CASE PRESENTATION

Maria Angelica U. Veloso

Identifying Data

Name: MVAge: 1Sex: MaleNationality: FilipinoReligion: Roman CatholicAddress: TaguigChief informant: Mother and FatherReliability: Fair

Chief Complaint

Seizure (Few mins PTA, lasting approximately 5 mins)

History of Present Illness

1 week PTA

•Coughing episodes, productive

•No dyspnea, wheezing, colds

•Consult done Salbutamol nebulization 3 times a day and Prednisone 3 mL OD, which offered some relief

HPI

Day of admission

•Cough still present

•Fever– (T max = 38.2 C) – Temporarily lysed with paracetamol– Still with good activity and good appetite

HPI

Few minutes PTA•Seizure

– Sudden onset without aura– Upward rolling of eyeballs, stiffening of extremities,

pooling of saliva, frothing around the mouth and generalized cyanosis

– No vomiting, loss of consciousness or incontinence– Lasted around 5 minutes– Post ictally upward staring– No recurrence

•Immediate consult and subsequent admission

Review of Systems

(-) Weakness, loss of appetite, colds, dyspnea, vomiting, diarrhea or urinary changes

Past Medical History

• No history of head trauma

• First seizure occurrence

• Asthma– Ventolin nebulization– With previous hospitalizations last year

Past Medical History

Previous hospitalizations: - URTI x 2 (Aug 2010)

- AGE (2011)

Previous surgeries: None

Allergies: None

Immunization history:- BCG, Hepa B x 3, DPT + OPV x 3, Measles

- No HiB, MMR, Varicella, Pneumococcal, Rotavirus

Family History

• Asthma Maternal aunt

• Brother had a cough few days before which was treated with antibiotics

• No history of febrile seizures, epilepsy

• No HTN, DM, heart disease

Birth and Maternal History

• Born full term via NSD to a 31 y/o G3P3 (3003)– Unrecalled BW; No complications; Good

activity, cry and color– NBS done

• Planned pregnancy

• Regular PNCU

• No maternal illnesses/vices during pregnancy

Nutritional History

• Breastfed until 1 month then began taking formula (Enfalac)

• Not yet weaned

• Currently on pure formula milk diet

Developmental History

Gross Motor: Walks well alone

Adaptive Fine Motor: Throws toys, drinks from cup

Language: Obeys commands or requests, can say mama and dada

Personal Social: Does nursery games, helps dress himself, does not attempt to feed himself with a spoon

At par for developmental age

Environment and Social History

• Lives with 4 others in a well lit but not well ventilated home, which is quite small

• Water source: Delivered mineral water• Daily garbage collection• No smokers at home but some neighbors burn wood for

cooking• No pets but some neighbors raise pigs• Mother is a housewife• Father is a TMC employee• Patient is active and playful despite being asthmatic

Physical Exam

General Survey: Awake, Alert, Irritable, Not in cardiorespiratory distress

Vital Signs: HR - 161, RR - 40, BP – 90/70, Temperature – 38.6 degrees C, Height – 80 cm, Weight – 12 kg, HC – 46 cm, CC – 50 cm, AC – 53 cm

Physical Exam

HEENT: Normocephalic, Closed fontanelles; Anicteric sclerae, Pink palpebral conjunctivae; No nasal discharge; Dry lips, moist buccal mucosa, and tongue; No TPC, (-) CLAD, Supple neck

Physical Exam

Chest/Lungs: Equal chest expansion, No retractions, Harsh breath sounds, Bibasal rales

CVS: Adynamic precordium, Tachycardic, Regular rhythm, Distinct heart sounds, Good S1 and S2; (-) Murmurs, (-) S3 or S4; PMI at 5th ICS MCL

Physical Exam

Abdomen: Globular without any visible masses or scars; Normoactive bowel sounds; (-) Obliteration of Traube’s space; Soft, (-) Masses or organomegaly upon palpation, (-) Tenderness

Physical Exam

GU: Grossly normal male external genitalia

DRE: Not done

Skin/Extremities: Good skin color and turgor; (-) Pallor, (-) Cyanosis, (-) Jaundice (-) Edema; Full and equal pulses; Good capillary refill

Physical Exam

Neurologic:

GCS 15, Irritable

VII – No facial asymmetry

VIII – Lateralizes/Localizes sound

IX, X – Intact gag reflex and swallowing

XI – Moves shoulders

XII – Tongue midline

Cranial nervesI – Not assessedII, III, IV, VI – Pupils 3 mm equally brisk and reactive to light, Able to track objects, No ptosisV – Able to bite down hard on tongue depressor

Physical Exam

Motor: Spontaneous active movement on all extremities

Sensory: Intact

Absent Babinski, No ankle clonus, DTRs ++

(-) Nuchal rigidity, (-) Brudzinski, (-) Kernig’s

Salient Features

• 1/M• 1 week of productive cough• Fever• 1 seizure episode lasting 5 minutes without recurrence• First occurrence and no family history of febrile seizures

or epilepsy• Bilateral rales• Essentially normal neurologic exam without nuchal

rigidity or meningeal signs

Working Impression

Benign Febrile Convulsion secondary to Pneumonia

Differentials

• Complex febrile seizure

• CNS Infection

• Electrolyte imbalance

Diagnostics at the ER

CBC Hgt 90 mg/dL

Na 136

K 3.9

Ionized Ca 5.36

O2 sat 93% 98%

CXR

Consider interstitial pneumonia, bilateral

133605

0.3918.3

0.77/0.16/0.07/0

Treatment

• Admit• Diet as tolerated• Monitor VS q 4 and I&O q shift• IVF: D5IMB 500 mL x 10 hours

(maintenance + 10%)• Paracetamol 120mg/5mL, 5

mL every 4 hours for T >/= 37.8 C

• Salbutamol nebulization once every 6 hours with chest clapping after every other nebulization

• Standby diazepam 3 mg IV for frank seizures > 5 mins

• Ampicillin 300 mg IV every 6 hours

• Zinc 10mg/5mL twice a day for 14 days

• Standby O2• Seizure precaution• Refer to neurology

Course in the Wards – Day 1

Subjective Objective Assessment Plan

- Afebrile (last fever 4:40 am)

- No seizure reoccurrence

- Occasional cough- No dyspnea- Good activity and

appetite

- Awake, alert, irritable

- HR 120s, RR 30s, Afebrile

- No alar flaring, retractions

- Bilateral rales- GCS 15- Supple neck

BFCPneumonia

- Continue present medications but revise paracetamol to 100mg/mL, 1.5 mL every 4 hours for T >/= 37.8

Course in the Wards – Day 2

Subjective Objective Assessment Plan

- Afebrile - No seizure

reoccurrence- Occasional cough- No dyspnea- Good activity and

appetite

- Awake, alert, less irritable

- HR 120s, RR 30s, Afebrile

- No alar flaring, retractions

- Harsh breath sounds, occasional wheezes

- GCS 15- Supple neck

BFCPneumonia, resolving

- Continue present medications but revise paracetamol to 100mg/mL, 1.5 mL every 4 hours for T >/= 37.8

Seizures

• Transient occurrence of signs and/or symptoms resulting from abnormal excessive or synchronous neuronal activity in the brain

Seizures

• Either:

1.Focal (partial) initial activation of a system of neurons limited to part of one cerebral hemisphere

• Generalized synchronous involvement of all of both hemispheres

Febrile Seizures

• Occur between the age of 6 and 60 months

• Temperature of 38°C or higher

• Not the result of central nervous system infection or any metabolic imbalance

• Occur in the absence of a history of prior afebrile seizures

Simple or Complex?

Simple •Primary generalized•Usually tonic-clonic, attack associated with fever•Lasts for a maximum of 15 min•No recurrence within 24 hours

Complex •More prolonged (>15 min)•Focal •Recurs within 24 hours

Febrile status epilepticus febrile seizure lasting >30 min.

Febrile Seizures

• Between 2% and 5% of neurologically healthy infants and children experience at least 1

• Do not have an increased risk of mortality• No long-term adverse effects of having ≥1

simple febrile seizures (No brain damage)• Only 2-7% of children who experience febrile

seizures proceed to develop epilepsy later in life

All in the family

• In many families, the disorder is inherited as an autosomal dominant trait

• Multiple single genes causing the disorder have been identified

• In most cases the disorder appears polygenic, and the genes predisposing to it remain to be identified

Genes, genes, genes

• Identified single genes include FEB 1, 2, 3, 4, 5, 6, and 7 genes on chromosomes 8q13-q21, 19p13.3, 2q24, 5q14-q15, 6q22-24, 18p11.2, and 21q22

• Only the function of FEB 2 is known: it is a sodium channel gene, SCN1A

Some syndromes

• Almost any type of epilepsy can be preceded by febrile seizures

• A few epilepsy syndromes typically start with such

• Generalized epilepsy with febrile seizures plus (GEFS+)

• Severe myoclonic epilepsy of infancy (SMEI, also called Dravet syndrome)

• And, in many patients, temporal lobe epilepsy secondary to mesial temporal sclerosis

Work Up

Lumbar Puncture

• Recommended in children <12 mo of age after their first febrile seizure to rule out meningitis

• Especially important if the child has received prior antibiotics mask clinical symptoms of the meningitis

• The presence of an identified source of fever, such as otitis media, does not eliminate the possibility of meningitis

Lumbar Puncture

• Seizures are the major sign of meningitis in 13-15% and 30-35% of such children have no other meningeal signs

• American Academy of Pediatrics (AAP) strongly recommends LP in infants <1 yr of age because other signs of the infection might not be present

Lumbar Puncture

• A child between 12 and 18 mo of age should also be considered Clinical symptoms of meningitis may be subtle in this age group

• For children >18 mo of age indicated in the presence of clinical signs and symptoms of meningitis (e.g., neck stiffness, Kernig sign, Brudzinski sign) or if the history and/or physical examination otherwise suggest intracranial infection

Electroencephalogram

• Not needed if the child is presenting with his or her first simple febrile seizure and is otherwise neurologically healthy

• Would not predict the future recurrence of febrile seizures or epilepsy even if the result is abnormal

• Spikes during drowsiness are often seen in children with febrile seizures, particularly those >4 year old, and these do not predict later epilepsy

EEG

• Often have nonspecific slowing, if performed within 2 weeks usually posteriorly. Thus, in many cases, if an EEG is indicated, it is delayed until or repeated after >2 weeks have passed

• Generally restricted to special cases in which epilepsy is highly suspected

• Should be used to delineate the type of epilepsy rather than to predict its occurrence

EEG

• Should be performed for at least 30 min in wakefulness and in sleep avoid misinterpretation and drawing of erroneous conclusions

• At times, if the patient does not recover immediately from a seizure, it can help distinguish between ongoing seizure activity and a prolonged postictal period -- nonepileptic twilight state (NETS).

Neuroimaging

• According to the AAP a CT or MRI is not recommended after a first simple febrile seizure

• Patients with febrile status epilepticus have been reported to have swelling of their hippocampus acutely and subsequent long-term hippocampal atrophy. These patients may be candidates for neuroimaging, because they may be at risk for later temporal lobe epilepsy

Remember…

• The work-up of children with complex febrile seizures needs to be individualized

• This can include EEG and neuroimaging, particularly if the child is neurologically abnormal

• Patients with febrile status epilepticus swelling of their hippocampus acutely and subsequent long-term hippocampal atrophy which puts them at risk for later temporal lobe epilepsy

Treatment

• In general, antiepileptic therapy, continuous or intermittent, is not recommended for children with one or more simple febrile seizures

• Counseling on the relative risks of recurrence of febrile seizures and recurrence of epilepsy, how to handle a seizure acutely plus emotional support

Treatment

• If the seizure lasts for >5 min acute treatment with diazepam, lorazepam, or midazolam – Rectal diazepam is often prescribed – Buccal or intranasal midazolam may be used

and is often preferred by parents– IV benzodiazepines, phenobarbital,

phenytoin, or valproate may be needed in the case of febrile status epilepticus

Treatment

In the vast majority of cases it is not justified to use these medications for intermittent therapy Risk of side effects and lack of demonstrated long-term benefits, even if the recurrence rate of febrile seizures is expected to be decreased

Treatment

Antipyretics

•Can decrease the discomfort of the child but do not reduce the risk of having a recurrent febrile seizure (seizure often occurs as the temperature is rising or falling)

Treatment

• Chronic antiepileptic therapy may be considered for children with a high risk for later epilepsy

• Currently available data indicate that the possibility of future epilepsy does not change with or without antiepileptic therapy

• Screen for iron deficiency, as it has been shown to be associated with an increased risk of febrile seizures

Prognosis

• Benign events with excellent prognosis

THE END