August 23, 2013

Preceptor: Dr. G. Taquiqui

Presented By: Paul Aries Lingan
Aple Llopis
Leo Marie Tumaliuan

Informant: Grandmother (70 %) reliability

General data:
T.C., 8 mos. old, female, Filipino, Roman Catholic, born on December 12, 2012, currently residing at
Captan, Tuguegarao City was admitted for the first time at CVMC on August 17, 2013.

Chief complaint: Seizure

History of present illness

Patient was apparently well until 10 days PTA, while the family was on a trip to Ilagan, the
patient experienced sudden fever, of undocumented reading, accompanied by the appearance of
macular rashes on her trunk and back. No consultation was done. Tepid sponge bath was given. The
symptoms were relieved the following day along with the disappearance of the rashes.
7 days PTA, the patient again experienced sudden onset of fever accompanied with runny nose,
of clear watery discharge, and sneezing. No consultation was done. Disudrin drops were given.
1 day PTA, the patient still with runny nose. After a few hours, while on the market with her
mother, the patient experienced sudden seizure characterized by the informant as generalized, tonic-
clonic, with upward rolling of the eyes, and lasted for 15 minutes. The patient was immediately rushed
to People’s General Hospital. The patient was noted to have a high grade fever, 39 C. She was treated
and given paracetamol for fever, and other medications unrecalled by the informant. Was referred to
Cagayan Valley Medical Center for further evaluation and management, hence was admitted.

Perinatal history:
The patient was born to an 18 y/o G1 (1-0-0-1). The mother had prenatal check up 4 times during the
entire pregnancy and had taken multivitamins and ferrous sulfate. No other drugs were taken and no
illness noted during the course of pregnancy.

Birth history:
The patient was delivered via NSD in a lying-in clinic assisted by a midwife, full term and of cephalic
presentation. The mother was noted to be febrile at the time of delivery. No other conditions were
noted.

Neonatal history:
The patient was born w/ good suck and good cry. No jaundice, no cyanosis and no sepsis were noted.
The patient was put on heplock for 1 week, of which, according to the informant, was warranted
because of the mother’s fever.

Nutritional history
The patient was breastfed from birth up to 2 months, and then was introduced to Bonna. And then on
her 6th month, she was shifted to Bonamil. Frequency and interval of feeding was dependent on baby’s
need.
Growth and development:

Mean Gross Fine Receptive Expressive Personal Social Cognitive

Age Motor Motor Language Language Development Development Development
(months)
3 Good Hands Vocalizes & Opens mouth Smiles Reach for
head open, coos expectantly responsively dangling ring
control grasps
4 Reaches Turns to
for noise &
objects voice
5 Roll Transfer
over objects
6 Sits w/ Holds Monosyllabic Imitates Respond
support bottle babbles action playfully to
mirror
7 Respond
to name
8 Sits Says dada,
w/o mama
support nonspecifically

Immunizations:

The patient received:

1 dose BCG
3 doses DPT
3 doses OPV
3 doses HepaB
1 dose Hib

Past Medical History:

The patient had a history of AGE when she was 5 months old.

Family history:
Paternal Maternal
CA - -
HPN - -
DM - -
Heart - -
Disease

Personal and social history:

The patient is the first child. The father is a farmer and the mother is a BBQ vendor. They live in a house
made of wood. Their main source of water comes from the NAWASA, but according to the informant,
they utilize Wilkins distilled water for the baby.
REVIEW OF SYSTEM:
Integumentary system:(-) pruritus , (-) bruises, (+) rashes
Nervous system: (-) headache, (-) dizziness, (-) loss of consciousness (+) seizure
Cardiorespiratory system: (-) cough, (+) colds (-) difficulty of breathing
Gastrointestinal system: (-) diarrhea, (-) constipation, (-) melena, (-) anorexia
Genitourinary system :(-) hematuria, (-) oliguria
Musculoskeletal system: (-)myalgia,(-) arthralgia
Hematologic system: no bleeding tendencies
Endocrine- metabolic system: (-) weight loss, (+) fever (-) easy fatigability, (-) anorexia

PHYSICAL EXAM:
General survey: The patient is awake and not in cardio respiratory distress.
Vital signs:
HR- 157 bpm- tachycardia
RR-50 cpm- normal
Temp.-37.7 ºC- febrile
Weight: 8 kg
Length: 46 cm
Head circumference: 46 cm
Chest Circumference: 48 cm
Abdominal circumference: 49 cm

Skin: no pallor, no jaundice, no rashes, warm to touch, good skin turgor

HEENT: normocephalic, PERRLA, pink palpebral conjunctiva, no nasoaural discharge,
no neck vein engorgement, no cervical lymphadenopathy
Chest and lungs: symmetrical chest expansion, (-) retractions, (-) wheezes, (-) crackles
Heart: adynamic precordium, PMI at 4th ICS LMCL, no murmur, rapid rate regular rhythm
Abdomen: globular, normoactive bowel sounds, soft, nontender, no masses, (-) organomegaly
Genitalia: grossly female, (-) urethral opening discharge
Extremities: no edema, no cyanosis, full and equal pulses, capillary refill < 2 seconds

Neurologic Exam:
MSE: The patient is awake.

Cerebellar: (-) tremor

Cranial Nerves:
CN I: not assessed
CN II: pupils equally round, reactive to light and accommodation
CN III, IV, VI: follows object without deviation
CN V: (+) corneal reflex
CN VII: no facial asymmetry
CN VIII: able to hear
CN IX, X: not assessed
CN XI: not assessed
CN XII: no tongue deviation
Motor: able to move extremities in different directions (grade: 5/5)
Sensory: withdraws to pain
meningeal signs: (-) kernig’s sign (-) brudzinski sign (-) nuchal rigidity
Reflexes: (+) Babinski reflex, (-)Rooting reflex, (-) Tonick neck reflex, (+) Palmar grasp

IMPRESSION:
Febrile Seizure secondary to URTI

SALIENT FEATURES:
 Generalized clonic-tonic seizure lasting < 15 minutes
 High grade fever
 (+) Hx of URTI
 (-) Neurological deficits
 (-) Meningeal signs

DIFFERENTIAL DIAGNOSIS

1. Meningitis – a clinical syndrome characterized by inflammation of the meninges.

Rule In Rule Out

• (+) Fever • (-) meningeal signs

• (+) Seizures • (-) neurological deficit
• (-) altered level of consciousness
• (-) signs of increased ICP

2. Epilepsy – a brain disorder characterized by an enduring predisposition to generate epileptic

seizures and by the neurobiologic, cognitive, psychological, and social consequences of this
condition.
Rule In Rule Out

Seizure >/= 2 episodes of unprovoked seizures

(+) fever

3. Space-occupying Lesions of the Brain

Rule In Rule Out

Seizure (-) Increased ICP

(-) Altered mental status
(-) neurologic deficits
 DISCUSSION

Febrile seizures

Febrile seizures are convulsions in infants and children triggered by a fever in the absence of CNS
infection. Febrile seizures affect 4-5% of children aged 6 months to 6 years. These occur in association
with a high fever, typically above 38.5°C (101.3°F), although some believe the rate of change in body
temperature is more provoking than the absolute temperature in febrile seizures. There is often a
positive family history of febrile seizures in other family members. A second episode occurs in 33% of
children, and only 50% of those have a third episode. Few children, approximately 3-6%, with febrile
seizures develop afebrile seizures or epilepsy.
Three Groups:
Simple febrile seizure

 The setting is fever in a child aged 6 months to 5 years.

 The single seizure is generalized and lasts less than 15 minutes.
 The child is otherwise neurologically healthy and without neurological abnormality by examination or by
developmental history.
 Fever (and seizure) is not caused by meningitis, encephalitis, or other illness affecting the brain.
Complex febrile seizure

 Age, neurological status before the illness, and fever are the same as for simple febrile seizure.
 This seizure is either focal or prolonged (ie, >15 min), or multiple seizures occur in close succession.
Symptomatic febrile seizure

 Age and fever are the same as for simple febrile seizure.
 The child has a preexisting neurological abnormality or acute illness.

Pathophysiology

Low Seizure Threshold

I
Infection (URTI)
I
Leukocytosis
I
Production of interleukin-1B
I
Increased Neuronal Excitability
I
Seizures

EPIDEMIOLOGY
Febrile seizures are age dependent and are rare before 6 months and after 5 years of age. The peak age
of onset is approximately 14-18 mons of age, and the incidence approaches 3-4% of young children.
They most commonly occur in children between the ages of 6 months and 5 years and are twice as
common in boys as in girls.
 ETIOLOGY
The direct cause of a febrile seizure is not known; however, it is normally precipitated by a recent upper
respiratory infection or gastroenteritis. A febrile seizure is the effect of a sudden rise in temperature
(>=39°C) rather than a fever that has been present for a prolonged length of time.

Infectious agents causing bacteremia: 3mons – 3y/o

 Streptococcus Pneumoniae – 90%
 Neisseria meningitides and Salmonella – remainder
 Haemophilus influenza type b

A strong family history of febrile convulsion in siblings and parents suggest a genetic predisposition
(chromosome 19p and 8q13-21). An autosomal dominant inheritance pattern is demonstrated in some
families. Children with febrile convulsions are more likely to suffer from afebrile epileptic attacks in the
future if they have a complex febrile seizure, a family history of afebrile convulsions in first-degree
relatives (a parent or sibling), or a preconvulsion history of abnormal neurological sign or developmental
delay.

CLINICAL MANIFESTATION
The convulsion is associated with a rapidly rising temperature and usually develops when the core
temperature reaches 39 C or greater. The seizure is typically generalized, tonic-clonic of a few seconds
to 10-min duration, followed by a post ictal period of drowsiness. Febrile seizure lasting of 15min
suggests an organic cause such as an infectious or toxic process and requires thorough investigation. If
any doubt exists about the possibility of meningitis, a lumbar puncture with examination of the CSF
indicated.
Simple febrile seizures do not cause permanent brain injury; do not tend to recur frequently (children
tend to outgrow them); and do not make the development of adult epilepsy significantly more likely
(about 3–5%), compared with the general public (1%).

Other manifestations:
 stiff body
 twitching or jerking of the extremities or face
 rolled-back eyes
 unconsciousness
 inability to talk
 problems breathing
 involuntary urination or defecation
 vomiting
 confusion, sleepiness, or irritability after the seizure

DIAGNOSIS
Laboratory Tests:

 No specific studies are indicated for a simple febrile seizure.

 Physicians should focus on diagnosing the cause of fever.
 Other laboratory tests may be indicated by the nature of the underlying febrile illness. For example, a
child with severe diarrhea may benefit from blood studies for electrolytes.
 Imaging

Neither computed tomography (CT) nor magnetic resonance imaging (MRI) is indicated in patients with
simple febrile seizures.

Other Tests

EEG is not indicated in children with simple febrile seizures. Published studies demonstrate that the vast
majority of these children have a normal EEG. In addition, some of those with an abnormal EEG have
remained free of seizures for the duration of their follow-up. On the other hand, some of the children
with a normal initial EEG have experienced 1 or more afebrile seizures subsequent to the EEG. Finally, no
evidence indicates that beginning anticonvulsant therapy for a child with simple febrile seizures and an
abnormal EEG will alter the child's eventual outcome.

Procedures

 Strongly consider lumbar puncture in children younger than 12 months, because the signs and
symptoms of bacterial meningitis may be minimal or absent in this age group.
 Lumbar puncture should be considered in children aged 12-18 months, because clinical signs and
symptoms of bacterial meningitis may be subtle in this age group.
 In children older than 18 months, the decision to perform lumbar puncture rests on the clinical suspicion
of meningitis.

TREATMENT
On the basis of risk/benefit analysis, neither long-term nor intermittent anticonvulsant therapy is
indicated for children who have experienced 1 or more simple febrile seizures.

1. Continuous therapy with phenobarbital decreases the occurrence of subsequent febrile seizures.
oBoth therapies confer significant risks and potential adverse effects, whereas additional simple
febrile seizures have no proven risk.
o These medications are not recommended, since the potential benefits do not outweigh the
potential risks.
2. No evidence suggests that any therapy administered after a first simple seizure will reduce the risk of
a subsequent afebrile seizure or the risk of recurrent afebrile seizures (ie, epilepsy).
3. Oral diazepam can reduce the risk of subsequent febrile seizures. Because it is intermittent, this
therapy probably has the fewest adverse effects. If preventing subsequent febrile seizures is essential,
this would be the treatment of choice.[3]
4. Although it does not prevent simple febrile seizures, antipyretic therapy is desirable for other reasons.

Anticonvulsants:
Phenobarbital
 Neonates (<28 days): 3-5 mg/kg/day IV/PO in 1-2 divided doses

 Infants: 5-6 mg/kg/day IV/PO in 1-2 divided doses

  1-5 years: 6-8 mg/kg/day IV/PO in 1-2 divided doses

 6-12 years: 4-6 mg/kg/day IV/PO in 1-2 divided doses

 >12 years: 1-3 mg/kg/day IV/PO in 1-2 divided doses, OR 50-100 mg BID/TID

Antipyretics:
a) Acetaminophen (Tylenol)
Dosage: 10-15 mg/kg PO/PR q4-6h; not to
exceed 5 doses/d or 2.6 g/d
b) Ibuprofen (Advil, Motrin)
Dosage: 5-10 mg/kg/dose PO q6-8h prn; not
to exceed 40 mg/kg/d or 2.4 g/d

Prognosis
Prognosis for normal neurologic function is excellent.

 About one third of children who experience a single simple febrile seizure will have another.
 The lifetime rate of epilepsy in these children is slightly above that of the general population.[4]

Patient Education
 Inform parents that these dramatic events do not indicate future neurologic dysfunction or disease.