Febrile Seizures: A Case Discussion

Ryan Em C. Dalman MD MBA - 070070

“Co-co-co-com Bulsyon!”“ehem…”

Outline

Objectives Case Presentation Case Discussion

Objectives

Present a case of Simple Febrile Seizures

Discuss the pathophysiology and management of Simple Febrile Seizures

Case PresentationPatient History

General Data

CM 1-year-old born on 4/4/2009 Female Admitted for the first time Roman Catholic Lives in Manggahan, Pasig City

Chief Complaint

“Combulsyon” (Convulsions)

History of Present Illness

Fever – intermittent, undocumented

No associated symptoms Convulsions Consult at Angono Hospital

38.4oC CBC: normal Urinalysis: WBC (6-8) pyuria Dx: UTI Rx: Paracetamol 10 mk/dose and

cotrimoxazole 50 mk/day Unproductive cough and colds

1 day PTA

History of Present Illness

Undocumented Fever Convulsions

2-3 minutes Prompted consult

7 hours PTA

henceadmitt

ed

Review of Systems

General: no weight loss, no change in appetite

Cutaneous: no lesions, no pigmentation, no hair loss, no pruritus

HEENT: no rednessno aural dischargeno neck massesno sore throat

Review of Systems

Cardiovascular: no easy fatigability, or fainting spells

Gastrointestinal: no vomiting, no loose bowel movements, no constipation

Genitourinary: no genital discharge, no pruritusno problems in urination

Endocrine: no polyuria, polydypsia, no heat/cold intolerance

Review of Systems

Muskuloskeletal: no joint or muscle swelling, no limitation of movement, no stiffness

Hematopoietic: no easy bruisability, or bleeding

Maternal and Birth History Born full term via NSD to a 31 year

old G4P3 (3013) by an obstetrician at PCGH

with complete prenatal consults No intake of any medications except

for multivitamins No maternal illnesses No complications at birth

Nutritional History

Breastfed from birth to the present No formula given Supplementary foods were given at

6 month old Current diet

Breast milk 4-5 bottles a day Rice + (chicken, vegetables, w/ soup) 3x

a day Bread every morning

Past Medical History

Pneumonia (Aug, 2009)No Tuberculosis, Asthma, TraumaNo previous surgeriesNo previous hospitalizationsNo Allergies

Immunizations

BCG – 1 dose DPT – 3 doses Hep B – 3 doses Measles – 1 dose

Developmental History

Stands alone Throws toys Obeys commands or requests Attempts to use a spoon

Family History

PTB – father No diabetes, hypertension, heart

disease, cancer, stroke, kidney disease, asthma, or allergies

Personal and Social History Father works for Reagent, in the

packaging department Mother is a housewife They live in a makeshift house in

Pasig City

Environmental

Not exposed to environmental hazards like chemicals, pollution, cigarette smoking, etc

House prone to flooding Has their own toilet Water comes from Manila Waters

Drinking water from faucet boiled for 5 minutes

Case PresentationPhysical Exam

General Survey

awake, active, with good cry but consolable

in cardiorespiratory distress

Vital Signs/ Anthropometrics

Vital signsTemperature – 37.5oCCR – 140 (70-110) RR – 36 (20-30)

AnthropometricsWeight: 7.1 kg (<5th) Length: 75cm (50th) HC: 42cm (<5th) CC: 45 cmAC: 42 cm

Skin

Light brown No rashes, hemorrhages, scarsDry good skin turgor CRT 1-2 seconds

HEENTHead

normocephalicno lesions, fontanels closed

Eyesanicteric sclerae, pink palpebral conjunctivapupils 2-3mm

Earscone of light present inferomedially on both earsno discharge noted

Noseseptum medline, moist mucosa

Throatmouth and tongue moistno TPC

Chest and LungsNeck

with cervical lymphadonapathyno nuchal rigidity

Chestadynamic precordiumno heaves, thrills, or lifts, PMI at 4th ICS MCLregular rate, normal rhythmno murmurs

Lungssymmetrical chest expansion, no retractionsEqual vocal fremitiall lung fields resonant on percussionharsh breath sounds with bilateral fine crackles

Abdomen/ Perineum

Abdomenglobular, no scars, no lesionsnormoactive bowel soundstympanitic on all quadrantsno tenderness on all quadrantsno masses, no organomegallyliver edge palpatedkidneys and spleen not appreciated

Neurologic Examination

Glasgow Coma Scaleverbal response: 5eye opening: 4motor response: 6total: 15

Cerebrumawake and active

Cerebellumno nystagmus, tremors, or abnormal movements

Neurologic Examination

Sensoryturns to pain

Motor5/5 on all extremities

DTR++ on all extremities

Neurologic Examination

Cranial NervesI: not elicited II: 2-3mm pupils, equally reactive to lightIII,IV,VI: EOM’s intactV: corneal reflex presentV1, V2, V3 intact (turns to touch)VII: no facial asymmetry VIII: turns to soundIX, X: gag reflex presentXI: turns head from side to sideXII: tongue midline

Case PresentationAdmitting Impression, Salient Features, Differentials, Course in the Ward

Admitting Impression

Benign Febrile Seizure secondary to pneumonia

Salient Features

13 month old, female Fever (intermittent, undocumented) Convulsion

2-3 minutes General tonic-clonic

Unproductive cough and colds Tachypneic, tachycardic Bilateral lung crackles Normal neurologic exam

Differential DiagnosisBFC 2o to PN

Bacterial Meningitis

13 month old + +Intermittent fever + +Convulsions (2 episodes (different febrile episodes; 2-3 mins; general tonic-clonic)

+ +

Unproductive cough and colds + +/-Tachypneic; tachycardic + +Bilateral lung crackles + -Normal neurologic examination + -

Differential DiagnosisBFC 2o to PN

Viral Encephalitis

13 month old + +Intermittent fever + +Convulsions (2 episodes (different febrile episodes; 2-3 mins; general tonic-clonic)

+ +

Unproductive cough and colds + -Tachypneic; tachycardic + -Bilateral lung crackles + -Normal neurologic examination + +/-

Course in the Ward

ERT: 40.1 oC CR: 138RR: 35

awake, in mild cardiorespiratory distress

rales on bilateral lung fields

D5LRParacetamol 10mkd

Course in the Ward

ERCBC: normalUrinalysis: pus cells – 2-4

Course in the Ward

1st Hospital DayS O A P

-Good suck

T: 36.5oC CR: 120 RR: 36-Awake, with good cry-In mild cardiorespiratory distress-no seizures-With febrile episodes

-No retractions-Fine crackles, bilateral

-She is afebrile but has febrile episodes recorded

-Patient is tachycardic and tachypneic.

-IV Fluids-Ampicillin -Paracetamol for fever-monitor vital signs-diet as tolerated-for CSF culture

Course in the Ward

2nd Hospital DayS O A P

T: 37.6oC CR: 110RR: 34-with good cry-In mild cardiorespiratory distress-no seizures

-No retractions-Fine crackles, bilateral

-still no episodes of seizures and fever

-still tachypneic

-Continue medications-monitor vital signs-diet as tolerated-for CSF culture

Course in the Ward

3rd Hospital DayS O A P

T: 36.6oC CR: 108 RR: 30-not in cardiorespiratory distress-no seizures

-No retractions-Fine crackles, bilateral

Chest X-Ray-bilateral lung PN w/ non-specific lymphadenopathy suggest follow-up study after treatment to r/o primary infection PTB

-absence of seizures-responding well to medications-the patient is no longer tachypneic-with no more febrile episodes

-continue medications-monitor vital signs-Diet as tolerated-For CSF culture

-For PPD

Course in the Ward

5thHospital DayS O A P

T: 36.9oC CR: 110 RR: 29-Awake, with good cry-not in cardiorespiratory distress

-No retractions-Fine crackles, bilateral

- No more febrile episodes and not tachypneic (day3)-responding well to medications-resolution stage

-switch to oral medication-Monitor vital signs-diet as tolerated-follow up CSF culture

Course in the Ward

6th Hospital DayS O A P

T: 37.0oC CR: 105 RR: 24-Awake, with good cry-not in cardiorespiratory distress-no seizures

-No retractions-Fine crackles, bilateral

CSF analysis-clear, sugar 3.3s (N), protein 27.6 (N), cell count 0

-no more seizure episodes-resolution stage of pneumonia-CSF analysis rules out meningitis

May go home

-amoxicilliln 50mk/day

Final Diagnosis

Benign Febrile Convulsion secondary to Pneumonia

Case Discussion

Definition/ Clinical Manifestations

Simple Febrile Seizures Ages 3 months – 6 years Axillary temperature 37.8oC or

greater Generalized tonic-clonic seizures Less than 15 minutes Does not recur within the same

febrile illness Normal neurologic exam No underlying CNS infection or

abnormalityCPG on First Simple Febrile Seizure

Incidence

2% - 5% have febrile seizures by 5 years old (US)

5% -10% for India, 8.8% for Japan, 14% for Guam,0.35% for Hong Kong, and 0.5-1.5% for China.

Nooruddin R Tejani, MD, Assistant Professor, Department of Emergency Medicine, SUNY Health Sciences Center Brooklyn; Director, Pediatric Emergency Medicine, Downstate Medical Center

Pathophysiology

Increase neuronal excitabili

ty

Endogenous Pyrogens

(interleukin 1 beta)

High frequency burst of action

potentials

Seizure propagation

Loss of surround inhibition

Spread of seizure activity!

American Epilepsy Society – 10/04

Diagnostics

Lumbar puncture should be performed in all children below 18 months for benign febrile convulsions For >/= 18months, it is recommended in

the presence of clinical signs of meningitis

Neuroimaging studies should not be routinely performed in children for benign febrile seizuresCPG on First Simple Febrile

Seizure

Treatment

Antipyretic use Used to lower fever and should not be relied

upon to prevent the recurrence of febrile seizures

Antiepileptic drug use (continuous anticonvulsant) Not recommended in children after a simple

febrile seizure. It can reduce the recurrence of febrile seizures,

but its adverse side effects do not warrant their use in this benign disorder

CPG on First Simple Febrile Seizure

Treatment

Antiepileptic drug use (intermittent anticonvulsant) Not recommended for the prevention of

recurrent febrile seizures There is no difference in the risk of

seizure recurrence in children receiving intermittent diazepam and placebo

CPG on First Simple Febrile Seizure

Prognostic Evaluation

Electroencephalogram (EEG) Should not be routinely requested in

children with a benign febrile seizure There is no evidence that EEG can

predict future incidence of epilepsy Presence of abnormalities in the EEG

does not change the recommendation the use of anticonvulsants

CPG on First Simple Febrile Seizure

Prognosis

Simple febrile seizures may slightly increase the risk of developing epilepsy, but they have no adverse effects on behavior, scholastic performance, or neurocognition.

Children with febrile seizures have a slightly higher incidence of epilepsy compared with the general population (2% vs 1%).