Lapkas Dai

CASE REPORT

Complex Febrile Seizure

Presenters : Ika Nopa Nst; Siti Rizky A Nst

Day/ Date : Monday / May 14th 2012

Supervisor : dr. Hj Sri Sofyani, Sp. A (K)

CHAPTER 1

INTRODUCTION

1.1. Background

Febrile convulsions, or febrile seizures (FS), are seizures that occur on the rise in body

temperature caused by the extracranial process.1 Expert opinion about the age of the patient

during a febrile seizure are not same. Most expert argue that febrile seizure occur at children

aged between one months to five years old.2 According to American Academy of Pediatrics

(AAP) the youngest age of febrile seizures is 6 months old.3

Most of 90% patients with febrile seizures occur in children younger than five years

old.Most febrile seizures occur in children aged between six months to twenty two months.

The highest insiden of febrile seizure is at 18 months.

Incidence of febrile seizure in worldwide is 1–14%. In everycountry , the incidence

and prevalence of febrile seizure is different.In Japan incidence of febrile seizure is rangers

from 8.3% - 9.9% . In United States and Europe prevalence of febrile seizure is 2 - 5 %. In

Asia prevalence of febrile seizure is 2 fold higher than prevalence in united states and

Europe.4

Febrile seizures are classified as either simple or complex. Simple febrile seizures

consist of a brief (lasting less than 10 minutes) tonic-clonic convulsion which occurs only

once within a 24-hour period. There are no focal features and it resolves spontaneously.

1

Conversely, complex febrile seizures are prolonged (greater than 10-15 minutes), focal, or

multiple and recurrent within the same febrile illness over a 24-hour period. While the

majority of febrile seizures are simple (70-75%), 9-35% of febrile seizures are complex.10

Prognostic of patient with febrile seizure is good. The mortality rate of patients with

febrile seizure is only 0.64% – 0.75 %. Most of patients with febrile seizure have complete

recovery and a small fraction develop into epilepsy (2-7%). Four percent of patient with

febrile seizures were significantly impaired behavior and decreased levels of intelegence.5

1.2. Objective

This paper is done in order to complete the task in following the doctor's professional

education program in the department of pediatrics. In addition, providing knowledge to the

author and readers about complex febrile seizure.

.

2

CHAPTURE 2

LITERATURE REVIEW

FEBRILE COMPLEX SEIZURE

2.1. Febrile Seizure

2.1.1. Defenition

Febrile convulsions, or febrile seizures (FS), are seizures that occur on the rise in body

temperature caused by the ekstracranial process.1

The peak occurrence of FS is 18 months, FS are excluded in children with seizures due

to a CNS infection, a previous afebrile seizure, or an underlying CNS abnormality. 6

2.1.2. Epidemiology

Incidence of febrile seizure in worldwide is 1–14%. In everycountry , the incidence

and prevalence of febrile seizure is different.In Japan incidence of febrile seizure is rangers

from 8.3% - 9.9% . In United States and Europe prevalence of febrile seizure is 2 - 5 %. In

Asia prevalence of febrile seizure is 2 fold higher than prevalence in united states and

Europe.

Most of 90% patients with febrile seizures occur in children younger than five years

old.Most febrile seizures occur in children aged between six months to twenty two months.

The highest insiden of febrile seizure is at 18 months.4

2.1.3. Risk Factor

- Family history of febrile seizures

- Duration of febrile illness (the shorter the febrile period)

- Presence of prior neurological abnormalities

- Under five years old 7

2.1.4. Predictors of recurrent febrile seizures include:

- A history of focal, prolonged, and multiple seizures.

- Influenza A viral infection.

- Family history of febrile seizures.

- Onset of febrile seizure <12 months of age.

- Temperature <40°C (<104 °F) at time of seizure.

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- And a history of complex, initial febrile seizures..8

2.1.5. Pathophysiology

1. Fever (>38.3°C rectal) can decrease gamma aminobutyric acid A (GABA(A)

receptor mediated inhibition to a greater extent than it decreases excitation, which

may shift the balance towards excitation and contribute to seizure generation. This

appears to be mediated by reducing GABA release from presynaptic terminals, but

fever may also decrease post-synaptic GABA(A) receptor function.

2. Fever can decrease the seizure threshold in immature cells.

3. Fever can increase the mobility of ions to the cell. It facilitate the occurrence of

depolarization.

4. Sudden increase in body temprature can increase glutamat acid which is excitator. 9

2.1.6. Classification and Clinical Findings

a. Simple febrile seizure:

In a child who is otherwise neurologically healthy and without neurological

abnormality by examination or by developmental history is defined as:

- Seizure less than 10 minutes

- Single seizure which is generalized or tonic clonic

- occurs only once within a 24-hour period

b. Complex febrile seizure:

- Seizures are prolonged (greater than 10-15 minutes)

- Seizures are focal, or multiple

- Recurrent within the same febrile illness over a 24-hour period.10

2.1.7. Differential Diagnose and Diagnose

Table 1. Differential diagnoses of fever and convulsions16

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Complex febrile convulsion- Prolonged- Focal features- Seizures recur within 24

hours or same illness

- Consider differential -diagnoses (Table 1)

- Investigate further (eg. LP if suspect CNS infection)

Febrile seizures Simple

Complex

Central nervous system infection Meningitis

Encephalitis

Other precipitants of seizures in a child with

fever

Systemic illnesses (eg. occult bacteraemia)

Head trauma

Intoxication

Electrolyte imbalance

Hypoglycaemia

2.1.7.1 Investigations:

Routine blood work is not indicated for simple febrile seizures. Laboratory

investigations are dictated by the clinical condition of the child and by an appropriate clinical

policy for children of that age presenting to the emergency department with fever.

- Lumbar Puncture (LP)

An LP is not recommended in children considered to be haemodynamically unstable.

Strongly consider LP if the child is less than 12 months and consider LP if the child is less

than 18 months.

LP is recommended if:

- Child has received antibiotics prior to the seizure as partially treated meningitis could be

present in children who were on antibiotics prior to the seizure, and in these cases

consider an LP regardless of age. Even if an LP is performed and the results are negative,

one may consider treatment of meningitis, as cerebrospinal fluid (CSF) may be normal in

the early stages of meningitis.

- Meningeal signs are present:

Meningeal irritation is defined as presence of Brudzinski sign (flexion of the neck causes

flexion of the patient’s hips and knees), Kernig sign (pain elicited with 90 degree hip

flexion and knee extension), or neck stiffness in children older than 1 year of age. In

children 1 year or younger, signs of meningeal irritation are the signs mentioned herein

or irritability during manipulation of head or legs by the physician and/or a bulging

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fontanel.8 It should be stressed that clinical signs of meningitis are insensitive and if the

clinician is suspicious that meningitis is present the LP should not be delayed while

awaiting for these signs to develop.

- Imaging

Neuroimaging is not indicated after a simple febrile seizure, but could be considered

when there are clinical features of a neurological disorder, e.g. micro/macrocephaly,

neurocutaneous abnormalities, pre-existing neurological deficit, postictal neurological

deficit persisting for more than a few hours, or when there are recurrent complex febrile

seizures, particularly where there is doubt whether the seizures are febrile. Magnetic

resonance imaging is more sensitive than computed tomography for brain disorders that

may present with seizures.

- Electroencephalography (EEG)

EEG does not predict which children progress to a seizure disorder. Epileptiform

abnormalities are relatively common in children with benign febrile seizures. EEG has a

low sensitivity in children under three years of age following an unprovoked seizure.

EEG may have a limited role in the diagnosis of acute encephalopathic disorders if the

child remains encephalopathic for longer than normal following a febrile seizure. 9

2.1.8. Treatment

2.1.8.1 Acute Management of Febrile Convulsion:

- Maintain a clear airway.

- Protect the child from injury.

- Place the child in a semi-prone position.

- Loosen clothing or remove excess clothing.

- Give oxygen if available.

- Apply suction for nasal or oral secretions if

facility available.

- Treat fever by sponging with tepid water and

antipyretics (e.g. acetaminophen).

- Monitor vital signs.

- If facilities and medications are available give :

Short acting anti convulsant for termination of acute seizures

Drugs Administration Dose

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Diazepam

Diazepam

Phenytoin

Phenobarbital

Rectal

IV

IV

IV

BW < 10 : 5 mg

BW> 10 : 10 mg

0.3-0.5 mg/kgbb/kali

10-20 mg/kgBB /kali

10-20 mg/kgBB/kali

2.1.8.2 Hospital Admission

Children should preferably be observed for several hours after a febrile convulsion. If

they are clinically stable with cause of fever identified and treated, they may be sent home.

However, follow-up care must be assured. Hospital admission is individualized. It depends

on the experience of the practitioner, specific clinical situation and family circumstances.

2.1.8.3 Management of Fever

- There is no evidence that antipyretic treatment prevents the recurrence of febrile

convulsions.

- Fever should be treated in order to promote the comfort of the child and to prevent

dehydration.

- Use of antipyretic drug is effective and,

paracetamol or ibuprofen is advised.

- An adequate fluid intake is advisable. 12

-

2.1.9 Prognosis

Prognostic of patient with febrile seizure is good. The mortality rate of patients with

febrile seizure is only 0.64% – 0.75 %. Most of patients with febrile seizure have complete

recovery and a small fraction develop into epilepsy (2-7%). Four percent of patient with

febrile seizures were significantly impaired behavior and decreased levels of intelegence.5

CHAPTER 3

7

MEDICAL RECORD

COMPLEX FEBRILE SEIZURE

3.1. Objective

The aim of doing this paper is to report a case of Complex Febrile Seizure of a 2

month 10 day old boy that was admitted at Pediatrics Department of Haji Adam Malik

General Hospital.

3.2 Case

MA, 2 month 10 day old, male, weight 4,3 kg, height 55 cm, was admitted to Haji

Adam Malik Hospital at the Infection Unit Pediatric Department on April 09st 2012 with main

complaint seizure. It started one weeks ago starting from, seizure three times a day, with

duration less than 5 minute. Seizure generalized, with eyes rolling up, jerking extremities,

and patient alert after seizure over. Patient experienced fever since one week ago. Fever in

high temprature, and decreased with antipiretic drugs.

History of previous illness :Patient was treated by pediatrician in RSUD Langsa

and diagnosed as Complex Febrile Seizure

History of previous medication : Stesolid syr, Tempra, Transfusi PRC

75cc

Physical Examination

Presence Status : sensorium : Alert , temperature: 37,5C. Anemic (-), dyspnea (-),

cyanotic (-), edema (-), icteric (-).

Body weight (BW): 4,3 kg, body length (BL): 55 cm

Head: Eye: Light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra

(+/+). Ear/ mouth/ nose: normal.

Neck : Lymph node enlargement (-), nuchal rigidity (-)

Thorax : Symmetrical fusiform , retraction (-)HR: 124 bpm, regular, murmur (-)RR : 36 bpm, regular, rales (-)

Abdominal : Soepel, peristaltic (+) N, liver and spleen not palpable

Inguinal : Multiple lymph node enlargement (-)

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Extremities : Pulse =124 bpm, regular, adequate pressure/volume. Warm acral, CRT <

3 seconds. Baggy pants (-), hypotrophy muscle (-).

Physiologic Reflex : APR/KPR (+/+)

Pathologic Reflex : (-)

Meningeal Reflex : (-)

Genitalia : Male, within normal limit

Laboratorium:

Test (10-4-2012) Results Normal ValueComplete Blood Count

Hemoglobin (Hb) 9.70 g % 10.7 – 17.1 g %Erytrocyte (RBC) 3.45 x 106/mm3 3.75 – 4.95 x106/mm3

Leukocyte (WBC) 9.57 x 103/mm3 6.0 – 17.5 x103/mm3

Hematocrite 29.10 % 38 - 52 %Trombocyte (PLT) 265 x 103/mm3 217 – 497 x103/mm3

MCV 84.30 fL 93 - 115 fLMCH 28.10 pg 29 - 35 pgMCHC 33.30 g % 28 – 34 g %RDW 15.80 % 14,9 – 18,7 %MPV 8.50 fL 7,2 – 10 fLPCT 0.20 %PDW 8.8 fL

Cell Count:

Neutrofil 34.20 % 37 – 80 % Limfosit 47.50 % 20 – 40 %Monosit 15.60 % 2 – 8 %Eosinophil 1.90 % 1 – 6 % Basophil 0.800 % 0 – 1 % Neutrophil absolute 3.27x103/µL 1.9 – 5.4 x103/µL Limfosit absolute 4.55x103/µL 3.7 – 10.7 x103/µL Monosit absolute 1.40x103/µL 0.3 – 0.8 x103/µL Eosinophil absolute 0.28x103/µL 0.20 – 0.50 x103/µL Basophil absolute 0.08x103/µL 0 – 0,1 x103/µL

Differential diagnose : - Complex Febrile Seizure

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- Anemia

Working diagnose : Complex Febrile Seizure

Management : IVFD D5% NaCl 0,225% 6 gtt/minute micro

Tempra Syr 3 x 0,4 cc

Stesolit Syr 2 x 0,5 cth

Investigation planning : Consult to neurology division

Consult to hematology division

EEG

Head CT scan

Follow up:

Follow Up April 10th - 14th 2012

S : Fever (-), convulsion (-)

O: Sensorium : Alert, weight = 4.3 Kg, Temperature = 37 0C

Head : Eye: Light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra

(+/+). Ear/ mouth/nose: normal.





Extremities : Pulse =126 bpm, regular, adequate pressure/volume. Warm acral,

CRT < 3 seconds. Baggy pants (-), hypotrophy muscle (-).




A : dd/- Complex Febrile Seizure

- Anemia

- Observasi convulsi

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P : - IVFD D5% NaCl 0,225% 6 gtt/minute micro

- Tempra Syr 3 x 0,4 cc

- Stesolit Syr 2 x 0,5 cth






Cell Count:


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Test(14-4-2012) Results Normal Value

Analysis of electrolit

Calcium (Ca) 8.9 mg/dL 8.4 – 10.8 mg/dL

Natrium (Na) 137 mEq/L 135 -155 mEq/L

Kalium (K) 4.9 mEq/L 3.6-5.5 mEq/L

Phospor 5.7 mEq/L 5.0 -10.8 mEq/L

Clorida (Cl) 106 mEq/L 96-106 mEq/L

Magnesium (Mg) 1.75 mEq/L 1.4 -1.8 mEq/L



O: Sensorium : Alert, weight = 4.3 Kg, Temperature = 37.70C


(+/+). Ear/ mouth/nose: normal.











- Suspect Anemia




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Cell Count:


Test(18-4-2012) Results Normal Value

Analysis of electrolit

Calcium (Ca) 8.7 mg/dL 8.4 – 10.8 mg/dL

Natrium (Na) 137 mEq/L 135 -155 mEq/L

Kalium (K) 4.9 mEq/L 3.6-5.5 mEq/L

13

Phospor 6.2 mEq/L 5.0 -10.8 mEq/L

Clorida (Cl) 104 mEq/L 96-106 mEq/L

Magnesium (Mg) 1.75 mEq/L 1.4 -1.8 mEq/L





(-/-). Ear/ mouth/nose: normal.











- Anemia





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(-/-). Ear/ mouth/nose: normal.










A : - Complex Febrile Seizure




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Refference

1. Ikatan Dokter Anak Indonesia. Unit Kerja Koordinasi Neurologi. Konsensus

penatalaksanaan kejang demam. Badan Penerbit IDAI 2006.

2. ILAE. Guidelines for epidemiologic studies on epilepsy. Epylepsia 1993; 34: 592-

596.

3. American Academy of Pediatrics. Practice parameter: the neurodiagnostic evaluation

of the child with a first simple febrile seizure. Pediatrics 1996;97:769–75.

4. Hauser WA. The prevalence and incidence of convulsive disorders in children.

Epilepsia 1994;35:S1–6.

5. Knudsen FU. Febrile seizures: treatment and prognosis. Epilepsia 2000;41:2–9.

6. Offringa M, Moyer VA. Evidence based paediatrics: evidence based management of

seizures associated with fever. BMJ 2001;323:1111–4.

7. Madeleine Grace M. Sosa, MD., FPPS, FPNA,FCNSP, MSCE.Febril Seizure,

College of Medicine, Dasmarinas, Cavite Consultant De La Salle Health Science

Institute, 2011.

8. Berg AT, Shinnar S, Darefsky AS, et al. Predictors of recurrent febrile seizures: a

prospective cohort study. Arch Pediatr Adolesc Med 1997;151:371–8.

9. Nelson KB, Ellenberg JH. Prognosis in children with febrile seizures. Pediatrics.

1978;61:720-727.

10. Tonia Jones, Steven J. Jacobsen. Childhood Febrile Seizures: Overview and

Implications.2007.available from www.medsci.org.

11. Rosman NP. Evaluation of the child who convulses with fever. Pediatr Drugs

2003;5:457–61.

12. V Wong, Mhk Ho, Np Rosman, Y Fukuyama. Clinical Guideline on Management of Febrile Convulsion. HK J Paediatr (new series) 2002;7:143-151

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http://www.medsci.org/

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