CASE REPORT

Symptomatic
Generalized Epilepsy in
Children
Presented by:
Rizky Indah Soraya (110100151)
Supervised by:
dr. Hj. Tiangsa Br. Sembiring, M.Ked (Ped), Sp.A
(K)
Program Pendidikan Profesi Dokter
RSUP Haji Adam Malik Medan
2015

INTRODUCTION
Definition
Brain disorder characterized by an
enduring predisposition to generate
epileptic seizures and by the
neurobiologic, cognitive,
psychological, and social
consequences of this condition
Incidence
About 4-6 per 1000 children in the
world
40-50% of 70000 new epilepsy cases

Diagnosis
History taking
Physical examination
Investigation (blood test, urine, CSF,
EEG and Imaging)
Management
Anticonvulsant
Surgery

Prognosis
Depends on type of epilepsy
causes, when treatment is started,
and adherence to medication

The aim of this paper is to report

a case about Epilepsy in a 2
years old girl

Case

Name
: KA
Age
: 2 years 4 months
Sex
: Girl
Medical Record No.: 63.51.92
Address
: Jl. Karya Yasa No. 72
Date of Admission : April, 12nd 2015

History of disease
Main complain :

Seizures

Seizures occurs since today with the

frequency 2 times a day, last seizures
experienced one hour before admission
to the hospital, seizures occur all over
the body with duration of 10 minutes
History of seizures: (+) since the age of
5 months with the frequency 5 times
daily with generalized seizure, seizures
occur in the whole body with jerking
movements of the arms and legs
repeatedly and accompanied by stiffness

 History of fever was found since one week

with a temperature of fluctuation, Fever is
not accompanied by shiver
History of trauma (-)
History of Birth: Second child, spontaneous
birth, not cried immediately as soon as
born, enough months at birth, birth weight
was 2.4 kg, history of cyanosis (+)
History of previous illness
Epilepsy in neurology unit of Adam Maliks
General Hospital and regularly controls

History of previous medication

Valproic acid syrup 2 x 1.6 cc (22 mg / kg
/ day) and paracetamol
Feeding History
From birth to 5 months : Breast Milk
From 5 months until now (2 years 4
months) : Formula milk + Rice Porridge
History of Growth and Development
Lying to the left/right : 8 months
Crawling, sitting, standing, walking: Not
yet
History of Immunization was

Physical Examination
Generalized status
Body weight: 7,4 kg, Body length: 72 cm,
Head circumference: 40 cm, Arm
circumference: 14,4 cm
BW/BL : -2 SD < z-score < -1 SD
(normoweight)
BW/age : z-score < -3 SD (
BL/age : z-score < -3 SD
HC/age : z-score < -2 SD
AC/age: -1 SD < z-score < 0 SD
Presens status
Sensorium : Alert

Heart Rate: 128 x/i

Respiratory Rate: 40 x/i
Body Temperature: 40,1oC
Anemic (-), Icteric (-), Cyanosis (-). Edema
(-), Dyspnea (+)

Localized status
Head : Face: No edema. Eye : Light reflex
(+/+), Isocoric pupil (+), inferior palpebra
conjunctiva pale (-), no icteric sclera and no
edema in inferior and superior palpebra
Ear / Nose / Mouth : within normal limit
Neck : No lymph node enlargement

 Chest : Symmetrical fusiformis, no

retraction and muscle wasting; HR: 128
bpm, regular, no murmur; RR: 40 tpm,
reguler, coarse crackles (+/+)
Abdomen : Soepel, Liver and spleen
were not palpable, No shifting dullness,
Bowel peristalsis was normal
Extremities : Pulse was 128 bpm,
regular, adequate pressure and volume,
warm, CRT < 3, BP: 100/60 mmHg
Urogenital : Female, Anus (+)

Motorical Examination : within normal

limit
Right/left muscle strength : 55555 55555
55555 55555
Physiological reflexes :
Right Left
KPR/APR
(+/+) (+/+)
Biceps/Triceps (+/+) (+/+)
Pathological reflexes : Babinsky(-/-),
Chaddock(-/-), Gordon (-/-), Oppenheim (-/-)
Meningeals sign : Nuchal rigidity (-),
Kernigs sign (-), Brudzinski I/II (-), Laseque
sign (-)

Electroencephalography Test
Result: July 8th, 2013 in ST.
Elisabeth Hospital
EEG can be in accordance with the
general convulsion disease with
multifocal irritative focus (+)

 Differential Diagnosis:
DD/Generalized symptomatic epilepsy
Generalized idiopathic epilepsy
+
Bronchopneumonia + Global
Development Delayed + Cerebral Palsy +
Gastroenteritis without Dehydration
Working Diagnosis:
Generalized symptomatic epilepsy +
Bronchopneumonia + Global
Development Delayed + Cerebral
Palsy + Gastroenteritis without
Dehydration

Management:
O2 L/i nasal canule
IVFD NaCl 0,9% 10 gtt/i micro
Injection Paracetamol 100 mg / 8 hour /
IV
Injection Ceftriaxone 400 mg / 12 hour /
IV Skin test
Zinc 1 x 20 mg
Valproic acid 2 x 1,8 cc (25 mg /
kgBW / day)
Diet : chicken porridge in diluted 740
kcal (100 kcal/ kgBW/ day) with 15
gram = 125 cc/6 hour

Follow up: April 13rd 14th, 2015

S
O

Fever (-), Seizure (-)

Sens: GCS 15 (E4 V5 M6), Temp: 37oC, Anemic (-).
Icteric (-). Edema (-), Cyanosis (-), Urine colour :
yellowish
Head : Light reflex (+)/(+), Conjunctiva palpebra
inferior anemic(-), Isochoric pupil
Neck : Jugular vein pressure R-2 cmH2O, Lymph node
enlargement (-)
Thorax : Symmetrical fusiformis, no retraction and
muscle wasting
HR: 138 bpm, regular, no murmur
RR: 40 tpm, reguler, coarse crackles (+/+)
Abdomen : Soepel, liver and spleen were unpalpable,
shifting dullness (-), bowel peristalsis (+) normal
Extremities : Pulse 138 x/i, regular, adequate p/v,

Follow up: April 15th, 2015

S
O

Fever (-), Seizure (+)

Sens: GCS 15 (E4 V5 M6), Temp: 37,5oC, Anemic
(-). Icteric (-). Edema (-), Cyanosis (-), Dyspnoe (+)
Head : Light reflex (+)/(+), Conjunctiva palpebra
inferior anemic (-), Isochoric pupil
Neck : Jugular vein pressure R-2 cmH2O, Lymph node
enlargement (-)
Thorax : Symmetrical fusiformis, no retraction and
muscle wasting
HR: 165 bpm, regular, no murmur
RR: 40 tpm, reguler, coarse crackles (+/+)
Abdomen : Soepel, liver and spleen were unpalpable,
shifting dullness (-), bowel peristalsis (+) normal
Extremities : Pulse 165 x/i, regular, adequate p/v,
warm, CRT < 3, Pitting edema (-) pretibia, BP:

A Generalized symptomatic epilepsy +

Bronchopneumonia + Global Development
Delayed + Cerebral Palsy + Gastroenteritis
without Dehydration
P O2 nasal canule l/menit
IVFD NaCl 0,9% 10 gtt/i micro
Injection Paracetamol 100 mg / 8 hour / IV
Injection Ceftriaxone 400 mg / 12 hour / IV
Valproic acid syrup 2 x 1,8 cc (25 mg /
kgBB / hari)
Zinc 1 x 20 mg
Nebule Ventolin respule + 2,5 cc NaCl
0,9% / 8 jam

AGeneralized symptomatic epilepsy +

Bronchopneumonia + Global Development Delayed +
Cerebral Palsy + Gastroenteritis without Dehydration
P O2 nasal canule l/menit
IVFD NaCl 0,9% 10 gtt/i micro
Injection Paracetamol 100 mg / 8 hour / IV
Injection Ceftriaxone 400 mg / 12 hour / IV
Valproic acid syrup 2 x 2 cc (30 mg / kgBB /
hari)
Zinc 1 x 20 mg
Nebule ventolin respule + 2,5 cc NaCl 0,9% / 8 jam
Diet : chicken porridge in diluted 740 kcal (100 kcal/
kgBW/ day) with 15 gram protein 125 cc/6 hour 125
cc/6 hour
Chest physiotherapy
Planning: Liver function test

Follow up: April 16th 23rd , 2015

S
O

Fever (-), Seizure (-)

Sens: GCS 15 (E4 V5 M6), Temp: 37,5oC, Anemic
(-). Icteric (-). Edema (-), Cyanosis (-), Urine colour :
yellowish
Head :
Light reflex (+)/(+), Conjunctiva palpebra
inferior anemic (-), Isochoric pupil
Neck : Jugular vein pressure R-2 cmH2O, Lymph node
enlargement (-)
Thorax : Symmetrical fusiformis, no retraction and
muscle wasting
HR: 165 bpm, regular, no murmur
RR: 26 tpm, reguler, coarse crackles (+/+)
Abdomen : Soepel, liver and spleen were unpalpable,
shifting dullness (-), bowel peristalsis (+) normal
Extremities : Pulse 165 x/i, regular, adequate p/v,

A Generalized symptomatic epilepsy +

Bronchopneumonia + Global Development
Delayed + Cerebral Palsy + Gastroenteritis without
Dehydration
P IVFD NaCl 0,9% 10 gtt/i micro
Injection Paracetamol 100 mg / 8 hour / IV
Injection Ceftriaxone 400 mg / 12 hour / IV
Valproic acid syrup 2 x 2 cc (2 mg / kgBB /
hari)
Zinc 1 x 20 mg
Nebule Ventolin respule + 2,5 cc NaCl 0,9% / 8
jam
Diet : chicken porridge in diluted 740 kcal (100
kcal/ kgBW/ day) with 15 gram = 125 cc/NGT/6
hour
Planning: Hipoalbuminemia correction

DISCUSSION
Case

Theory

The age of patients

first seizure are at
the age of 5 months
and patient does not
have a history of
preterm birth

Epilepsy is seizures
less frequently
found in premature
babies because
their nervous
system has not
developed but more
common in infants
age.
Epileptic seizure is
relatively rare in the
first months of age,
and more often

Case

Theory

Seizure types that

exist in these
patients is
generalized tonicclonic seizures
because seizures
occured in the
whole body with
jerking
movements of the
arms and legs
repeatedly and
accompanied by

The types of
seizures seen in
SGE are in the
following: (1)
Myoclonic; (2)
Clonic; (3) Tonic;
(4) Atonic; (5)
Generalized tonicclonic seizures; (6)
Atypical absence

Case

Theory

EEG test result

There are
high-amplitude
and slow spike
wave in the
posterior right
temporal and
left frontal
multifocal
irritative focus
(+)

The typical
EEG of SGE
includes slow
(<2,5 Hz) spike
and wave
complexes and
multifocal
spikes

Case
Patient history at
birth were not
immediately cry as
soon as born and
cyanosis
Patients diagnose
with cerebral palsy
and global
developmental
delayed

Theory
Asphyxia can
cause lesions in
the hippocampus
and the lesions
can become the
epileptogenic
focus
Neurological
disorders can be
caused by nonprogressive
neurological
disorders such as

DISCUSSION
Case
Patient history at
birth was in low
birth weight (2,4
kg)

Theory
Babies born with
low birth weight
will soon be able
to experience
hypoxia ischemia,
and or
intraventricular
hemorrhage, with
clinical
manifestations
such as seizures
and can progress

Case
Valproic acid 2 x
1,8 cc (25 mg /
kgBW / day)

Theory
For symptomatic
generalized
seizures among
children,
valproate has
been the
treatment of
choice (first-line
monotherapy)
However,
valproate stands
out as a broadspectrum

Cases

Theory

The patient had a

history of using
valproic acid as much
as 22 mg/kgBW/day
in divided doses
At the treatment of
seizures when
admitted to the
hospital, valproic acid
dose is increased to
25 mg/kgBW/ day in
divided doses
On April 15th, 2015,
valproic acid dose
was increased to 30
mg/kgBW/day in
divided doses

As adjunctive
therapy, valproic
acid may be added
to the patients
regimen at 20
mg/kgBW/day
(initial therapy)
and may increase
by 5-10
mg/kgBW/week to
achieve optimal
clinical response.
Ordinarily, optimal
clinical response is
achieved at daily

RESULT
It has been reported, a girl with the
main complain of seizure and was
diagnosed with generalized
symptomatic epilepsy. The diagnose
was established based on history
taking, clinical manifestation,
laboratory finding, and
electroencephalography. The patient
got antiepileptic drug and still need
to be followed up.