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%).