Case Presentation by Dr. Erin Ge
History of present illness:
A 1 year old male presented to the ED with fever. The previous night, his parents noticed that he felt warm to the touch. He had been acting more tired than usual throughout the previous day, but was otherwise asymptomatic. While in the waiting room, the boy fell to the ground, became unresponsive and began to exhibit jerking motions of his arms and legs. The jerking motions lasted for approximately 3 minutes and then ceased. The child had no history of seizures or any other major medical problems and he was developmentally normal. There was no reported family history of seizures.
Review of Systems:
As stated in the HPI. Remaining ROS negative.
Past Medical History: None.
Past Surgical History: None.
Family History: DM, no history of seizures, no history of childhood or inherited illnesses
Full-term, normal delivery
Birth weight: 6lb15ozs
Complications: neonatal jaundice which resolved with phototherapy, no other complications
Up-to-date. No flu vaccine.
Initial Physical Exam:
General: Well nourished, unarousable male
Vitals: T 39.8 rectal, HR 70, RR 32, BP 97/50, O2 Sat 100%, Wt 10kg
Head: Normocephalic, atraumatic.
Eyes: PERRL, Normal conjunctiva
ENT: TM’s normal. Mild rhinorrhea. MMM. No evidence of tonsilar enlargement, edema or exudate.
Neck: No nuchal rigidity. No cervical LAD.
Respiratory: Clear to auscultation bilaterally. Respirations are nonlabored. Equal chest expansion bilaterally.
CVS: RRR. S1, S2 normal. No murmur.
Abdomen: Soft, nondistended, nontender. No palpable masses. Bowel sounds normoactive.
Skin: Warm to the touch. No rashes.
Musculoskeletal: No obvious deformities. Moving all extremities equally.
Neurologic: Not arousable, localizes physical stimuli, PERRL, normal deep tendon reflexes, normal tone
Repeat Physical Exam after 60 minutes
General: Awake, interactive male
Vitals: T 37.6 rectal, HR 82, O2 Sat 100%
Neurologic: Alert, makes appropriate eye contact, interacting playfully with parents, PERRL, normal deep tendon reflexes, normal tone
CBC: WBC 6.8 Hgb 10.8 Platelets 567
BMP: Na 133 K 144 Chloride 97 CO2 19 Glucose 104 BUN 14 Creatinine .4
Calcium 9.6 Magnesium 2.1 Phosphorus 5.4
Influenza A - Influenza B + RSV –
Blood culture: No growth
1) Which of the following is true about the prognosis of a child with a first time simple febrile seizure?
a) Antiepileptic medications should be used to prevent further seizures
b) Likelihood of developing epilepsy is doubled
c) Over 75% of children under 12 months at time of first seizure will have another febrile seizure
d) Acetaminophen and ibuprofen use is effective in preventing recurrent febrile seizure episodes
2) Which of the following patients who presented with fever and seizure should an LP be considered for?
a) 1 year old male who was diagnosed with acute otitis media one week ago and currently taking amoxicillin
b) 4 year old female who has been complaining of headache and asks for the lights to be turned off in the exam room
c) 10 month old male who has not been seen by a physician since being discharged after birth
d) b and c
e) all of the above
3) Treatment of febrile status epilepticus includes which of the following?
a) Phenobarbital IV 15-18mg/kg loading dose, 5mg/kg repeat dose
b) Phenytoin IM 15-18mg/kg loading dose
C) All of the above
d) None of the above. Febrile seizures do not progress to status
Discussion & Answers
1) The answer is b. Patients who have had febrile seizures have approximately a 2% incidence of epilepsy as adults which is twice the general population incidence of about 1%.
Answer a is incorrect. Although antiepileptic medications have actually been shown to decrease reoccurrence of febrile seizure activity in patients with a history of febrile seizures, they are typically not initiated due to the risk of medication effects outweighing the benefits of preventing a typically self limited seizure. In a subset of patients who have increased risk for complications from seizures, however, these may be considered.
Answer c is incorrect. Having one simple febrile seizure does increase the risk of having another and increases it even more so the younger the patient is at time of initial seizure. The risk, however is around 50% for patients younger than 12 months at first seizure and about 33% for patients older than 12 months.
Answer d is also incorrect. Although use of ibuprofen and acetaminophen is commonly used to help break a febrile seizure, these medications have not been shown to have any effect on preventing seizure activity.
2) The answer is e. All of the described patients should raise some concern for a CNS infection. The patient described in a is currently on antibiotics which can mask the presenting symptoms of a meningeal infection. While clearly not an indication for an LP, extra consideration should be given to possible LP in this patient. The patient described in b has other concerning neurological symptoms, headache and photophobia, which may be indicative of meningeal irritation. The patient in c has not received proper vaccinations and patients without known immunization against Haemophilus influenzae b and Streptococcus pneumoniae are at increased risk for meningitis. Once again, none of these are indications for LP, but they should increase your suspicion for an occult infection.
3) The answer is a. Status from febrile seizure should be treated in the same manner as status from any etiology. First line treatments are benzodiazepines and if those fail to break the seizure phenobarbital can be given as a second line treatment.
Answer b is incorrect. Although phenytoin is a second line treatment for status, it should not be given IM due to its poor absorption via this route and its tendency to cause hemorrhagic necrosis at the injection site.
Answer c is incorrect because answer b is incorrect as stated above.
Answer d is incorrect. Although rare, febrile seizures can progress to status epilecticus.
This patient presented with a brief, generalized seizure associated with fever which was followed by a short postictal state and then complete neurologic recovery. This presentation in a previously neurologically normal patient between the ages of 6 months and 6 years is characteristic of a simple febrile seizure. Febrile seizures are classified as “simple” when the seizure activity is generalized, lasts for less than 15 minutes and only occurs once within a 24 hour period. Seizures are considered complex if they do not follow any one of the classifications of simple febrile seizures (ie seizures are focal, last longer than 15 minutes or occur more than once in a 24 hour period). Febrile seizures typically will occur during the first day of illness and are often associated with higher elevations in temperature and when temperatures increase or decrease rapidly.
Febrile seizures are common and may occur in up to 5% of children. They are typically benign in nature. A small number of patients who present with complex febrile seizures do have underlying pathology, so clinicians should be more wary with a complex presentation. In general, however, patients do not have any long term sequelae due to these seizures. As previously discussed in the question answers, there is a greater risk of epilepsy in adulthood for patients who had febrile seizures, but it is still only seen in about 2% of this population. Also as previously discussed, febrile seizures do often recur and while administration of antiepileptics can decrease recurrences, the risks associated with use of these medications is viewed as greater than the risk posed by the seizures in most children. Factors shown to correlate with increased recurrence risk include: younger age at first seizure, first degree relative with history of febrile seizures, lower degree of fever in the ED and brief duration between onset of fever and seizure activity.
The treatment of febrile seizures is similar to that of any seizing patient. The initial concern is to stop the seizure activity. While febrile seizures usually are self limited in nature, they can also persist and rarely progress to status epilepticus. First line treatment is administration of benzodiazepines, typically lorazepam or diazepam. Preferred route is IV, but as IV access can be difficult in a seizing patient both lorazepam and diazepam are available and effective via rectal administration. Midazolam has also been shown to be effective when administered intramuscularly. If repeated doses of benzodiazapines do not break the seizure, the second line agents are phenytoin and phenobarbital. As previously discussed, phenytoin should not be used intramuscularly due it poor absorption and tissue necrosis. It should also not be administered at a rate faster than 1mg/kg/min as it is prepared with propylene glycol which can cause cardiac complications when infused at a higher rate. Use of Fosphenytoin circumvents both these issues, but is significantly more costly. Simultaneous reduction of fever is appropriate for patients. Rectal acetaminophen and ibuprofen can be administered.
Patients diagnosed with simple febrile seizures typically do not require admission or further follow up as long as they have shown full neurologic recovery and the source of the fever does not require more intensive treatment.
There should be an appropriate investigation for etiologies of fever in children that would be treated i.e. pneumonia, otitis media, urinary tract infection…etc.
The diagnosis of febrile seizure should only be given when other causes for seizure have been ruled out either from the patient’s clinical presentation or further lab and/or imaging studies. Patients who raise any suspicion for meningitis should receive steroids, antibiotic therapy, antivirals, and further work up including a lumbar puncture. Any patient with signs of neurologic impairment prior to seizure activity or incomplete neurological recovery after seizure requires further workup.
The patient presented in the case was brought back to the pod actively seizing since at that time there were no open spots in resuscitation. He was administered rectal acetaminophen and was about to be given a dose of lorazepam when his seizure activity ceased. As stated in the discussion, his history and clinical presentation did not seem to indicate an underlying pathology for his seizures other than the fever, so we chose to perform basic lab studies and observe him. His labs results were within normal limits with the exception of testing positive for flu, as shown, and his neurological state upon re-evaluation was completely normal. Our final impression was that this child had a simple febrile seizure secondary to fever caused by the influenza virus. Our plan had been to discharge him home, but upon discussion we the family over concerns that the child may seize again, we did decide to admit him to observation overnight. He was started on a course of oseltamavir and administered ibuprofen and acetaminophen for fever control. Overnight, he did not have any further seizure activity. He was discharged home the next morning and was given instructions to follow up in the neurology clinic.