Intern Report 6.11

Case Presentation by Dr. Erin Ge

Chief complaint:

Seizure

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.

History:

Past Medical History:  None.

Past Surgical History:  None.

Medications:  None.

Allergies:  None.

Family History:  DM, no history of seizures, no history of childhood or inherited illnesses

Birth History:

Full-term, normal delivery

Birth weight: 6lb15ozs

Complications: neonatal jaundice which resolved with phototherapy, no other complications

Immunizations:

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

Labs:

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

Questions:

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

Question 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.

 

Febrile Seizures

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.

What Happened

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.

6 Responses

  1. 1) I’m not sure any of these answers are correct. But it is true that children who have a febrile seizure under the age of 1 are at higher risk for recurrent febrile seizures, but 75%?? Only 30% of kids overall who have seizures will have another one in their lifetime.
    2)
    3) you can give fosphenytoin IM for status, but not phenytoin. Phenobarb is not a first line agent.

  2. It would have been nice to know the intervention between the first physical exam and the second one. Also I was under the impression that “all of the above” answers were not allowed.

    1. Acetaminophen and ibuprofen use is effective in preventing recurrent febrile seizure episodes

    2.

    3. Phenobarbital IV 15-18mg/kg loading dose, 5mg/kg repeat dose — I know they like phenobarbital a children’s but I can’t find any literature stating it’s superior in peds to benzos. This question should have been changed before being submitted.

  3. 1
    2
    3 none of the above? Phenobarbital is a possible choice, although not usually first-line, but the 15 minute repeat dose is the same as initial (15-20mg/kg). B: Phenytoin is given IV, rather than IM. D: Febrile seizures do progress to status, although that isn’t the norm.

  4. 1. although several sources state that neither Tylenol or ibuprofen will prevent recurrent febrile seizures. But other choices do not appear to be correct either.
    2.
    3. (although very unlikely for febrile seizure to progress to status)

  5. 1) the risk is higher when less than 15 mo but not sure how high. No studies prove that tyl/motrin reduce risk of febrile seizures.

    2)

    3)although febrile seizures can last up to 1 hr. Rectal diazapam used

  6. Discussion between Drs. Scott & Ge behind the scenes:

    Hi Tim,

    The resources I used when coming up with these questions all seemed to state that the overall risk for developing epilepsy in any patient that had a febrile seizure was 2% and when compared to the risk in the general population which is 1%, the risk is doubled. It looks like you found resources that listed anywhere from 2-10% for risk, so I’m not sure if maybe those higher percentages were for subpopulations within the group with febrile seizures that had certain risk factors and the overall risk is 2 %?

    If, however, there is newer data suggesting higher percentages for epilepsy in general for children who had febrile seizures, then perhaps I should have rephrased the answer choice to be “LIkelihood of developming epilepsy is at least doubled”

    The rest of the things you wrote in the email were exactly what I was trying to get at in the question.

    Erin

    On Mon, Feb 18, 2013 at 6:03 PM, Jones, Kerin wrote:
    I’ll Let Erin & Erik field these questions. I’m just the secretary on cases I don’t edit.
    Kerin

    From: Scott, Timothy
    Sent: Monday, February 18, 2013 10:03 AM
    To: Ge, Erin
    Cc: Jones, Kerin
    Subject: RE: Web Case Posted

    Question 1, there is very clearly no correct answer

    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

    -absolutely all current literature states risks outweigh any potential benefits (National Institute of Neurological Disorders and Stroke [NINDS] agrees)

    b) Likelihood of developing epilepsy is doubled

    -UpToDate, NINDS, Epilepsy website, NYU febrile seizure site, 2 articles I found: 2-10% risk depending on how many risk factors

    c) Over 75% of children under 12 months at time of first seizure will have another febrile seizure

    -The absolute highest number I found in literature was 50% and even this seems high based on what most other literature states (This was also on UpToDate and the national epilepsy website – just to be clear this is with differentiation between the standard children under 3 and this specific question which states children under 1)

    d) Acetaminophen and ibuprofen use is effective in preventing recurrent febrile seizure episodes

    -Good for managing acute episodes but no benefit shown in preventing recurrent febrile seizures. Looks pretty unanimous amongst the literature I read on a simple pubmed search. (Also same facts on UpToDate, Medscape – not as much info on NINDS but doesnt mention anything about using these)

    They are all false. There is no correct answer.

    Tim

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