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'Papaya Seed' Appearance of Subependymal Nodules on Magnetic Resonance Imaging in a Patient with Tuberous Sclerosis.

A 14-month-old male was referred to the Department of Child Health at the Sultan Qaboos University Hospital (SQUH), Muscat, Oman, in 2014 with a two-week history of frequent abnormal movements of the body. A video, recorded by the patient’s father, revealed that the patient suffered from typical flexor body spasms and left side partial motor seizures. On physical examination, the patient had several cutaneous features of tuberous sclerosis, including depigmented skin lesions and Shagreen patches. A neurological examination was unremarkable. Sleep electroencephalography displayed interictal generalised and focal discharges from the left frontocentral region. There was no evidence of hypsarrhythmia. Magnetic resonance imaging (MRI) of the brain revealed multifocal cortical and subcortical tubers with subependymal nodules (SEN) which had a ‘papaya seed’ appearance [Figure 1A]. Four to five rhabdomyomas in both ventricles were visible on echocardiography. Ophthalmological examination revealed an astrocytoma along the inferior vascular arcade close to the optic nerve of the left eye. The patient’s father had a possible skin lesion on his back, while the rest of the family had normal examinations. The child was diagnosed with tuberous sclerosis and epilepsy. He was initially prescribed the antiepileptic medication vigabatrin; due to a lack of response, this was changed to topiramate and levetiracetam after two weeks.