UH Med Now
Laughter that needed a cure: UH professor and physician trainees solve a medical mystery that tormented a patient for three decades
Above, an original illustration by MD Candidate Christina Tse, JABSOM Class of 2022.
By Tina Shelton, JABSOM Communications Director
“This was a very medically intriguing case. Prior to this case, I didn’t know seizures could manifest in such a way as uncontrollable laughter,” said Dr. Nina Leialoha Beckwith (JABSOM MD 2018), a Family Medicine Resident who worked on the case with fellow residents under the supervision of UH John A. Burns School of Medicine (JABSOM) clinical professor Kore Kai Liow, neurologist and Chief of Staff Elect at Adventist Health Castle.
The case was academically compelling but it also stirred great empathy in the physician trainees. The patient, 40 years old at the time, had suffered from the uncontrolled laughter since the age of eight.
“I can only imagine what it is like for this patient to suffer from these bizarre seizures for so many years,” said Beckwith. “I’m grateful to have been a part of his care and I believe his story can help us as clinicians to identify and provide better care for patients suffering from similar conditions.”
As the physicians reported in the Hawaiʻi Journal of Medicine and Social Welfare, the medical term for the condition was a gelastic seizure. They wrote, “Gelastic seizures (GS) are a rare form of epilepsy characterized by inappropriate, uncontrolled laughter. They are highly associated with abnormal cognitive development and behavioral problems in patients. Research has shown that GS can originate from hypothalamic hamartomas, non-neoplastic masses consisting of gray matter with large and small neurons interspersed with glial nuclei. GS have also been observed in patients with frontal and temporal lobe lesions.”
The man had a history of both a brain tumor and of diabetes mellitus and schizophrenia, in addition to the laughter fits which struck two to three times a week. He had been considered by some to have longstanding behavioral issues. But –at least when it came to the uncontrolled laughter, there was indeed a physical cause, and when the hypothalamic hamartoma was detected and the patient treated with medicine, the laughter was brought under control, according to Dr. Liow.
The researchers concluded, “As demonstrated by this case report, in patients with behavioral issues, especially those with inappropriate uncontrolled laughter, gelastic seizures need to be included in the differential diagnosis. Thus, a thorough workup should include neuroimaging with attention to the suprasellar region and EEG. Accurate, early diagnosis and patient education are critical in avoiding excessive and unnecessary treatments. This condition may be pharmacoresistant and is often associated with progressive cognitive and behavioral issues. Studies have shown a surgical treatment approach may be effective.”
Dr. Liow is Director and Principal Investigator of the Clinical Research Center at Hawaiʻi Pacific Neuroscience, which sees over 25,000 patient visits each year including over 900 research patients seeking the ground-breaking neuroscience research therapy. He has appointments with both the JABSOM departments of Internal Medicine and Family Medicine (FM) and Community Health. His service to JABSOM is extensive and each year includes organizing JABSOM FM Residency Neurology Didactics for the some 20 residents, organizing the CSP (Clinical Skills Pathologic) for the MD6 module for about 15 medical students, organizing monthly neurology rotations for some 30 residents and medical students at the neuroscience center, and mentoring some 30 residents, medical and graduate students, offering opportunities to be involved in neuroscience research projects.
But the way he sees it, JABSOM is doing much of the giving. “JABSOM provides our 10+ neuroscience faculty an opportunity to give back to our community by mentoring the residents, medical students and graduate students,” said Dr. Liow. “It is such a privilege and honor to be able to be part of their journey as they discover their passion for certain areas of medicine and we are of course biased and hope some of them will ‘catch’ the fire and be on fire to pursue careers in neurology, neurosurgery or neuroscience. The residents and students teach us to be better clinicians each time we see our patients together and inspire us that there is always more we can do for our patients. In so many ways, they are our “teachers” and we cannot be more grateful for the opportunity JABSOM has provided us to mentor them and part of their journey.”
Before moving to Hawaiʻi in 2009, he was a Professor of Neurology at University of Kansas School of Medicine and trained as a research neurologist at the National Institute of Neurological Disorders and Stroke (NINDS), at the National Institutes of Health in Bethesda, Maryland. When he is not working or teaching or at home with his ʻohana and his Chihuahuas, you may find him surfing on his Starboard SUP either at Castle Beach or the flat island in Kailua. “My best ‘thinking’ and ‘ideas’ are actually birthed when I am one with the moana,” Liow said.