years of life. These included 14 cases who were negative for SCNJA mutations on singlesttanded conformation analysis ia our previous study (Wallace et IU,, 2003); the eight positive cases and two, who were negative on sequencing. arc not included in the data presented here. Our total cohort contained 66 with SMEI, 36 with SMEB including· the various subcategories, 25 with cryptogenic generalized epilepsy, 18 with ccyptogenic: focal epilepsy, IO with MAE and 12 with LGS. The remaining cases had a ral)ge of other syndromes or were unable to be classified (Table 1). Table I SCN/A mutations in encephalOf)athies patients with epileptic Total SMEI SME8 SHEB-0 SM EB-SW SMEB-M lCEGTC Cryptogenic: generalized ~ilepsy Cryptogenic focal epllepsy 66 36 16 ~ 4 2 25 18 SCN/A mutation 52 25 10 II 3 I 6 Myoclonic:-uta,tk epileiny IO "2 Lennox-Gastaut i.yndronie West 'yndrome ldiopnhk spasms EIJ'ly myodonic; tncephalopadly Progreutve myoclonic: epilepsy Atttrnating hemlplegia of childhood 11 I Unclanified TocaI s I I I I 12 188 SMEI. $CVerc myoclonlc epilepsy of infancy: SM EB-SW. SMEI borderland without generalized spike wave; SMEB-M. SMEI bor· derland without myodonic seizure.$; SMEB-0, SHEi bOf'derland lacking more than one feature of SMEl; ICEGTC, intractable child· hood epilepsy with generalized tonle-clonic seizures. 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 115 of 145 L A.. Harl-Jn et o/. Molecular' analysis Of the 188 patients examined, 90 (48%) had SCNIA mt1tations. Ninety-four sequence variants were identified in the 90 mutation positive patients as four children each had two changes. Jn each child, the putative pathogenic variant was distinguished fro m the likely non-pathogenic variant; the latter. Wa.5 not included in further analyses (sec later and Supplementary Table). The .majority of mutations are nuvel (72190, 80%), reinforci.ng . the mutational heterogeneity characteristic of SCNIA. Of . the 90 cases, DNA was available from 76 sets of parents and 73/76 (96%) were dt '11WO mutations. Amino acid alignments of the missense mutations show that they affect conserved domains of the protew in other human alpha chan.,els (SCN2A, SCN3A and SCN8A), chimpanzee, rat, mouse, Fugu and Droscph1/a consistent with their inrecpretation as pathogenic mutations (Supplcn'lcntary Fig. Sl). Moreover, the probability that these missense m utations are pathogenic mutatiom is supported by their de novo origin (in 34137 cases where pa rents have been examined} and previously published observations in SMEI. SMEI Fifty-two of the 66 (79%} of patients with SME1 had SCN JA mutations (Table l ). Forty-four percent (23/52} of th~ Sl>IElrelated mutation.~ were non-seJJSe or frameshift mutations resulting in protein trunoition, 39% (20/52) were misscnse mutations and the remaining 17% (9/52) were intronic splice donor or splice acceptor site changes. These mutation.~ were spread throughout the gene with the majority of missense mutations ( 14120, 70%) localized to the transmembranc region~ of the protein, in p~rticular the SS-S6 loop of domain II th2t forms part of the ion channel pore (Supplementary Table, Fig. IA). ln contrast, 57% (13/2J) of truncation mutations were positioned in 6e intracellular loops of the protein {Supplementary Table, Fig. IA). Parental DNA was available for testing for 42/52 SMEI patients who were mutation positive. Analysis of the DNA fror.i these parents confirmed that all 42 mutations were de 1tO"Vo. There were four patients with two sequence variants that posed chaUenges in clinico-mokcular interpretation (Supplementary Table). Patient 2 had two SCNJA sequence variants: one was a de r1ovo misseme change (Y84C) affecting a highly conserved amino acid site (Supplementary fig . Sl ) and the second wa$ a splice acceptor site change found to have a maternal origin. The mothet was unaffected; the maternal grandfather had a history of conV'.llsions until 7 year.s hut was negative fur the splice acceptor site change. There was no further seizure history within this family suggesting that the change within the splice site \V-.tS probably a benign variant. Therefore this varia nt was not considered in the determination of mutation frequencies. Patieo ts 6, 32 and 38 also had two sequence variants detected but parental DNA was unavailable in order to ascertain which variant was de 110110 a·nd thus the likely pathogenic mutation (Supplementary Table). Patient 6 had two intronic mutations detected, both potentially pathogenic. [n the abience of parental DNA we can oafy assume that one is likely to be pathogenic. The intron IVS3-13T-+ A change was chosen as the most likely variant to affect splicing since it is within the consensus CIT run in · the splice acceptor site. Patient 32 had both a missense (El238D) and an intronic donor splice site mutation. Since the misseose change affected a highly conserved amino add site {Supplementary Fig. SI), this was considered to be the true mutation. Patient 38 had a truncation mutation (R1525X) also seen in Patient 39 with SMEI a.nd in a previot.:s study (Supplemcntaiy Table) (Kcamey ct al., 2006). Patient 38 also had a mi$$enSe chai:ige not as highly conserved a.s most missense mutatiom (Supplementary Fig. Sl) su the truncation mutation wa.i considered the likdy pathogenic mutation. The second variant found in each case has not been included in the· mutational analysc3. Simultaneous double mubtion in the $3me patient is a theoretical po.1.Sibitity, as is a de novo mutation adversely interacting with a pre-existing rare variant. However, in the absence of definitive evidence from other SME1 cai;es and Fir. I Schemuic. r~prese11tation of mutations in SCNIA in patients with (A) SMEI, (B) SMEB and (Cl other phenotype,. Refer to Supplementary Tibte for details. The SCNIA protein consists of four domains designated I- IV, each contains six trammembranc segments designated Sl-56. • = truncation, O • = splice-site mutations. = missense, I 3:16-cv-00972-MBS SCN/A.,-ela'~eci Date Filed 03/28/16 Entry Number 1-1 Page 116 of 145 Brain (20(;7). 130, epileptic ence pha!apathies absence of parental DNA to establish de novo origin, the most parsimonious e:xplaoation is that of a single mutational event unless prove11 otherwise. SMEl-bordertand SCNIA mutations were identified in 25/36 (69%) patients with SMEB including all subcategories ·(Table 1). Over half of these changes wert missense mutations (J 3/25) with 40% ( 10(25) being truncation mutations; the remaining two were splke-site mutations. The mutations were spread throughout the gene with the majority (18/25, 7Z%) localized to the transmembrane domain regions. Missense mutations were clustered in the S2-s4 transmembranc segments of domain I (Fig. lD). Analysis of parental DNA from 22125 patients with m ubitions coofirmeri 95% (21/22) were de novo. Patient 63 had a paternally inherited mutation (A239T). The proband's father had febrile seizures plus (Scheffer and Berkovk, 1997) and the paternal grandmother had unclassi:1ed seizures. Both individuals were found to carry the A2~9T change, which when taken together with the amino acid conservation of this residue (Supplementary Fig. S 1), reinforces the status of this variant as a true pathogenic mutation of SCNJA. The family had a bilincal family history of seizures as the proband's · mother had febrile seizures and did not carry the SCNJA munition (Supplementary Fig.. S2). B~·3-~51 Cryptogenic generalized epilepsy Of the 25 patients with cryptogenic generalized epilepsy, six (24%) had mutatio11$. None of the mutations have been previously reported, however the T226M in Patient 78 was also seen in Patient 61 within this cohort with SMEB-0 (Supplementary Table). Four mutations arose de novo; parental DNA was unavailable for one patient and for Patient 82 the mutation (M973V) was found in her unaffected father. There was no . fumily history of seizures but the arnioo acid conservation at this site is reasonably strong (Supplementary Fig. Sl) providing circwnstantial rndence that it is a true mutation: If so, then it must be non-penet1ant in the father or else function as a susceptibility allele acting in tandem with other unidentified· susceptibility genes responsible for lhe phenotype in the pro band. Tb.e six cases with mutations hac.l heterogeoeous phenotypes with onset between 1.5 and 12 months (Table 2}. Two had a phenotype with onset in the first 2 months of life and abnormal early development but other fearures were similar to SMEI. Patient 80 fixed and followed . and smiled by 6 weeks when seizures began. Development slowed from 6 we~s: he sat late, walked at 18 months and developtncnt stagnated from 2 years. He died at 13 years. Patient 78 had seizur~ onset at 8 weeks, smiled at 3 months, never sat or acquired words. The other four cases pre~nted a mixed p icture, but generalized spike wave and focal discharges were umally T11ble l Clinical features of SCNIA mutation positive patients with diagno$ls other than SMEI and SMES Patient Age ac study Seizure Seizure types (years) onset (mC11ths) 78 s 2 79 2l 5.5 80 14 l.S 81 1'4 r2 GTCS, H,MJ. F.NCS FS,GTCS GTCS, H. At, MJ, F, SE FS. GTCS. a.Ab, Intellect Neurological signs Epilepsy SCN/A clauiRcation mutation Se~e Increased tone, CGE TI26M CGE CGE Al9SP Denll'IO V.422E Denovo Ataxil., intermittent CGE rn011ement disorder S616G NO None M973V Paternal IVSIS+IG-+ T De nOYO ID BJ 84 85 86 35 9 3 16 6 s 20 s 7 Oenovo later generalited hypotonia Mild-moderate ID None None ID ID MJ, SE 82 Inheritance FS. GTCS. MJ, F-SG Low avenge FS,GTCS, Mj Norma.I FS, GTCS, MJ, Mild ID F,NCS None MM d generalized sputicity CGE CGE CFE (SIMFE) FS7ShX62l Oenol'O ID None CFE (SIMFE) Fl543S Maternal Moderate ID Ataxia, mild CFE (SIMFE) Rl5'16C De novo FS, F..SG. SE Normal CFE Rl6S7H LGS 1\1636Q Oe novo Oeno1111 MAE IU93C De no\IO MAE Gl480V Oenovo 4..5 5 GTCS. MJ. F. ·r 18 F, H, SE left hemipa.resiJ 87 88 ll 0.75 IS. At, aAb, T, ID 89 II 4 SE. NCS FS. GTCS. MJ, At, ID None Mild right hemiparesis None 90 12 Moderate ID None T.H 13 FS. F. MA., MJ FS, febrile seiZtJres; aAb. atypical i1.h$ence sei:iure.s; At , atonic sci:iures; F. f11cal seiwres (not hcmldonlc/uoilitcral); GTCS, generalized conic-clonic ~eizures; H. hemidonic; IS, inr~ntile spa.sms: MA, myoclonic - aJtatit; HJ, myoclonic jerks; NCS, non-convulsive $tatus epilep- cicll.!; SE. status cpilepticus; SG. secondary generalitation; T, tonic seizures; CGE, cryptogenic: generalited epl!epsy; CFE, cryptogenic foul epilepsy: LGS. lenn())(-Gastaut syndrome; MAE, myoclonii;-astatic epilepsy: SIMFE, seve<"e infantile multifocal epilepsy; ID. intellectual disability; ND, not clone. 3:16-cv-00972-MBS 8rai;1 (2C07). Date Filed 03/28/16 Entry Number 1-1 ::w. s.;:;'7"t52 Page 117 of 145 L.A. Ha:-kin :!t aJ. seen. T.'le severity of the seizures varied with some only having generalized tonic-clonic seizures, which settled by adult life. alternating hemiplegia of childhood or the 12 cases chat could not be classified. Cryptogenic focal epilepsy The sodium channel alpha I subunit gene, SCNIA, is currently the most clinicaUy relevant epilepsy gene. Mutations in SCNIA are an important cause of SMEI and SMEB and its subset ICEGTC {Claes et al, 2001; Mullcy et al., 2005). Recently we showed that so--called 'vaccine encephalopathy' stwuld be regarded as SMEii SMEB on clinical and molecufar grounds (Bcrl<.ovic ct al., 2006). Whilst SCNIA was originally associated with a small proportion of patient& with the mild phenotypes characteristically seen in the GEFS+ syndrome (Esl"3yg et at., 2000; Mullcy et al., 2005}, mutations within this gene have been identified far more often in patients with more severe forms of epilepsy. This study examines epileptic encephalopathies beginning early in life and exp-ands the phenotypic spectrum of SCNJA defects beyond that previously recognized, to. now ioclude patients with cryptogenic generalized epilepsy and cryptogenic focal epilepsy. The majority of mutatiom identified in the 90 children in this study were novel (72190, 80%), whereas 18 (20%) had been previously published (Claes et al., 2001; Ohmori et al., 2002; Sugawara et aL, 2002; Fujiwara et al, 2003; Nabbout et al., 2003a; Wallace et al., 2003; Fuk.uma et 111., 2004; Mulley et al., 2005; Kearney et al., 2006; Mancardi et al., 2006; Marini et al., 2006). This expanded list of mutations, ta.ken together with those reviewed by Mulley et al. (2005), provides an essential mutational database for use as an interpretative aid for diagnostic laboratories offering SCN lA mutation testing. Unlike some disorders where mutations arc largely concen~ratcd in 'hot spots', the mutations within SCNJA are widely distributed throughout the gene. Parental DNA was available in 84% {76/90} of cases of which 96% (73/76) arose de ncvo and 4% (3176) were familial. Familial SCNlA mutations have been previously reported in around 5% of SMEI where family mcmbm have mild GEFS+ phenotype5, as we observed here (Supplementary Fig. 52) (Fujiwara et al., 2003; Nabbout et al., 2003a; Mulley et at, 2005). In these probands, it is likely that their disorder has a multifactorial basis where SCNlA is a major but not the sole contributing gene. This would explain the marked disparity in phenotypic severity between the proband and their relatives. This model could explain probands 63, 82 and 85 where the parent was unaffected or had a mild phenotype. It is worth coting that these probands had a range of phenotypes includi.,g cryptogmic generaliud and cryptogenic focal epilepsies. Given the current $la.te of knowledge, the majority of SCNJA mutations remain novel. This creates a challenge in determining whether new variants are pathogenic or not. Where the variant is de 11ovu or results in cruncation of the protein, then the likelihood of it being pathogenic is Discussion Of 18 patients with cryptogenic focal epilepsy within. this cohort of infantile epileptic enc.ephalopathies, four (22%) had mutations (Table l). Five cases presented with severe infantile multifocal epilepsy with developmental delay and are desc.cibed later. Three had mutations: two (Patient~ 84 and 86) arose de novo (FS75f'&X622, Rl S96C} and one was maternally inherited. The latter (Patient 85) had a putative mutation (Fl 543S) that was highly conserved (Supplementary Fig. SI) and was cal't'ied by her unaffected . mot:ier, and may represent a susceptibility allele. One {Patient 87) had recurrent febrile status epilepticus with onset at 18 months (Table 2). Twenty-four episodes of status cpileptkus occurred; some with focal features with variable lateralization. MRI was normai. The patient died al 5 years due to complications of status ep!lepticus. He had a de 1101•0 missense SCNJA mutation (Rl657H). Severe infantile multifocal epilepsy Five cases had this phenotype with seizure onset at a mean of 4 mcnths. Of those with SCNJA mutations (Patient~ 84, 85 and 86, Table 2), onset occurred at mean of 5.5 manths ( 4.5, 5 and 7 months} compared with 6- and 8·week onsets in the other two cases. Each child had multiple type.; of foca! seizures with varying $Cmiology. EEG studies iliowed abundant multifocai epileptiform activity typically with no (or exceptional) generalized or bilaterally synchronous discharges. The three patients with mutations had MRI brain stildies; two showed mild atrophy. The remaining two bad CT brain scans; one showed mild right sided atrophy. Developmental delay became evident in a.II cases. In the two cases that were mutation negative, seizures began at 6 and 8 weeks conctUTent with the recognition that develop· men~al delay was present. In the three cases with SCNJA mutations, early development was normal with develop· men:a.I slowing noted at the ages of 16 months, 3-4 years :and 6 years even though seizure onset occurred at 4.3. 5 and 7 months, respectively (Table 2). Developmentai outcome was poor with intellectual disability ranging from mild (one case, mutation positive: Patient 85), moderate (three case~. two had mutations: Patients 84 and 86) to sevefe (one case). Other phenotypes De na110 SCNJA muiations were identified in 2/10 patients vlith ~L\B (Patients 39 and 90} and 1/12 patients with LGS (Patimt 88) (Tables I and 2). No mutations were identified in patients with West ~yndrome, idiopathic spasms, early mycc!onic enc.ephalopathy. progressive myodonk epilepsy. 3:16-cv-00972-MBS SCN//.-1ela~G epileptic Date Filed 03/28/16 encephai~pathies extre:ndy high; 79 (88%) of our 90 positive cases fitted these criteria. tn cases with m~ense changes, where DNA from puents ii; unavailable, or where an unaffected transmitting parent is identifled, the case for pathogenicity rc~ts on· circumstantial evidence provided by evolutionary conservation of protein structure. Definitive functional studies are rar.ely available for this particular ion channel. Jn the four cases w!th two rare SCNlA variants, one of the tw6 was assessed as more likely to be relevant to the observed phenotype. [a cases where an unaffected transcitting parent is identified, these changes may be incidental benign variants, incompletely pcnetrant· pathogenic variants or represent a susceptibility allele that contributes to the phenotype io a polygeoic ·manner. Another alternative is that tne variant has a major dfect on the proband, whereas ·the tran&mitting p~rent has unrecognized protective molecular mechanisms. SMEI This study reinforces the high frequency of SCNJA mutations in patients with SMEI. The initial report describd mutations in 7/7 cases (Claes et al., 20(1l). Subsequently, large series from a nwnber of centres have reported mutations in 61-87% caSt:s consistent with our fin.iing of 79% reported here (Ohmori et al., 2002, 2003; Sugawara er al,. 2002; Fujiwara et al, 2003; Fukuma er al., 2004). Lower mutation rates of 35% (33/93) and 33% (55/ 169} ha•1e been reported (Nabbout et al., 2003a; Suls et al., 2006) and of 33% (8/24) by our laboratory (Wallace et al., 2003). The latter study used single-strand conformation analy$is for mutation detection, a rapid sereening technology less sensitive than dHPLC used bere. DHPLC bas >96% sensitivity and specificity (Xiao and Oefner, 2001 ). Additional direct sequencing was performed in five cases (two negative). Fourteen of the ·remaining negative SMEI cases from our study wen: tested by dHPLC (3 ca~) or direct sequencing (ll cases) here. Eight mutations were identified (two by dHPLC and six by sequencing), bringing the mutation rate lo 16/24 (66%) for those cases reported in our original study (Wallace et aL, 2Q03). Of. our SCNlA mutation negative SMEI cases on dHPl..C, 2 of l3 (15%) wcl'e sub~qucntly found to have whole exon deletions detect<:d by multiple liglsc-dependent probe amplification (Mulley et al., 2006). Other SMEI cases Jacking point mutations have been shown to have microdeletions including the SCNlA gene (Madia et a}., 2006: Suls el al., 2006). SMEB We found 69% of our SMEB cases had SCNIA mutations. This figure is higher than the 26% reported by Fukuma et al. (2004) and more in keeping with the 88% mutation rate of Ohmori et al. (2003). The majority of SMEB mutations detected in this study were novel changes (17/25, 68%}, with eight mutations being previously reported in Entry Number 1-1 Page 118 of 145 3roin (2C07), {)t), 8",~-&:J2 patients with SMEJ (Claes et al., 200 l; Ohmuri et al., 2002; Sugawara et al.. 2002; Fujiwara et al, 2003; Nabbout et al., 200311: Wallace et al.. 2003; Fukuma et al.• 2004; Kearney ct al., 2006; Mancardi et al., 2006; Marini it al., 2006). SMEB is distinguished from SMEl by the absence of specific features. The question of whether myoclonic seizures are an essential component of a SMEI phenotype remains controversial (Ogino et al.• 1988; Commission on Classification and Terminology of the International League Against Epilep~y. 1989; Ohmori et al., 2003; Fukuma et al., 2004; Dravet et al., 2005). Dravet and colleagues observed that myodonic. seizures may be segmental or occur immediat~ly prior to convulsive seizures and they postulate that subtle myodonus may be 1nissed (Dravet et al, 2005). Our data suggest that myoclonic seizures are not obligatory as three of four patients with an SMEI phenotype laclcil\8 only obvious myoclonic seizures (SMEB-M) carried a SCNJA mutation. Similarly, generalized spike-wave activity is considered the EEG hallmark of SMEI, but we found that 11/14 (79%) of our patients with a SMEI picture without demonstrated generalized spike-wave activity (Sr...IBB-SW) had mutations. Our findings in SMEil have important implications fur the 'lumpers and splitters' debate. Whilst Ohmori and co-workers (2003) found a higher mutation rate in SMEB (88%) than SME.I (72%), our Iaeger study shows the 'reverse. Moreover, three mutations are a.'ISociated with both SMEI and SMEB (Patients 4 and 54, 8 and 59, 48 and 74) in this study. Similarly, eight cases have a mutation previously associated with the alternate phenotype (Supplementary Table). The recent ILAE ·claMification proposal suggests the new name of Dravet syndrome for SMEI (Engel, 2001). Jn terms of clinical utility, we suggest that it may be more helpful to conceptualize SMEI and SMEB as a spectrum and incorporatt both under the eponym of Dravet syndrome. This would also resolve the inaccuracy in terminology ansmg &:om the absence of myodonic seizures in some cases of SMEI despite 'myodonic' being part of the syndrome's name. SCNtA mutations in SMEI and SMEB Our data show similar results to those previously snmmarized in out review o{ SCNJA mutations (Mulley et al., 2005}, with mutations comprising 43% (33177) tiuncation and 43% (33/77) missense changes. The proportion of ruisscnsc (39% versus S2%) and truncation (44% versus 40%) mutatiocs is similar in SMEI and SMEB. Our new data fail to fully confirm previous observations of a predilec.tion for missense mutations lo occur in the ion c.hannel pore region (Kanai et aL, 2004), with only 15/33 (46%) in this region. Previous studies suggested clustering of missel\Se mutations in SMEI in the SS-SS loops of domain l and H (Mullcy et al., 2005) but here, clustering in domain I was not seen (Fig. IA). 3:16-cv-00972-MBS Entry Number 1-1 Page 119 of 145 3rain (20Ci?), r:rn. a·i:J-352 650 No Date Filed 03/28/16 corui~tent pattern of clustering has emerged in SMEB although 18/25 mutations were located in the transrnem· branc domains (Fig. 18). Here, dustcring of mutations was noted in the S2-S4 transmembrane segments of domain I. in contrast to patterns seen previously where clustering in domain fi was observed (Mulley et at. 2005). More data are required in order to establish if a true pattern of clustering exists. Broader phenotypes of SCNIA mutations (Table l) The specific generalized epilepsy syndromes of MAE and LGS had a low yield of muMions with 2/10 and 1/12 posit1ve cases respectively confirming that SCNIA is rarely associated with tltese syndromes (Wallace et al., 2001: Nabbout et al., 2003b; Ebach et al., 2005). The nosological boundaries between these disorders, SMEI, S~IBB and other cryptogenic generalized epilepsies are blurred. Indeed, in the large group of patients with cryptogenic generalized 4!pilepsy of early onset where a more spec:itic syndromal diagnosis could not be reached, 6/25 had SCNlA muta· tions. Two patients had a phenotype with futures similar to SMEI but had onset in early infancy with abnormal early development and a more severe course. Others had heterogeneous phenotypes of generalized epilepsy with intellectual disability induding tho~e previously rccogn!zed in GEFS+ families (Scheffer and Berkovic, 1997; Singh et al.. 1999). In patients classified as cryptogenic focal epilepsy, we iden!ified a clinical subgroup who presented . with a devastating multifocal epileptic encephalopathy. Of the five cases, three had SCNJ.1 mutations. We designated this group severe ir.fantile multifocal epilepsy (SIMFE) as onset is in the first year of life aod multiple seizure types occi;r, with the most prominent being focal seizures. Multiple types of focal seiiurcs occur including complex partial seil.Ures of temporal lobe origin and hemidonic seizures. Video-EEG telemetry showed that the variation in seizure semiology was not due to seizure spread pattern.:;. Focal myoclonu.s may occur or even be brought out by specific: anti-epileptic drugs known to exacerbate myoclonic seizures, sucll as vigabatrin. Patients may also have convulsive or non-convulsive status epilepcicus, tonic seizures with focal features and tonic-clonk seiiul'es. lntcrictal Bl!Gs show abundant multifocal epilcptifonn discharges. These individuals do not have generalized spike-wave activity on· EEG. Their l.\1RI brain scans are normal or show non-specific features. They usuall1• have norroal early development foUowed by cognitive decline, with the refractory seizure disorder culminating in intellec· tual disability. Abnonnal neurological signs such as ataxia · and spastidty may evolve. The factor that distinguishes these c:hildren from SMEI is the absence of generalized absence and myodonic sei'Zures, generalized spike·wave activity on EEG, and that their cognitive decline may be later than the second year of life. These: children had a severe, progressive and hitherto puul.ing phenotype, where extensive investigations had been perfonned searclling for an aetiology such as muscle biopsy, lumbar pum;ture and liver biopsy. Similar cases are described in the literature by many authors (Noriega-Smchez and Markand, 1976; Markand,. 1977; Blume, 1978; Malik et al., 1989; Ohtsuka et aL, 1990, 2000; Bumstine et aL, 1991; Ohtahara et a~. 1995; Nabbout and Dulac. 2003; Yamatogi and Ohtahara, 2003). Some clinicians regard thh phenotype as being the later evolution of a 'burnt out' symptomatic generalized epilepsy, but these patients never have the EEG signature of generalized spikewave activity. The phenotype could also be regarded as part of 'severe epilepsy with multiple independent spike foci' described by Ohtahara and 'olleagues where generaliud mir.or seizures are also emphasized (Ohtsuka et al.. 1990; Ohtahara et al., 1995; Yamatogi and Ohtahara, 2003, 2006). This group incorporates a heterogeneous array of causes Table l Epileptic encephalopathies with SCNIA mutations Avenge age seizure onset {months) Clinical features Hcmklonic: and/or generalized convulsions Myoclon1c: seizures Ocher foci\I seizures Other generalized seizures EEG Generali1ed spike wave Mulcifocal epileptiform activity SCNIA mv.:ation5 Trcntation Mis$ense Splice site SHEi SMES CGE ~=l6) ~==25) CFE ti ::013) SIMFE ~=66) s.s 6 9.5 8 1 Always Always Often Ofte11 Often Occasional Always Occasion al Often Oftc:n Often Always Often Often. Always Occasional Occasional 2S (69%) Rare 6 (24%) 10 ll s 2 No Alway$ J (60%) I 2 I Occasional 52 (79%) 23 20 9 ·Often Often Occasional Often Ofte11 Occasional . Occasiortal I {8%) ~=5) Always Rare SMEI, severe myoclonic epilepsy of infancy; SMEB. SMEI borderland; CGE. cryptogenic gene1";11i7.ed epilepsy; CFE, cryptogenir. focal epilepsy; SIMFE, severe infa~ile multifocal epilepsy. 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 3rain (20C7), SCNl/,.;·elated epileptic enceph:!lopa•hie$ such a.s tuberous scl:rosis. and birth asphyxia. In contrast, SIMFE encompasses those patients hitherto without a knot1.11 cause, with 3/5 found to have mutations of SCNJA. Sll\'tFE is an important group of patients with a devastating epileptic encephalopathy who are presently diffic'llt to classify. The discovery of SCNlA mutations as the basis of their disorder avoids further potentially invasive investigations for alternative causes and as.sists in targeting therapy. For example, anti-epilepti<:: drugs that exacerbate myoclonic seizures, such as vigabatrin and tiagabine, shocld be avoided. This extensive study of the role of SCNlA mutations in epileptic encephalopathies beginning iii the first year of life has, no1 surprisingly, expanded the phenotypic spectrum. Disorders are initially identified in a 'pure cohort' with a specific group of esscntial features. As the molecular basis is determined, phenotype--genotype rorrelation results in broadening of the phenotypic spectrwn to include milder cases or seemingly unrelated disorders. This is just begi::mi.ng to be pos~ible in epileptology, as SCNIA is the first gene shown to have a role io epilepsies previously regarded as cryptogenic. An important finding is that children with an epileptic encephalopathy with multifocal fcatu:cs ir. the setting of norm3l MRI may have SCNIA mutations as may children with c;ryptogenic generalized epilepsy. A strong indicator for SCNJA analysis is an epileptic encephalopathy with seizure onset before l year of age, even if cognitive decline does not occur for several year$ thereafter. The social and economic benefit in making a definitive diagnosis in children with epileptic encephalo· pathie.s can.not be underestimated. Neurologists continue to perform investigations looking for an aetiology in children with· cryptogenic encephalopathies such that establishing a definitive molecular diagnosis is cost-effective. More impoitantly. families are very grateful fur a specific diagnosis especially with the treatment and genetic c;ounselling implications that a SCNJA mutation c;arries. Su~plementary rr1ut1?1'ial Supp!cmentary material is available at Brain Online. Ao::kni>Wlt!dgements We thank the patients and their families for participating in this research. Funrling was provided by the National Health and Med:cal Research Council of Australia, Thyne-Reid Charitable Trusts and Bionomics Ltd. Tne Infantile Epileptic Encephalopathy Referral Consortiwn includes Kim Abbott, Ian Andrews, Barry Appleton, Andrew Blea.sel, Neil Buchanan, Christopher Burke, Anne Bye, Caroi Camfield, Peter Camfield, Gabriel Chow, Kevin Colli~. Mark Cook, J. Helen Cross, Yanick Crow, M. Danicia D'Agostino, Martin Delatycki, Colin Dunkley, f oc fawke, Colin Ferrie, Michael Geraghty, Gail Graham, Pad:aic Granan-Sm:th, Elizabeth Hallam, Lorie Hamiwka, Page 120 of 145 no, :H3-6::i2 clSI Anton Harding, Simon Harvey, Michael Hayman, Ian Hufton, Peter Humphries, Pierre Jacob, R.aimond Jacquemard. David Jamison, Philip Jardine, Steve Jones, Daniel Keene, Kent Kelley, David Ketteridge, Andrew Kim, Sara Kivity, Chris Kneebone, Andrew Kornberg, Chris Lamb. Cec:ilie Lander, Tally Lennan-Sagie, Dorit Lev, Richard Leventer, Mark Mackay, Steven Malone, Jim Manson, Ailsa McLellan, Philip Moore, Lakshmi Nagarajan, Margot Nash, Marina Nikanorova, Doug Nordli, Mary O'Rcgan, Rohert Ouvrier, 'ayesh Patel, aair Pridmore. 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A miss:nse muiatioQ in SCN l .\ Ui brothers with $tVere myoclo:>ic epU•psy in infu.ncy (SM£\) inherited from a &ther with fro:ilc ieizutt&. Brain Dev 2005; 27: 424-30. Mnlik S, Rothnor AD, Korai;nl P. WyUic £, Cruse RP, E.reoberg G. M~ilifocal independent spike syndrome (MISS): an identifiable nnd pre&ctob!• rlecuoclinkal •yndromc [ahstracrJ. Neurology 1989; 3'1: !89. Mancudi 1'1M, Striu no P. Gennaro E. Madill P, Paravidlno R, s...,,polan S, e1 al. famifol occumnce of febrile s.izu"'s 3od epilepsy in i~•r• mycdonic epilepsy ur infancy ( SME!) patients with 5CN1A mutations. Epl}.psi3 2006; 47: 1629-lS. M~;uad ON. Slow rpike-wa•e activity in EEG and associiltcd clinical fo1l\lle1: ofte11 c:sJlcd 'Lennox' or 'l.eM0it-Gutau1' l)11drome. Newology 1n7: 27; 746-H. M~ri.ni C. Mei 0. Gnus JH, Gumini R. Mosaic SCNIA mutation in familial scvu~ n1yoclonic epilepsy of inltncy. Epilepsia 2006; 4 7: 17'7-IO. Morimoto M, Ma.u.kl £. Nishimura A, Chiyonobu T, Sa-i Y, Murakami A, ct •I. SCNI.\ mutoti<>n mosoici>m in a famil)" with ~n IM. et al. A mnleculu mcd:anLsU of the ~nnox-Guuut 'yndrom•. Jpn I .Psydllotr Neurol 1990: 44' 257-64. Oh~iW Y, Yuibinai:a H, Kobayuhi K. Refractory childhood "Pikrsy md fwors rtl:ited to rdractorinm. Epikpsia lOOD; ti lSuppl 9): l+-7. SchriTer IF. 5e-'l!1e infantile epilopsiec molecular gtoetia dwknge dinie<1I dusi!kation. Brain lOOJ; 116: 5 IJ--4. Schdfer IF, lkrkovk SF. Cenl!f'3liud cpilep!I';· with febrile seizures plw.. A genetic dilhalognphic study of srvue myodonic epilepsy in infancr (Dravct). 7pn I Psychiatr Neurul 1987; 41 : 463-S. Sugn'"'"' 'f, Muw -Miyuzaki E. Euk!Uhima K, Shlmarnur:t J, fujiwar11 T, Hamano S. tt al. Frcqul!'nt Jnullltioru of SCN IA in &evcrt myodonic cpilcp~y in inf:an~1'· Neurology 201'.12; 58: lll2-4. Snh .\. 01"1" KG. Goo.<.«n~ D. H:nding 8. Vin Luijk R. Scb~r:s S, et al. Microddcrions involvin11 the SCN IA gene m1y b.. common in SCN!Amutation-ncgati~ SMEl paticnl~. Hum Muta! 2006; Z7; 91+.20. Wallace R. HodgJoll BL, Grinton BE, G~rdillcr RM, RobinlOO R, Rodrigues-Ca.mo V, ct al. Sodium cbamiel .tlph•-l $\lbunit inuhttions in sc•m m)'Qdtlnic epilepsy uf infancy &nd infantilo spasms. Ntim~lo!!)' 200;; 61: :"6$-9. W•ll•cc Rtl. Scheffer 1£. lbrneu S. Ricbards M. Dt'bhcn.s 1., Dwi llR, ct ii. N•~rono.l sodium-channd alph.il -~ubunil muhltioru in gcacralizcd opilepsy with fcl>rile smatography: • revirw. Hum Muuat ?001; 17: 4)9-H. Yamotogl Y, Ohtahara S. ~ere epilepsy with multiple independ~l\t £pike foci. / Clin Neurophysiol 2003; 20: 442-8. Yomitogi Y, Oh1ahara S. Multiple indepcndenl spike foci and epilep$y, with spG Y!WC N-tcrminal lnlron 9 c. /J78-IG>A WS9-IG>A DJ-DI/ linker N-terminal No,·cl Navel No~! - 11on pathogenic 3 SMEI F 7 lntron 1 c.265-IC-·A rvst-JG>-A 4 SMEI F 6 Exon 2 c.30lCT 5 SMEI M s Exon2 c.302G>A RIOIW RIOIQ 6 SMEI f 4 lntron) c.474-l JT:- A JVSJ-IJT>A N-tenninal DIS2 ND /11tron4 c.602+JG>A JVS4+5G>A DJS3 ND Novel - JWll palho~1mlc 7· g• SMEI SMEI F s.s c.49S_496insGTGA.\TC T166fsX170 Novel 5 c.602+\G: A IVS4+ lG- A DIS2 DISJ Denowi F Exon4 lntron 4 Denovo '} SMEI f 3 lntron 1 c.1028+1G>T OISS-S6 loop Denoiio 10 M c.1028+1G>T DISS-S6 loop Denovo Novel - this study [SMEil F M35QfitXJSS DISS-S6 loop De.no110 SMEI Elon 8 · Exon 8 c. I048_ \ 049deJAT 12~ 3 2.25 6 lnrron 7 11 SMEI SMEI JVS7+1G>T l\.S7+tG: T c.IOSS_IOS6delTG V3S2f&X3SS DISS-S6 loop Deno110 Novel Novel 13" SMEI SMEI SMEI SMEI SMEI SMEI SMEI SMEI SMEI SMEJ M 4 Exon9 Y399X DIS5-S6 loop Denovo Novel F ·4 Exon 9 c.1197C>A c.1207T>C Novel l'\on 9 Exoo !O lntron 10 lntron lO Exon II N-tennin•I Novel - this study [SMEB-SW] Fukuma ct at .. 2004 [SMEB) . l'ujiwara Gt al., 2003 (SM EJ] This study [SMBB} 14 I.~ 16 17'-' !!!* 19 20 21 22'' r F 7 35 3 M 9.5 F 5 4 F M DIS6 c.123'.'T> .\ f4-0JL \'.JUlli Denovo DI~ De nO\iQ Novel c.1639_t640delAA KS47fsX569 Dl-011 linker ND c.1662+2T: C 1vs1o+2r.-c 01-Dll !Inker Denovo c.1663-IC:..C c.1687delC c.2021.A:·G IVSIO-IG-C L563fsX622 DJ-DI! linker Denovo Novel Novel Novel DI-DU linker Deno1<0 D674G (long. isoform) L783P DI-DI I linker De novo Novel Novel Novel M 6 Exon ll c.2348T: C DUSI D~IW\JO F 8 Exon 14 G854fsX876 DIISJ-S4 loop Denovo Novel F 4 lntron 14 c.2562ddA c.2589+JA>T IYS14+3A: T Denol'O Novel Exon JS Exon IS c.2831T- A \'944£ Denovo Novel 1:.2833~C F94SL DHS4 DllSS-S6 100p DJISS-S6 loop ND No\'el 2.F 24 SMEI M 1 2s~, SME! F 6 SMEI Exon 11 Novel - this study [SMEI] ' 3:16-cv-00972-MBS Padcnt Phenoty~ Sc.>x Onset l.oa.tlOD NucleA c.284'>G>A c.289JC>T R946H C Rl24SX DllS4 ND Novel - non pathogenic DlllSl-S2 loop ND Nabbout et al., 2003 [lx SM El} Rl407X DlllS5-S6 loop De l'IOVO Suga\l/ara et al. 2002 [SMEI] SMEI f 7 faon 19 SMEI f 7 E"on21 c.3733C>T c.4219CT 6 Exon22 c4J21G- C Al441P lllllS~-S6 loop De now> Novel Eic.on 24 c.4526dclA NIS09fsXISI 1 Eicon 24 c.4547C:-A Denovo De 11ovo Elton 24 c.4S73C>T S!Sl6X RIS2SX 0111-0IV linker Diii-DIV linker 0111.01v linker ND Novel Sugawara el al., 2002. [2x SMS!) Kearney et al.. 2006 {SME!] This study [SMEI] E.rco11 11 Eilon 24 c.181/U:A R604H DJ-DI/ liHku ND c.4S73CT Rl52SX 0111-0IV linker ND Fukuma et al.; 2004 (SMEii 35 36 37* 38'' 39 40 41 42 43 44 4S 46 SMEf SMEI M SMEI F 2 4.S SMEI F 8.S SMEI f ' F 8 Exon2S c.4633A-"'G M 4 Eicon 2S c.47')4'f>A M 9 M 4 6 lnrron is Exon 26 Exon 26 3 E11.(ln26 c.48SJ-141'..<. c.49JJC T c.4934CJ; A dJt9j': 0 c.Sl620G f M M 4 faon 26 Exon 26 SMEI M SMEI F 9 4 49 SMEI f 6 so··' SMEI F 4 Kearney ct al., 2006 {SMEI) This ~tudy [SMEii SMEI SMEI SMEI SMEI SMEI SMEI, SMEI 47" 48 Novel - non pmhogenic llS4SV YIS98X IVS2S-14T: Ci Rl64SX Rl64SQ Fl707V Tl721R DIVS! Denovo DIVS2-S3 loop De 1'101/0 DlVS3 DIVS4 DIVS4 DIVSS-S6 loop DIVSS-S6 loop DIVSS-$6 loop Denovo De 110110 DenoY-A Wl812X C-tenninal Denovo Novel - this study [SMEB-SW) No,·el c.56S6C·T R1886X C-tcnninal Denovo Mancardi ct al., 2006 fSMEIJ c.5176T>C DlVS6 Denovo 3:16-cv-00972-MBS ParlMt Pllmntype S~I Onset Loradoa N ucleodde change Date Filed 03/28/16 Prntrin change Entry Number 1-1 PU'litioo lohmtaoc:e (mths) Page 124 of 145 Pabluhrd lpbenotypel I Novel# SMEI M 6 Exon 26 c.5710C>T M s EK.on 26 c-term Intl! De novo NO M 3 Elion I c.S765T:C c.23SG:·C Ql904X Il922T SJ SMEI SMEB-0 D79H N-bmninal Denoi.oo 54 SM EB-SW F 8 Exon2 c.301C·T RIO!W N-tenninal Deno~'O. S5 S6 SM EB-SW M 1 fuon4 <:.Sl2T>A 1171K DIS2 Denowi SMES-0 F Exon4 c.523G~A Al75T Denovo Novel c.SSOG:' A d96C>G Dl94N ND Tl99R Mancardi et al .. 2006 [SMEI) Novel 51~' 52 C-terminal 57 S8 SMEB-0 F 6 3 SM EB-SW F 7 Exon4 Exon4 59• SMEB-0 M 4 lntron 4 c.602+1G>A JVS4+1G:·A DIS2 DIS3 DISJ DISJ 60 SMEB-0 f 6 E~on S c.664CT R222X 61 SMEB-0 F 6.5 Exon S c.677C T Exon6 DenoWl Novel Novel Novel Novel - this study [SMEIJ Novel Denovc Fujiwara et al., 2003 [SM El"} Marini ct al. 2006 [SMEI] This.study [SMEil DIS4 Denovo Claes C( al..1001 (SMEIJ TI26M OIS4 Denovo c.680~G t227S OIS4 NO A239T DIS4-SS loop W384X DISS-S6 loop Paternal ND Nabbout et al, 2003 {2x SMEI] 62 SM EB-SW M 6 Exon S SMEB-SW M f Exon 8 c.71SG;..A c.l IS2G>A Denol'O Al783T DIVS6 DIVS6 Denovo Novel - this study [SMEil Kl846fsX18S6 C-teiminal Denovo Claes et al.• 2001 [SMEI) Wallace et al., 2003 (SMEl} Kellfiley et al.. 2006 [SMEJ) SMEB-SW M lntron 14 c.2S89+2T>A IVS14+:ZT=-A OllS4 De110\>0 SM EB-SW M s.s EJton 16 c.3022G>T E1008X Oii-Diii iinker Denoll(I 67 SMEB-0 F 3 Exon 16 Oii-Diii iinker De11ovo SMEB-M F 5 Exon 21 c.3231delA c.4062dclT K10771sX1079 68 Cl354fsXl3S9 Dll!SS Denovo 69'" SMEB·M M 9 c.4168G:A Vl390M OlllSS-S6 loop Denovo 70 SMcB-SW SM EB-SW SMEB-M p 6 c.4949_4950in~T Q1427X I l 6SOfsX1672 OlllSS-S6 loop OlllSS-S6 loop DIVS4 Deno>'O F 6.S 4.S c.41861':0 c.4279CT CIJ96G f Exon 21 Ex.on 21 Exon11 Ei1on 26 4 Exon 26 c.53391'.< Ml780T c.S347Q:.·A C.SS36_SS39de1AAAC 71 72 SME6-0 74 SMEB-0 SM EB-SW F F JO Exon 26 75• SMEB-SW F 4 Exon 73 26 et Novel Novel Novel Novel Novel Novel Ohmori et al .• 2002 [SMEI] Novel Novel Novel Nabbout ei al., 2003 [SMEI] 6 6 7 63 64 6S 66 Novel - this study (CGE) Nabbout al., 2003 (h SMEI) De no\IO Denovo 3:16-cv-00972-MBS Patient Phertotyp~ Su Onset Location Nucleotide ehange Date Filed 03/28/16 Protein ehaage Entry Number 1-1 Po~ltloo lnbtritanee Page 125 of 145 hbllshecl lphmo~pel I Novel# (mths) 76 SMEB-0 f 3 Exon26 c.S674CT R1892X C-terminal lknovo Sugawans et al .• 2002 [SMEI] 77 ICEGTC f 7 Exon 26 c.S741_5742delA.\ Q1914fsXl943 C-1erminal Denovo Novel 78 79 80 CGE CGE M 2 T226M OIS4 Denoll'O Novel - this study (SMEB) s.s Exon S Exon9 c.677C:T M Denol!Q Novel CGE M Exon 9 A39SP V422E DISS-S6 loop l.S c.l 183G~C c.12651'! A c.1876A:.(i 0156 De11ow Novel 01-Dll linker ND Novel Novel Fukuma et al., 2004 fl.>r. SMEI J 12 9 Exon 11 Exon IS 82 CGE CGE c.2917A~G DllS6 Paternal 83 CGE f p S626G MIJ73V 6 lntron IS c.2946+10: T IVSIS+IG>T OllS6 Denovo Novel 84 CFE (SIMFE) F 7 Exon 11 c.1724de1T FS7SfsX622 Dl-011 linker Denovo Novel OIVSl· OIVS1.-S3 lonp DIVS4 Matemal Novel 81 M 85 CFE (S!MfE) F 4.5 Exon 25 c.4628~C PlS43S 86"' CFE (SIMfE) F s Exon 25 c.47860-T RIS96C 87• 88 CFE M 18 c.49700:-A LGS M 0.15 Exon 26 Exon 26 c.4907G: A Rl657H Rl636Q Exon9 c.ll77C>T R393C 89;:; MAE M 4 Gl480V DIVS4 DISS-S6 loop c.44390._.T DlllS6 Exon 24 M 13 90 MAE ,; Novel mutations refer to those not previously rcponed, note that some no,·et muraiinns are recurrent in this cohon ""''° Novel Denovo Novel ()e Denovo 'Novel Denovo Novel DenOV{) Novel '· P.itr(;nt, ~equen~d b:~ .\thcna. D1df'l''tlc.~ Mutations in italics were not considered pathogenic, see text fur explanation, and are not included in figure I. ~;MEI= Severe Myoclonic Epil~sy oflnfancy, SM EB-SW= SMEI Borderland without generalised spike wave, SMEB-M = SMF.1 Roroerland without m~clonic seizures., ~;MEB·O ~ SMEJ Boroerland lacking more than I feature of SM El, ICEGTC: Intractable Childhood Epilepsy with Generalised Tonic Clonic seizures, COE •·· Cryptogenic Generalised Epilepsy, 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 126 of 145 Lamotrigine and -Seizure Aggravation in Severe Myoclonic Epilepsy Renzo Guetrini, *Charlotte Dravet, •Piem Genton, Anna Belmonte, t Anna Kaminska, and tOJivier Dulac 111.fttNN crj Child N•wology 1R1d Ptychiatry. Untunlty of Pi.ta. lrvlitMte for Clinfal Ruearda Sr.Ua Mam Fo""'1atiott. C111kalbrone, Pisa. Italy; "'Cmlrt Sail'I! Po11I. Mar,eUJ11; and tNewropidiatrl11. Hopll4l SabU·VUlctnt-d.-Paul, Pari.t. Frt111C1. 5am1aar1: Purpose: lo severe myoclouic epilepsy of iJlfancy (SME}, mulliple drug·reai.lllant focal and gcnmlillld seizure typu OCDJt. I..lmoui,me (LTO), t~ variltiona compared witll Ille 2 momhs preceding . L10 wm consideftid bidicaton of rcsp<>llSC. also tald1lg into account du: de~ crf diMlbility each soiz.utc type produced. Remlts; LTO induced worsening ill 17 (809&) patieim, DO clw!ge hi tlln:ie, and it.Dprovemem ill me. The:ni wiu >509D Sevm myocJonic epilepsy (SME) in infants (1) is one of the most di.s.abling epileptic syndromes. Seizures~ gin rlw:ing the first year of in p.ievlou&ly uornUl.l children as genttllized or unilateral. atueb, facilitated by fevtr, ud often oc.curring in the form of status epilcptiC\13. S11Ch seiZW'CI are followed later, between ages 1 and 4 ycan, by myoclonus, atypical abaencc.s, and COlll_plcx partial seizures, aooornpanied in some children by clinical photosensitivity. Often coinciding with the miset of myoclonus, th.ere is a slowing in psychomot01 development, patients being variably mentally ~tanle.d tre&tment ot maoy generalized an.cl partial seizure types in both adults and children (3-5). AJtbough LTG is curIC11tly used in various childhood epilepsy ayndrome& (4, 6,7), concluaivt. data on its efficacy in severe epilepaie1 with multiple seizure types ~ scanty. Add-on LTG ~t of Lennox-Gastaut syndrome and nooapoclfic forrDll of symptomatic generalhed epilepsies ·bas been eval.uatcd. with sevmt open studies (7- 10) and mM"J conq:olled study (11). Results appear to be favol'lble..., reflected in ~ction of atouic, tonic, and atypical absence seizures. No data an the efficacy of LTG in SME arc available to daft. A~ preliminary obaervations of aci~ure aggravttl.on in four patie!lts (12), we examined the multi of LTO treatment in 21 patienu with SME, the majority of wbom had be.en. lrem.d with add:On in the .framewoit of prospective studies m<:lllding children affe&d by diffctettt types of sevue ~ilepsies. incnue iii convuld~ sei~ In elp (O!llhs bl most patieuu but was iDlidi01.11 In aomc. LTO was tuapeudcd in 19 patients lift.er I' days-5 years (mean, 14 IDOlllh.t) with oomoqaeot improvcam in 1~ ConclwioM: The pronounced teiwre detr.riorad.on dllrinJ LTO 1Z'l:lllm:Dt WM uot .itributable to tbe a:amral 1:0une of the diaeaae llld could be a direct effect of ~ LTG cbes. LTO treatment seems Uiapproprillo ill SMB. Key Wmla: J.a.. moc:rigioc-S~ myoclonic ~ wor$«1ing. lire from school age on. All seizure types arc extremely re- sistant to dnlg ~tment. Although SMB is diagnostd only in -1'Ji of patient' with epilepsy (2), the management of these patients is particularly lill;le deDJanding and eo1tiy, as they undergo multiple periods of hospitallution and antiepileptic drue (AED) trials in which almost all combiNtiona of available dru8s arc tried. Lamotrigine (L1U) bas proven to be effective in the PATIENTS AND METHODS Ncepltd January 6, 1998• ...~ c:cl'l'tap«1dence and reprint requesu llO Or. R. Oueninl It l111till:re of OlildNcurology wl ~ch~tey. Via diei. Oiacivtl, l , 3<.otl ColarnbtOM. Pin, !Wy. Data were oolleaed in three centers. Twenty-one pa· !fonts with SME. aged 2-18 years (mean, 9 years t J08 ~ EXHIBIT 0 ~ ~ c:\ 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 127 of 145 '"' LTG AND SEIZURE AGGRAVAT/ON IN SME were treated with Lro. 20 in add-on and ooe in mooothmpy. All patientJ lwl poorly controlled epilcpsy. N"tneteen had two or mpre types of seizures, and lWD had one sctZW'e type only (Table 1). All patients had been treated with Vari.OU$ antiepileptic druS' (AEDs). &i:lgly or in varicus combi.nationa., which had failed to achieve seizure .control. LTG was added to lhe fircexi&t· Ing dnig regimen, ataftins witb A daily do&age of 0.2-2.S q/kg (the miallcr starting dosages were used to minimi.r..e the risk of skin rashes, espcdally in VPA-treated padents) and increased to a maximum dose of 2.S-10 mg/kg/day according to type of comedlcation and c:liniCll respome. A twice-daily dosing nsgimen was used in &11 patieats. AED& used at tbe start of L TG tteatmcat are shown.in Table 1. Concurrent AEDs were adjwttd depaidlng cm patients' reepouse. but on account of tN! lack o1 positive clinical respon&e, in most paiients previous medication oould not be tapered. One patient (patient 12) month) was emallod in a prospectiv~ trial of LTG lllOllOdsmpy that was continued for l year. Si.x~ palieau w= ineluded in prospective studies of add-on LTG Ueat:malt Dua for the remaini.Dg four paticnb were ~ m- . roapectively. All patients uoderwent EEG during W-. fulness md sleep while receiving LTG ~ How· ever, only In 12 of the 21 patients wai one EBO performed within tbe 2 month1 preceding LTO treatment. and anotbu. dealgned to be C()mpmble, during !lelltme:nt. Throughout the period of LTO treatmmt. padem were seen n:rularly every 1-3 rnonthi in the clinic for cvaluatioo of c:lioical efficacy of the drugs and any Idvene eff~ through 1enml questioning of parents ud clinie&J examination. Seizwa weire rec:ocded daily in calcndars by the patienta' tclatives. ~atment was oonlinucd for aa long aa it wu thaupt either to improve aei· zures or to have beneficial effoct:11 on patienl well«Ing. LTO was discontinued by reducing the maintenance dole TABLE l. Mabt clini.col ,/iNJlltgi iJf 21 paMtllJ wirlt s~vtre my«lonlc ~'1 '1nd ~ of LTG trea/IMI# ... Pr.Na. Mai Ll'O AFlll ~ ~at sm-tJI* bctore t:ro Aaaoo:w..I CP,M. UO, ' Myccl 00,SP.CP, .!10 00. Myocl. T Vl'A. CD ot LY'G r"!l<> ....."P UP 6 yr ,,,.... ' 11' 6 ft>I> w 1fl'IO!O 5 )'f7111 3.'P 2 )"r '11" 4\( •Jtl lllO 6,,3_ w UCJ,Cl.M SP, Myocl $Jtl0mo i yi-3-- OTC.AA. ff ; ,, 10 ..., 1IF 10 )'r 10 .mo l'l)'I ' yr ~ SP, M7ocl. AAGit: SP. 30, AA. GCI. G1C A.f!D1 s yr 7 yr uctSO.M. !Ir\! 12JT IS )'! G'l'C. MyocC. uw ltr7mo ,,.,.4mo llM ~"'""' N"o II yr M.. "Mrocl. LTO 6- ~.uoa 2 yr 6 n Aamall• Myocl No 4lllO l Y' I lllO ~ 4.1 No OTC S11JO ·I ff ..... ~ Mycd l'lo Sn> VPA.CZP 10 SP, M1ocl S"o Vl°l'I. c:J7 %j No cm: No l)'t2- ) l90 J..J No oa No 2 mo 1 ,,. 1,.1.mo YPA. DM, CZ1' ,,.. .\qtllYt.IWa ~· ~ GVQ,Cll' 10 No OTC No 1mo VPA. CZP s No Myocl·.t. l yr \ ao l yr PB,CZP 1.$ OTC, Myod No M1ocl No 1- lyrlmo ~ Ko CP No 0.SlllO I yr 6 mo "'anMtiGC 5.S No M,ocL-' I Pl } yr '' !'lo l'fo l'fo No No ~""' l yr No 1 )'I No 8.1110 1011\Q I yr 10 mo VPA.0.8, Myocl, GTC VPA. ISSN 4 yr 11,v 4Jt'f mu 77r 6mo OT'C,.M)'OCI. Myoc:t All 1111' 9yrl()- l7 yr OTC,CP.GO. . M)locl, SP VPA,a.B 19if Z)'T3 mo • yr 6 lllO OTC. Myocl. WA.CD. ll J" J ""' GClAA. u mi 14)'16 mo VO. GTC Get Gel, Myocl PKT'. Cl.B OCI. Cite. Myocl WA.a.B, l'Oll VPA. CZP - ~ !'lo 4 yr4..,.. 13 yr 12)'1' 6 yr6 11110 IOyrSmo AA.MyGd. O'l'C. "tyud ,_ $ ro• VPA ')'? 4yt91111J . 10rr11110 00.CP 0-.-11 VPA.. CU. AA al'C.M. CP. ~ -... l'cll4•gp ofter LTO ~ afLTG No Myocl 5 yr ua ~ oa 2lJT 2J.1' of.._ No 19 yr 2~? No A~ 43 '9, 0VO No 14'1' ~ VPA. t u Myccl 1W 16'1' - ~ w.......i T. MYotl Ill' OM. lliL """" {~ WA. GVO 1"Gll OVG,CZP, Q..11 1'9.CD arc NQ No No 1'19 OCt l.5 OTC Myod ~ 1.4 CJ Myoel ·! No s yr • No Unil No 3mo u UC!. N'o NQ ~ )T :J 1110 No No 4 S.3 - OTC J~ N"o t,rllhO 1 yr 2 yr 21111> 9 "'° ~on .,.__ Aarav.iloe Aanmlioll Aam"llimi Noch.qa Na~ ~ Aagiaftlialt ~ i yr Slill!Wlg LTO 5yr41111> lliD W:iq A&P"ovlliOll Im~ No cbanp LTO F, fou:al•, M, male, AA. atypical absellllCI: .i, do!lic. Cl, elouic;; CP, compiox part.id; OCI, genel'l.lizcd eloaie: OTC. aenCl'llmd tQll.i~loak: MyocL myoclcmic: M)"ocl Ab, t11yoclonie absences; SG. 1econdatily gecerallZed: SP, lim.P~ partial; T, ~: UCJ. 111111:rtcial i:lonio: Ullil. llll.ilaleral: lll. elSO'f> we~ taken u indicators of improvement or worsening. Because epilepsy syndromes wilh multiple seirure types may show different degrees of disability and varying response to treatment, we assessed the efficacy of LTO relative to each se~ type, e~cll)Cfing atypical absences. and expressed a global im· pruaion of seizun:-n:Latcd disability. In general, convulsive seizures were considen:d more seven: than myoclouic seizures, which in tum were more seven: lhan complex partial seiiures. To estimate sei2un:-related disability, we also took the specific seizure clwactetisties of each patient into ac<;OUnC. because extensive intra· &nd imerindividual variation was observed in any given category. For example, prolonged clonic seizures followed by protn.et.ed pootseizure Kdation were found to be fu mare disabling than brief tonic:-danic seizures OC(:unlng during sleep, although beth are convulsive selZllt'e$. Because clinical detection of subtle seizures such as atypi· cal absences is a.-bitwy, eapecially in mentally retarded children, for the latter, we merely requested parents to provide us a global impression of the modification in total quantity of absences. RESULTS Results are summarizd in Table 1. LTO tt~tment prowonening of lhe epileptic syndrome in 17 (80%) patients. resulted in no substantial change in three and in improvement in one. Table 2 shows the cumulative eff~t on che main seimre type&. There was appearance of new seizure rypea in three patients. Analysis of the-distribution of che variOW1 drugs administered as comedication in patients who showed no seizure exaced>ati.on compared with those wilb wonening suggested that the aggtavation was not attributable to a particular association with other AEDs. duc~d TABLE 2. CIUflUfaltve llf{tJcil of LTG on the main ui:Jln The most impOXU.nt fmding waa the >50% increase in the frequency of convulsive aei:zures (unilatttal. generalized clonic, and generalized tonic-clonic) in eight (40'lfl) of 20 patients. Myoclonic seizures also wonerted in six (33%) of 18 patients. in one of whom a tint ept. sode of myoclonic status ~ after LTG e.dmlnistration. Allhougb aa improvement in at least one 8Ciwre type was t:ound in five patient$ (patients 4, 9, 17, 18. and 20), four of chem were considered to have had no improvement because there was a concomitant ~ of more disabling iypes of selzum (pllierus 4, 9, 17, and 18). In most patients. seiiu.re woneniDg appe«ed between JS days and 3 months after the atart of LTO aeatment. occurring in thn:c or them during titra.tion. In some pa· Oents, however, wotseniJlg WllS lloW and insidious, be.. coming evident over seven! ltlOllth&. LTG was suspended in 19 patlcntil after IS days to S years {mean. 14 mooths) from its introduction. tn li patients. scizutes improved 'Mrh revmal to levels preceding LTG treatment In 14 of them. including !he ooc receiving LTG monotherapy (patient 12), improvement occurred on LTO discontinuation, without introducing further medication, whereas in the remaining five, LTG was repl~ by anodaer drug. After LTO discontinuation, patient 12 waa maintained drug free for 1 year because lhe p81'Cllu were skeptical about the usefulness of any ttea~ Me.an duration of follow-up after cessation ofLTG treatment WllS 21 mondu (nmge, l montb-7 years). The paientsoffourchildren who had improved or unchanged seizutei claimed to have noticed an improvement in their child's behaviGr and alertness (better contact, less irritable). Por this reason, treatm\mt was con· tinued i.n some oftbe unchimged patients (14, 15, and 21) at their p&rC11ts' rcqaest. even after a lack of efficacy on seizute3 had been observed. Of the 12 patients who underwent BEG in lhe 2 mouths before and during LTG thcqpy. Wee (palieuts 6, 7, and 17) showed increase in ln!erictal paroxysmal EF.~ed no change, and one, an improvement. with matted reduction of interictal paroxysmaJ activily (pa· ticot 20). .l'Jpts (21 patients) DISCU~ION Mycclonii: 18 6 A~e J2 10 0 3 12 5 3 SP S 0 UCl S Cic11 Clo!W: OeslC CP 1 2 2 0 Although pediatric experience with LTG is ~I Jim· ID u ited. Ibis drug ha& been reponed to be ctfecU~ in con· l 6 ~ 6 1r01li.ng generalized and partial aeizures in childhood and to be of partkular value in Che management of absence 0 4 4 2 Ger~ gC11tt11.liicd; TC, ~Jo11ic; CP. complel parti1l; SP, 1imple partial. UCI, 1Ulila~ral clollic. sei.%utts (7). The poor ~sults we obsecved in SME, with seizure worsening in 80% of patieats, have no ea&y c~Jananon. Severe childhood epileptic syndromes arc particularly 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 129 of 145 LTG AND SEIZURE AGGRA VA'nON IN SME prone to ABO-induced seiuue aggravation (13,14). through mechanism' that are as )'et poorly undc:rstood. Altllougb the majority of reports refereed to West and Lennox-()asmut 1yndrome, i&ggravatiod of generafucd C9•mllsive se~s in SME also has been ~d with CBZ treatment (IS,16). . Exacerbation of scizun'J frequeocy has been .reported io eome studies involving LTG jo ehildten (4,7), although no mention was made as to whether this adverse o!fect involved a particu.lar seizure type ot a specific 1yndroroc. However, in these studie$, the nurnber of patiema who worsened did not exceed 119', a nu:e of worseaimg ao blghu tbaa !hat observed in patients whh dlugresistant seizures after addition of placebo (17). Although periods of spontaneous improvement or wonening are quite rommonly observed in severe epiiep,1" (18). especially in childn!n, lbe rate of dete.riora· don we rcoordcd duri11g LTO llUlment too proIJOunced to be attn'buted to che natural ccurse of tbe dileiie la most patienta. Oa the other hand. deteriora.tion c:oald not be ascribed to concwmtt tapering of previous mcdi~on or to a particular combination of LTG v.ith other dmgs. ll appears, lhcrefore. that deterioration of conVlllsive and myoclonic seimres in SME should be mau:d to a direct effect of LTG admlniscered at therapeutic doses. Although in three patients, severe wol'Selling occurred during LTG titration, inause in seizures was insidious rattier than showing the sudden onset: 1hat generally occun after inappropriate drug chclonic epilepsy Is Infrequently ~ified. On die other band. LTO can be effective in myoclonus associated with typical 3-Hz spike-and-wave di8Charges of myoclonic ast.alic epilepsy, juvenile myoclonic epilepsy, and myoclonic absences (21 ,22). A characteristic of SME is the multiplicity of .seiture. typea obscNed, with multiple brain areas appearing able generate seizures. In this syndrome, it has beeo suggested that myoclonic seizures would seem to be more an expression of local than of gencraliud epileptogcnesia (23). Yet the known efficacy of LTG in convulsive sci· zu.m . (24) makes the deterior:ation we obsctved in this type of seirure particulatly sUiprising. SME is a oeurobiolcgically Unitary syndrome, as testified by its ccyptC>- ID geniclty, low convulsive threshold. homogeneou.s clinical pmcntation, and strong family history of epllcpsy (25~% ; 25- 29) with several affected siblings includ- 5ll ing m.onozygotic twins ( l.30.31). Multifocal microdysgcncsis of cerebral and cerebellar ooctu. observed by Renier and Reo.kawek (23) in one autopaied cue, could be the neurop1thofogic substrate for this syndrome. Although such &tructural ·changes 1ltied further confirmation, Ibey collld 1CCOunt for the high epileptogenicity. LTO is tepotto:i to be effective in the treatmeutofboth typical and atypical ab!lelloe seizures (9,32,33). Even tho11gh ~reports have llA>t been 8upported by qwmtifu:ation of aelzure& with EEO monitoring, the amount of clinical evidence gathered so far seema to indicate that LTO is a powerful dNg against absence seizures of epiJepsies wJth abundant epin-wave activity. In SMB, genenliud sp~ and wave activity, although present in almost all patient&, Is scanty. A.l)lpical absences were described b)' the pm.n tl of our patients 111 showing no sobslanlial cbange in frequency with LTG. However, beassessment of atypical abseIICC$ in our study wu performed without prolonged f.EG monitoring, we do not believe our experience can provide my roli1ble informaaion cO!ltlel11iq file effecu of LTO oa thi1 t)'JJC of Cl.119e lei~isJSMR Although ~irulta of medic.al tratment are ia gmerat diappoinling ia S.ME (34), VPA md BZD1 Ille pn:fcrable to oCher drugs. Jn these paticou, PIIT offers no obviou. advantage and may produce more aevere aide effects th.an PB (1,2). CBZ may wonen myoclonu& and atypical ab5aloc: &eizure& (35,36). ESM may be helpful in reducing myoc.lonus. Among \ho new AEDs, VGB may lead to i.ntereating results. reducing conwlsive l!Cizwu, but only in older patients in whom myoclOllus is no longer a promiocnt aymptom (37). The poor resolLs obtained, with a marked fl:Mency toward seizure aggravation. sugge&t that use of LTO is inappropriate in SME. REFERENCF.S 1. Dnve.t C, D111Uu M, Guarini 0, Glnud N, Jtoaer J. Sevm: m.YoeloiUc ~y ID iafiDl.I. h\: Roger I. ~ M. Dravet C. ~­ fua FR, PCQ'llt A. Wol:f P, om. EpWptf.i; ~1 ir1 ift/tlN;y, c:Jtl1411dOJ and tldiol6rnicc.. 2lld ed. Loadon; Jobll Ubbey. 191n: 7S-H . 2. Ooerrlnl R. Dnvet c. Seven: qM!cptlc; eacq>li&lopilhica o( lnhoq ._ <1bcr thLO. Wat 1~ ln: ~ J. Pedley TA. eds. Ep/Jq>iy: a ir;tHrf/N'~V. Wdbool. AW~hia: Lippi.Dc1i4, YoL 39. No. S. 1119& 3:16-cv-00972-MBS Date Filed 03/28/16 512 Page 130 of 145 R. GUERRJNI ET AL. Larnwig.tne in the tleal.me!lt of 120 chlldmt with epile~. Epi· /q.ri4 t 994~~:JSCM?. I. Olla' LEV, Ru1i A. o.u.l.lt. L. 1-iaiJll in Lenooll-Oa&lall.t ayndromii, ~ilqria t 991;ll(Rppl 1):,1. 9. 'l!mminp PL. Riebezl• A. Lunotriflnc u fldd..OQ dnic in llltt -.gemeal of U:.mia&-Ouanat ~ &Ir Neurol 1991;32: JCS-7. . 10. MulltcS L. Ollllahm" 1, Mmuco P. for 'The l..amic:tal 1-1Gur.u& St\lcly Group. lmprow4 DOUido~ flinctioll 11C00111P111iea ~tr.ic:dve canlrCll ot Ille l..cmlm.-Ouuiut i)'lldronle 1ritb Lim· lml: resalll of • ...!nMl.-J plac:e~lllld lzi.al. ~lq.114 1996;37{111ppl '>:tS. 11. Billard C. Mou. 1, Arvi~ D, et .t. .DueJ.blind, pl~ eantrol*I evaluttion ~ IM safety 1111<1 df-.:.i:y or. liii:oolrialiie (i...mictal) for die ~I af patimltt wish I cliU.•l diatnoeiJ of Lcnaoic.0.-C ~ ~"' 1996;37(11lpP 4):92. 11. ~ u '° • ;au, ti! wotJ6;1~26. 19. ~ IWAS, Hu1 YM, Pmalos PN. 0 - JS, Sborw11 SD. w. 1.amouiaioc IDd gCllel'&liz.ed lllrizur:a. l!pfkp1lo 199l;32{tuppl l): 31}, 20. (iibba 1, Apple40n ltE. Rosenbloom L, Y'llCD WC. l.amolriJI~ fw illtni:lahle c:hlldliood epllepty: a JmOlimillllY ClllTllll1ml~OIL 1hv Mftl Clllld Nftrol 1992;l4;361-7 t. 2 l. n.aimm,. PL. Richo111 A. ~ of lamolrigioe 115 mo11atbnpy to: juv011ilo lll}'O(;lOllio epllcpt)': pilot st!Jdy mlU!u. Eplil!p•i4 1993:34{1!ippl 2): l60. l;pile~~ Entry Number 1-1 Vol. 39, No. S, lf/98 2:2. ~CD, ~ 11.0, l[llOll C, Pa.oayiOlapCIUlos CP. LTG • add- dr.lg i1I typial llbsePca ld>iures. kto Ntwol SCil1llJ 1994; 91;2'»-2. 23. Reaier WO. lentawck X. Qlaical .n4 lll:Ulllplthological·fiadi:qa i.n. • - C1f ~- myoc:looic epilepsy of IDfasy. Eplllpllo 1990; ~l :l87-91. 24. ~ 1!.. -n. - aaenlioD of~~: ldvullages and 4i..ivmla3U Br J Clili PlwmtlcoJ 19116;42:.531-3. 2S. Ddla Demanliu B, ~Illa B, Olaom a. a 111. l!pilep&le m~ cl011~ sraw do IA pmni6111 Ull6e. 'lln ££0 NGro,h1nol 19B2; ll::Zt-, . 26. Du~ 0, AIGIW1 M. L'~l.a ai.yoclOD14aa 94!\-9. 35. Shlddt WD, SalOtl 8.. Myoctoalc. uoalo, -4 Uulllce .afollcJwtn& illldartioa of ~.. lllel'IP')' iA dllldmi. H~­ rolon l9113;:l3:1417-9. 36. ~ s-o o. ff.09cy LC. BxllCabation of~ la dlildrea by ~· N &11 J Mn 198.S;31l:91~1. l7. CluDn\ni R. ·~ o. Dnftt c. u at ~ of~ • ldd-oa tt.npy in td.aion 111 type af cpil&p1y or epilepUe t)'ltdro1111:: ~Jllllltive amdy ot 17.0 plllat\ll. Epilqsia 1994:35 {•~l 7):65. 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 131 of 145 Caibamazepine-exacerbated Epilepsy in .' Children and Adolescents Chades S. Hom. MD•, Stcwaft B. Ater. MDt, and Daa.ie1 L. Hunt, MD4 FOttf...- chidrm ad adolwu ....._ .a~ l!CpDQedly "9llClllCd while ..mag cubamtr&piac (OIZ) .... studied ~ft!,.~.., padmts met aUaia for acellmt doaumatacioo of ar· "'""'tP•~ ed1w.. foar epilcpac ... ~were ~ltidy atil:icted: dtitdhood ab- C..tal lobe aad IC9Cft m.,-.UC ..,., o£ L.laac:J. 1iJbt of cbc J6 p&ticou clcftlopid detr491d d.:Da: leiiuta IMic ~ with cwtab'ilhd - - - cpi1cpJ '4 ch:oc:ed .i..cc .azwe 'J'Pel, aw...m.ta .~. tiOGic. . . myodmW:, dndaped ia cipt ~ caamd with CBZ. aad ... poealir.ed ..... and-wawe dikbaqs Weft ob.ened in eltt· wpiu1lop• of Dine padcett. CBZ is a widely ued, ~ anacpilepti< ctru,. paniaalady fut partial or paniaJ aampl.a llCizwa; ~. if un· ~. p.aeralited .mu.a oo=ur after CBZ u plC9dibed w dWd1CSI or •dolacar. .ida lbleau or mmd eeiaam. a aial of CBZ dilcoaci.ouatiaA it waauu:d. The daca tepOded bac do noc permit ca&c.cio.n of cbe incidcacz oi dUt pbeoomenoo. eeatt epilepy; &ial aympmmaric, ~; l.coac.-G.aar qadmme; ••·Other Hora CS. Attr SB, Hurst DL. Oubunazcpinc· encubarrd epilepsy in childn:n and adole1Cma. ~atr NCUtOl 1986;l:J4 cbildttn trirh OZ-nacubued ~ [4]. 0£ dtac. l.S patients II bad "uypical" absc:ncc, eight hacl. "gencralUcd con..ulsi11t:, •' and four had simple ptutial rmu.ra u tomponcft.n of their epilepsy. Jlcthodl llCGldt- obDibrd on 49 dlilckm Cid~. ~ s.t fi£Jrim<1Gs Almy Mtdia.I Cmllot' (FAWq hm ltmWi t~ to Dcmnba l9flj ec:ialll'O ~.~by di~~ tobew """* •oneaecf~~wiibciz. l1M ~. . . . . ~ ... obi.incd fro• medical l'ISOClb: .......le ~. - ' - ~llllCtcristia, utocilud or:v.nllacic ~. -~~.and EEG The IO&triaf t'Ktots rrlaUrc: iv ~ thdlff -- ~ m ctmr a.nu bcfixe, . . .. JD.I &Ra rlu: Paliou ...,...ts. liad ~- dnll~ (l ) 0Zdoli111; (.2) Olhu~--llJ; ()) SNuft quelity, qpe' usd fmiuenc:y; (4) l!EG 111111!.,; u>d. (j} Blaod ie.e1s oftntiepilc:pcic dnap. The d&G -.te c:nlwed 10 ~ if -ucai docum~ o'=d 111 clrm- t11at az -...;blmd w ~~;.-..,. For~ to be ocdltn1, -~Of factoci 1-4 ieq~ W..-:. ~. uii .&er OZ dun)); fK10c ) C~ Wood Ind) ccqi,Wed duq ~ dialpJ!. All «ioi("iO!ll o( ld&ute aairity tad ..il joiapicadoim of J!BG.. '""' bacd on~~ a..iilb&ioO of~ 161 uid O!I lk lac~ a.dotlioa of!(illq.r rn T1ir duoi&axlaN of ~ ~· ~i.twa .._. -ipec1 IG dcll::nlllnc w!Uc:h lrinal'C '1PCI - ' " " " - weft ~.C by CBZ, and wbic.11- t....d «~by the chf. A 1.omain( ,,(tcinrr aai'li., _ddiocid • : (I) Aa ~ olioaa.ed ~ &aiur:m, of~~.. o!lhat «poncd for a 1*cliaepcriocl of- llllOlltll or -iood ab!le!IC• CA(a) 0.ildhood ahlm(c (uypical) = A.conic Fehn le ~-J .::: Czroid llpo!uC LOC = l.oJ5 of ~O\ISllC511 EME. "' M PL .. c = Myocb.k = Pan.ill complex T TC ::t f()nic = T<>n.ic-clooic "" Uoc.i1$1Jfitd Virual Foul. all types fS·Bk lMC ]A t.GS "' Focll 1J1Dptornatic -not fun:hcr cWaificd • ldiopa!bk cnyoclollic "' Jineailubseoa :: tcnnoa-Guu.11t JJlldrome = Mrocloni<-nutic Pb Un v F = = Pocai ddca FS FS'illl => foul IJlikcl FooU 'Pi~.cnd ·wne MI'S NI PSW SW "' "" "' "' SSW o;; Sia• si>iU-and-....ve '/fh -SW =: 'IHI apilr.c...nd-wa'i: = SMC = Occipital lobe (focal symproinatic) Severe lll)'O sStnle s.mic Same S-+Ab, M PSY ... Twcoty-D puimts ma the c:ritcria ix excellent d~meaiadoo of ~bated cpileplf. Thcit 1ei:iirc typa, EEG findiftcs, md· cpilcpey type• are littcd (Table$ H). Twau:y·t-.o o( thCIC ~ had iAaeues in teiaure mquency' eipt had iu~ in duration of indiTidwlJ·sciaaun. and~ hsd ODICt of new seimre lfpel (Table 4). Twel•e ~ bacJ two ctt.oces aoc1 ooc patialt had .u tbrcc of these c:bangcs in ~e actmty. the matt commoaly .dfa:ted KWue type WU lh· sence. R!rTen pat:ieoiS h.d ~ frequency of their at.nct ~ures while ruci.viag CBZ. Other seiiuce typd that ouwrcd more often "Weft U>Oic-doiUc in 1neo patients. myodonic in~. atOOic in nro, Uld ~la•ifi.hlc in two. EleYCG othei patieuts clncJoPed a:c;'it-ol1'Ct abscace sci.aura (m.:ludlli1 . ~te~ paQcatS 'Who.developed absence statwi} while ttaiving CBZ. A •arictr of otbcs sc:~uu: types also dt¥eJoped: atonic in chtte ~am, tonic , myPt:lonic in two, and uacl....m.ble in one. 'New IU'Cbiiied spilre·and--.ave ~ ftrc seen on H padeats' EEGs: 31-h spjh·and-wavc in five , "2 fl. CA NID N/D 11 16 2" Yet NID N/D N/D CA(•) 11 2) 26 Yes NID PSW Same Ab '" Page 133 of 145 ·---·- ------ Dow-Mu.al w-u., WldaCllZ ll(likply~ PD, )HzSW SSW 'fS, PS'fl 5.n>t+TC 9 10 1.2 H e:BG~llf" ScinnTppe &uhe " Entry Number 1-1 ,.._wldlCIZ-ae...-lli._,.....CIZ•) 1 J Date Filed 03/28/16 PliOl.AnJC NWKOl.OOY Vol. 2 No. 6 CA )A NID CA Yo IMC NID IBM6 a.P-J MID N/D SVC NIP LGS Yet 103 N/D WfJ Ya SM!I Yet 2., Ha l(lm~..ra.e io two, 2Hz.1pi.K~....9C io rwo, and pol~·~ in two. ~~ - ab ­ aottilaliticl amliar.ecl of focAl spim iD oae-.v.clas ~ multifocal tp~md.owave uuootbtt. .· ·· Sncra1 cpilepcic ~ . woncuecl. widl caz therapy. fuW' ~.mes we« dictted: tha4bogd absenu in ais patieau; lnmraJ-lobe in ·•ix; .~l:"fere myodooic epilcpq of in&Dq in nro; ~ ~­ Gataut syndrome in n-o. AdditiooaU1. tnRe pMjenu dndoped l.eonoir·~ lfDdromc- .apd ·d uft puieou lwl the "new onset" of chlldhodd ~e epilepsy while rueivitt1 CBZ. AJJ. illlUU&taft cue ~ appeaa below. c.~ TbO fl8licnt ...... 17.,at~d ~ • I f ._, "' ~ ~­ pcrim«o •Mint .,.ii.1'ailli i . • JO~ Tbcit. ~ - - 0 collh.iplc tiaicl pct da1; but~ been ~ ~ .U.r~. ID.Jou l~, IM had a~ .Gnic"cbiic .cihrt Wti.1>f -m llli&ila. prUit-,., dim.I llrillll't,iibt 1IM"...,. lltr riomial tUtt otf balth. ~ ~t ~.. . lia4 ,\ca >- OO(iccd dlat .-..inc. Sbc _..-.... h1 m~ ~-. 'but the ~af che~ -DOt"clc-..Uaied, IDd~. U 111g/~/d&;) d>rl3Pf iaicdted bf lice pcdi••ri-ita. Ker EEG l I I I I I 3:16-cv-00972-MBS T.W.l. Paieocat Date Filed 03/28/16 ----CJIZ~ llidldawlil ~ ()diet Nnr Dnp "lf'sdawcCBZ· 9rntlo11tCBZ I No~ l OS& No Sa ~ Valproatc ·Multiple Non' " os~ E.thOJ~imidc ~ D~ No..e 6 os~ None 7 DSi DSz 9 Nb St Pficaytoia None: Nooe V&lprot.tt • Page 134 of 145 DUa.ioa CHZ is an efftcti~ anticpileptlr drug fur pa.rtial or partial com.ples seizures, but generalized seizures may be ~rbaud by it (1...(]. CBZ aacetbation of generallicd ~ii~ io humam is supported by animal tttearch. In the 010we subcutaneous pemyleo.ctmuoJ (ICl'TZ) tcSt, ftlpto&te, ethosuximidc, dona%qnm, and phcnobubical pconde protection :apinu threshold seizures (&). These anticpilcptic drup an: d.inia.lly useful i.o ueatlng gmenlizcd sei2tircS. CBZ and phcnytoin, how~, do not ptOducc sigoific:anc protcctiori fo the mou.se .ccPTZ test. In dW test, stizutn m- pocentiated by CBZ and become more frequent and more prolonged {8] . lhc current st1.1dy hu identified sevml primary generalized sci%utt types to be w-onmcd by CBZ: (1) 10 No Si II No~ Nont: 12 No St NoS& OSz &hllSUSimidc absence. (2) ttonic, (3) myodonU:. and (4) tonk·donic. None None Offmtds These finding arc i.o 11grecmcot with pinious hWIW:I 13 14' l rl D S1 OS& 17 No Sr Valpros~ EthOllJllimidc None Vup=c I~ 18 NoSz 19 No Si lO ZI DS:z NoSz 22 D~ 2, DSz 24 DSz: DSz OSt ZS 2G N~ Methswiimidt None M..Utiplc MC"tllMcimidc Multiple None «oQl,;d l Hr polyspilir-t.nd.nvc dishatga. Shdud no fun:ltcr 1oillt-donic •iw.~. bvt compltined of t(dniOfl: CBZ (8 "'' lq fday) w.Q prclnsidcrtd lhcnpcutic and the 1ru dischuti=d -.ith no ch:anrc In medications. l!nhuiced and uncnhluM:cd c"'1i.i romputcd tomccr-phr ns nonml . Htn1ogn:m and liver func.cia11 tcD ft'te 11111rmo.l. l!,., .~uin, ~ird chily wirh in=uina ircq'1mcy by 111id:JuJy. Cl!Zdoa~ ft.I in~~ 14 mc lkf lday. Thi& inaase wont11eib:-attd-'Wlloc oisdiaqcs during Entry Number 1-1 hy~tilaticm. She ..u ie~i.oed ¥1d rht addition of CBZ wm swptttc'd of baYiog 901'R~ th~ patimc's sciz.~: iborc:forr. CBZ ..., duaincim.ix-d. four cby• km after a marked d"1'nllC in llCiiw:e (rc:qumrmcd by cattful analysis of clinical councs aod ltalldud BHG data. Because a ~"R evalu11fo.o WN pclfonaed. it is 11ote1forthy that the ibCidcncc of CBZIJ could oot be CJJculatcd in our ·~t popuWio.o. hfmal biufut thcobsawdglZ~ also miiht tabdy Uicr~ the ~nee: in.dlll ltlldy . .AccwnlJlattd ·C'ri.dcncc ~pom • ptja.au)f ~ effect of CBZ on ~ed ~ ~, .u oppcitm tc. I coilK:identai ~iq with C8Z al .Put of tbc ~cal e\IOlution of a psticat's ~ ~. dmnlci. ThU effect bu been doaammi.tcl in~: ways. Fint, an abn&pt ~bedon ~f ~­ i:ricd/misedtejzwes with die iauod~'of; :CBZ.iit thc:rapcutic doses has bcca obseR:ed.. (t-41. this aacerbitloa is illustrued by our'c:aR ~.a ib:pwile ~ iA ~·.fu:ct~ e&n o¢gru·CBZ daal 111d I~ ate iocta.ed. (~] . 'lru,l ~~~n WU ot.erveci in at 1~ ~ ()f.oUt ~.~)),bl• ~. hticnt 10 bl thla doc~ jlhmO. .menon. dotwncatcd 'llrilh three iade~t wc:s of CBZ. Third, wit.h4'-.wal of CBZ cui rault~~ seizure conaol (HJ. FM paicrm had ~ .ic:iz1i1tt .._cs fi>r momb.t m ycaraon CBZi ~·~·~c­ ~·fm after withdmraJ of CB2 ~ die ad· dition ofochef amicpiteptiC dnap (Table 3). .rqion: 3:16-cv-00972-MBS Date Filed 03/28/16 Oassi:fication of patients by sefaurc typeS and epileptic syndtomcs gi'n:s accurate idcntdicatioo of patients at risk for CBZ"'C'l2a!rbatrd t:pilcpsy. uution, therefore, is needed when ptC$Cribing C'BZ to a child or a.dolescent with ab5cnce· or macd seizur~. Patients taking this drug who develop unoootrolled, generalized k'LaW'CS should be examined for CBZ cn.cerbated epilepsy. Oisc:ontinuat.ion of CBZ may ~ult in a marked improvemeor in epilepsy control in these patiet1ts. The opiniOlution of pa.rtial qtilt!J:tf. Neurology 198S;.)S:172S·J<>. · 1u1 l&odill EA. lli:al cs. J.m.nid PM. The clf«u of CU· buuutpioe an paalcau with i>sr:hOl'llOtOf epilepsy: lewlls of a doublc-bJind study. Epaq.ia lj14; 1~:547-61 . [IJ} Ham DL. Cubamazcpinc-iaduccd a~ and lllitlor m«ot seizutes. ~UIC!ogy 198S:l~:l86. Horn t't al: CBZ-cuurbe.tcd lipilcpsy J4S 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 137 of 145 714 W13S ar"1 Y) merungococcal vaccine. MeniDgc.coc:cal slr.lins can be separaied into twelve se:rogroups, based on their capsuw snucture. Scrogroup B is the most freq11e111 lsola~d straiJl. Pla«>nov has vac- cinated 18 L..CCD pacienu of whom 2 exper~nced IL meningoco~i disease, 9 and 12 mootlw llfle1' vaccination respectively. Unfortunately, t.he tnellingococcal strains of the 2 patients were nor 11Crogrouped and chartlcttrlzed fulther. Bcc•usc it is very likely that the meningococcal involved had another Ecrogroup than one of the four sei:ogroups included in the vaccine (A, C, W 115 or Y), we con not support the c:onclusian t.iat these cases represeut vaccine failures. 1n the same st11dy, Platonov found a lowu frequency of meningococcal dis· case in a period of 3 years a:fu:r vaccination thau before me vaccination. suggest· ing a beneficial elfea. We have immunized 21 LCCD indMduab wilh the tetra- valent meningococcll vac:cine and folJnd that 2 patients developed meningOCOCG.tl di5eue afi« vacciiution [ l}. One C8j3-deficient 19-year-otd female patient cwicc developed meningococal disease with serogrou.p B (not included in the vaccine), 1 and 3 ycara altet vaccination respectively. The first episode was due to mcningococcus B:4:Pl.4, md in the s~nd episCJde a meningococcua B:4:Pl.6 was isolated The second 21-year-old C8jHfefici.ent male patient developed mcningoc0ccal di!lUse with serogroup Y (1nc.luded Jn lhe vaccine), but the onset of \he dis· case was more th1111 3.5 ycan aftu vaccination. This patient .had developed a significant antibody re:iponse to serogroup Y (measarcd by ELISA) detc:nnined 6 . months after vacclmuion. McningoCOOCA! capsular polysaccharldos do not activate T-helper cells and induce tclatively poor memory. After va.ccination, a ptotective period o! 4 years is assumed. Thereto~. LCCD patients at risk for meningoccccal dhease reciuW: n:vaccination each 3-3.5 yean wilh !he t.etravalent v:iccine. The use of vaccine !hat also confers immunity to serogrou? 8 should be investigated f\u- . thtt. We agree entirely with Cremer and Wahn that LCCD patients should be informed about their risk to cQlltract meningococcal disease in order to lo111er the thrc3hold for early antibiotic ueatmcat. However, for screen.Ing of complement ~­ fioicncie; we strongly recommend to u.se also the more sensitivo 11.aernolysis-m-gelassay and not the traditiooal CH50 and AP50 test only fl]. 1.Fijen CAP (1995) Mcning1>coccaJ dis· esse a:1d complemerit deficiencies in the Nelheriands. Thesis, University of' Am· sterdam, Amslerdun, The Netherlands 2. Rjeu CAP, Kuijpcr E.T, Ha.nnema Al, Sjobolm AG. Putren JPM van (1989) Complement deficiencies in patients aver ten years old with meningococcal. disease due to uncommon serogroups. Lancet ll:S85-589 3.May.et MM (1961) Complement '11d compleolent tiution. In: Kabat EA, Mayer MM (eds) Experimental immunochemiatry. 211d cdn. Springfield, Il: Charles C. Thomas, pp 133-240 4.Nilsson UR. Nilsson B (1984) Slmpll· fied assays of hemolytic activity of the classical and altemab.ve 00111pltt11ent pathway. 1 Inununol Methods n :49-59 C. Pijeo · J Dankert · E. Xuijper Department oi Medical Microbiology. Uni-versity of Amaterdam, The Netherlands B. Derkx(B) Emma Ould=I'• Hospital, Oiildtens' Ac&diemic Medical Centre Amsterdam. The Nethcrlanda S. Van Devcntcr Department of HAemosWis, Thrombosis and. Inflammation ~b. Academic Medical Cmtre, Amsterdlllll, The Netherlands ~! infancy and childhood. Because lhis disor• dct featu;es both geQetlllir.ed and fo~ seizures [I}, it has seemed reasonable to u~ the antiepileptic drugs which ue ap· propriau: for putlal gcizu:res including caubamazepine (CBZ); Within the lase 5 years, we have treated seven children with SME. Mean onset of the illness was 11round 5 months of age. Perimi.tal events were unremack:able. Pieclpitating factors of me sciz.uru were mild fever, taking a bath and watching telev-i· &ion ar other flashing light sources. All patients had frequeru episodes of prolonged convulsive sdzures more lhan 30 min and also C1(hibit.ed panial seimres in addition to other lypes of l!eiv.Jre. Tile sciz.u1C3 of theac patierua ware ei:tn1mcly difficu It to co.ntroL ln m of seven patients, we admin.isr~ CBZ. 1t was not effective. On the contra?)', it aggn.valed geneializcd seiz:urei in at leut four of the six. patients. Sioce it la difficulI 10 make a rom:ct d.iag· no.tis of SME early in the phase of illnesa, the •ctending physician may prCl5cribe CBZ fur pu1ial seizures. If dtc:se aeizurca are aggravated by CBZ, SMB may be suspected. Once a dl.g,nosis of SMB has been cslabll.&hed, CBZ should not be adminis· tered. Ou{ experience is in accord with lhilt of oth.en [3]. 1. Commmion on clas.W'ic:ation and terminology .THOLOG'i' 5 RICHL.ANO ME.OIC.tlt PARK COLUMSIA. SOUTH CA~OL!NA 2920~ RI U i L\ '.\ fJ REPORT Of POSTMO~TEM .EXAMINATION • .Ame:r.dlld • CHART#: SEX:: M DATE OF AUtO?SY: l.'G:?l;.~;3 C9 30 c :-»::: · ~ :; ;· ~:··;~·. ~· !.~ ;. ~ :1 i : : ; t:·L~ ~~ '.·-.:~ !'.. (~ ~~;~ . f. ·!. !''; i ~ : ' i'i · ~·~r: .. ;~ .. ~; ~. ; ·.: • • ..: ~~ :., : :~: 1,..· h. -~1. [- ; ~if·! :::~ 1~. ~- ~,F ~..'"':- ~·~:; :._ ;;:·y l ..) £~b~g.~-?.?..P-~:..T.tl :r.: 5 s;: 1.z;.;~;;- t1Ufi j(} (:!)Mr'UC.A"fl(j~J~; o~::.OP.DF.R nr r: ~.~·:. r ~-~~: ;::iC ;.~ Mff(}(;tH)M.lH!t.l. (1'-rPF. N $iwwul Di>t"': \, '..:1:''~'.. ' 1 ' ·~ .. Entry Number 1-1 '' .. Page 139 of 145 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 140 of 145 PALME.TTC HEAL "!H ~!CHL.A>-;D OEPAFHMENT OF PATHOLOG'.' S R!CH lANC Mf Ol.CAL PARK COLUM8iA . SOUTH CAROLINA 29203 REPORT OF POSTMORTEM EXAMiN.ATiON .SEX :~.\ CHART#; REQUES TOR: G:'.NS Or M(l',Wt.HGNDR!Al !TY?E N(li SOf!.('.,;~iE::f:ti. :· :. ~ ! . ... ::: .. :- . ", 1~ •• • '': • ; ' • ~'.. . • _• • •• ·' · ~ : . • • • . 3:16-cv-00972-MBS Date Filed 03/28/16 ' ' ... ..,.. .,,. .~.::. · ·: • 00 • M .: .. •. .:, •• c. . -- Amu.ndmcf'tS . ......... ......................, •'"'-'·-·-·.. l\i"~ n~t?f.1 · ·~\':.~on . Entry Number 1-1 ....·.- ·;;.~ ·:.:.,~ ... =-.. •. . .. ,.. ......-................................ . ;. · -:.. .-:·-:·:. 1:, • ",.,.,. -., ..... 'i\:.;··· :.:. ~.. ·~: ·1 . : ........ ' I ••~ ~ Page 141 of 145 3:16-cv-00972-MBS Date Filed 03/28/16 Entry Number 1-1 Page 142 of 145 .... l'A 1.MJ:TH.~ } II~!(L\ LT H Hl .. \'.'.IJ PAL.METH) H EAl. ! H RICHLAN D OEPA.RTM.ENT OF PAiHOL.OGY 5 RlCH.LANt:lMEDl CAL !=>ARK C.Ol,,.IJMBIA, SOt.HH CAROLINA 2920:! REPORT OF POSTMORTEM EXAM.iNATiON DOS ·~·:·:. ....:.;-;:: .. . S~K : V HOSP#: f10'J:!.. G,?;c;·;(i OAiE OF DEATK: i ~·- ~~c:;:-.;;; PROVISIONAL REPORTErJ: ;·:·,:::::;ti;< REQiJESTi)R : r>~.r .1• :,\ 'hi·.n::; f.IROS:cC TOH : (:t.. .::,-:' :... ;.;ic:;.f:)~.S \1l) .. . ............. ~ ··· - - ··-···- .. ...... ................. ___ ____ ___ANAiOMICAL ..... .......... . . . ... .. DIAGNOS IS .... , ~ P~CiVl$10NA L •. ~-:. ·~ ; .. ' :',i I i,. •:• ,·' - -··· ···· .......... _...__ .__ . __ 3:16-cv-00972-MBS Date Filed 03/28/16 . \DllTH~IL\ITU a~ l'. FALME Entry Number 1-1 Page 143 of 145 nc Hf ALT!-f fHCf-H•••\NO OEPARTMENf Of PATHOLCG':' )I ~llLK!.:\.\;IJ .5 R.!C ~~LANP MEOIC..t•.l PARK COLvMBlA . SOLIT H CAROLINA 2SW3 REPO;n OF PosrMORTEM t:.X.AMlNA"TiON SEX: r,1 CHART f:I : ~,.1 REQUE'STOR : c.: .:..R.Y '·:'.i,\"T'T2. 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