Case 19

Question 1

What is on the differential diagnosis for a febrile seizure?

Answer 1

CNS infection (meningitis/encephalitis), Idiopathic epilepsy, Ingestion/poisoning, Head trauma

Question 2

What are the findings from testing with a febrile seizure?

Answer 2

CBC - Normal. CSF - Normal without organisms.

Question 3

What are some causes of unresponsiveness in a child?

Answer 3

Seizures, Syncope due to breath-holding spells, infection (meningitis/encephalitis), toxic ingestions/poisoning, head trauma with loss of consciousness, intracranial processes (tumor/hemorrhage), intussusception.

Question 4

Seizure causes:

Answer 4

Include metabolic disturbances, head trauma, genetic syndromes, developmental abnormalities, fever, idiopathic.

Question 5

Syncope due to breath-holding spells:

Answer 5

• Common between ages 1 and 3 years
• May be cyanotic or pallid
• Episodes quickly self-resolve; no postictal state

Question 6

Infection (meningitis/encephalitis):

Answer 6

• Up to 20-40 percent of children with meningitis can present with seizure activity
• Children with encephalitis will frequently present with fever and seizure
• Enteroviral and herpes simplex virus infections are typical pathogens for encephalitis.

Question 7

Toxic ingestions/poisoning:

Answer 7

• Most commonly seen between 9 mo-3 yrs

- Various medications may cause unresponsiveness (eg, opiates, benzodiazepines, clonidine, oral diabetic agents)

Question 8

Intussusception:

Answer 8

• Lethargy with a near-unresponsive state may be seen between episodes of colicky pain
• Dehydration due to vomiting and third-spacing of fluids may lead to mental status changes

Question 9

Seizures:

Answer 9

Result of excessive neuronal activity in the brain. Types include generalized tonic-clonic seizure, absence epilepsy (petit mal seizures), simple partial seizures, complex partial seizures.

Question 10

Generalized tonic-clonic seizure:

Answer 10

• Most common type in children
• Begins abruptly with tonic (rigid) stiffening of all extremities and upward deviation of the eyes
• Clonic jerks of all extremities follow the tonic phase
• Finally, child becomes flaccid; urinary incontinence may occur

Question 11

Absence epilepsy (petit mal seizures):

Answer 11

• Generalized seizure, but consciousness is regained more quickly than seen in a generalized tonic-clonic seizure
• Seen in children starting around age 3
• Characterized by loss of environmental awareness and automatisms
• Not associated with loss of tone
• May be precipitated by hyperventilation or photic stimulation

Question 12

Simple partial seizures:

Answer 12

• Motor signs in a single extremity or one side of the body

- Focal onset seizure activity may spread to become generalized

Question 13

Complex partial seizures:

Answer 13

• Alteration of consciousness is hallmark feature
• Signs and symptoms tend to localize around the eyes, the mouth, and the abdomen
• Commonly accompanied by automatisms, quasi-purposeful motor or verbal behaviors that are repeated inappropriately
• Lasts 30 sec to 2 min and are associated with postictal phase
• Secondary generalization can occur

Question 14

What are conditions that mimic seizures?

Answer 14

Motor tics, myoclonus, gastroesophageal reflux (sandifer’s syndrome), pseudo seizure.

Question 15

What is the etiology of febrile seizures?

Answer 15

• Typically a benign and self-limited illness like a viral infection causes a fever that triggers a seizure in a susceptible host (young child, positive family history, etc)
• With more serious CNS infection (such as meningitis or encephalitis), the infection itself causes both fever and seizure.
• Prolonged fever prior to the seizure - especially with irritability or inconsolability - is an indication of a more serious CNS condition causing the seizure

Question 16

What is the epidemiology for febrile seizures?

Answer 16

• One of the most common reasons for seizures in children
• Febrile seizures occur in children ages 6-60 mo at a frequency of 2-4 percent and tend to occur early in the febrile illness (often on the first day)
• Febrile seizures are hereditary, but mode of inheritance is unclear

Question 17

Classification of febrile seizures:

Answer 17

Simple febrile seizure: More common, last less than 15 min, occur once in a 24 hr period, generalized.
Complex febrile seizure: Less common, last greater than 15 min, occur more than once in 24 hr period, focal

Question 18

What is the recurrence risk for febrile seizures:

Answer 18

If a child has a first febrile seizure before age 12 mo, the recurrence risk for a second febrile seizure is about 50 percent. If first seizure is after 12 mo of age, the recurrence risk is about 30 percent. Parents should be reassured that recurrent, simple febrile seizures have no long-term effects on child development.

Question 19

What is the risk of epilepsy in a patient with febrile seizures?

Answer 19

• Risk of developing epilepsy in children with simple febrile seizures is slightly increased above the 0.5-1 percent baseline population risk.
• Epilepsy more common among children with early, recurrent febrile seizures, especially if there is a family history of epilepsy
• Children with complex febrile seizures and those with pre-existing developmental abnormalities are at increased risk

Question 20

Causes of fever without a source:

Answer 20

Viral infection, Occult bacteremia, UTI, Bacterial meningitis

Question 21

Viral infection:

Answer 21

Many common viral infections (eg enterovirus, adenovirus) may cause significant fever in a young child without any additional clinical signs or symptoms (eg congestion, cough, diarrhea, or rash)

Question 22

Occult bacteremia:

Answer 22

• Occult bacteremia may also cause fever without additional clinical signs or symptoms
• Febrile children ages 3-36 mo without a discernible focus of infection may have an “occult” bacteremia, usually caused by Strep pneumo or Hemophilus influenza type B.
• Since the intro of the protein-polysaccharid conjugate pneumococcal vaccine (PCV-7), the rates of invasive pneumococcal infections have declined. And Hemophilus influenzae, type B - once a feared pathogen- is now uncommon in the US due to universal vaccination.
• Undiagnosed, the child with occult bacteremia is at risk for the development of a more serious bacterial infection, such as meningitis or osteomyelitis, through bacterial seeding of these distant sites.

Question 23

UTI:

Answer 23

• Common cause of fever in children
• Because small children cannot complain of dysuria, frequency or costoverterbral angle (CVA) tenderness, UTI must be ruled out by laboratory testing.
• Clinical practice guidelines suggest when it is appropriate to obtain a urine specimen in the workup of a fever without a source.

Question 24

Bacterial meningitis:

Answer 24

One of the most potentially serious infections in infants and children.

Question 25

What is the epidemiology of bacterial meningitis?

Answer 25

Increasingly uncommon due to immunization (and herd immunity), but potentially devastating.

Question 26

What is the etiology of bacterial meningitis?

Answer 26

- Bacterial meningitis in immunized children 2 mo to 12 years of age is usually due to Step pneumo or Neisseria meningitides. - In younger infants, gram negative organisms, such as Escherichia coli, and organisms like Group B strep (strep agalactiae) need to be considered

Question 27

How does bacterial meningitis present?

Answer 27

- May present with increasing lethargy and irritability, as well as signs of meningeal irritation (nuchal rigidity or meningismus). - Alternatively, non-specific findings, including fever (in 90-95 percent of cases), anorexia, poor feeding, symptoms of an upper respiratory infection, myalgia, and tachycardia may predominate.

Question 28

How do you treat bacterial meningitis?

Answer 28

- In cases in which meningitis is highly suspected, antibiotics are generally given empirically as soon as the CSF culture is obtained (and in severe cases, even beforehand). - Start with high-dose IV antibiotics directed at the most likely organisms (usually a 3rd ben cephalosporin and vancomycin). Then tailor antibiotics based on sensitivities. - Treatment duration: 7-14 days

Question 29

What are complications of bacterial meningitis?

Answer 29

- Stroke, subdural effusions, and syndrome of inappropriate anti-diuretic hormone (SIADH) secretion - Developmental delay, seizures, and hearing loss - Unusual for treated meningitis to be fatal

Question 30

What are the bacterial meningitis findings in CSF?

Answer 30

Decreased CSF glucose. Decreased CSF glucose: blood glucose ratio. Increased CSF protein. Increased WBC count. Increased percentage of polymorphonuclear cells in CSF WBCs.

Question 31

What are the viral meningitis findings in CSF?

Answer 31

Increased CSF WBC count. Variable percentage of polymorphonuclear cells in CSF WBCs. Protein and glucose normal.

Question 32

What types of questions should be asked when obtaining a seizure history?

Answer 32

- Why did you suspect something was wrong? - What was the first thing you noticed? - Did you notice any movements in his arms and legs? How would you describe them? - Establish a clear timeline of events including how child recovered.

Question 33

What is supportive evidence of a true seizure (as opposed to a pseudo seizure)?

Answer 33

- History of alteration or loss of consciousness - Incontinence - Deviation of eyes - Rhythmic motor movements that cannot be stopped by touching or holding the child - Postictal state

Question 34

What is on the differential diagnosis for febrile seizure?

Answer 34

Infection (meningitis/encephalitis), Epilepsy, Ingestion/poisoning, Post-traumatic seizure.

Question 35

Febrile seizures:

Answer 35

Usually occur on the first day of the illness. Fever greater than 38 deg C is typically seen. Children with febrile seizures are developmentally normal and often have a positive family history for other first-degree relatives with febrile seizures as children.

Question 36

Infection (meningitis/encephalitis):

Answer 36

Approx. 30 percent of infants with meningitis present with a seizure. However, they typically have other signs of illness (vomiting, persistent lethargy, behavior change). Because clinical signs and symptoms of meningitis can be subtle in children, a febrile child with irritability and a seizure (esp. if he has not recovered to normal activity and behavior after a period of observation) should have meningitis including in the differential diagnosis, even when the physical exam does not demonstrate a stiff neck.

Question 37

Epilepsy:

Answer 37

A fever often triggers the first seizure in a child with epilepsy. Although some children with epilepsy also have developmental delay due to genetic, congenital or acquired disorders (symptomatic epilepsy), many children with epilepsy are developmentally normal (idiopathic epilepsy).

Question 38

Ingestion/poisoning:

Answer 38

A poisoning (accidental ingestion) may lead to a generalized seizure. Examples include hypoglycemia due to a diabetic medication, lead poisoning, and acute alcohol poisoning.

Question 39

Diagnostic studies for fever without a source with CNS symptoms:

Answer 39

WBC count and differential, CBC and blood culture, Urinalysis, Urine culture, lumbar puncture.

Question 40

White blood cell count and differential:

Answer 40

A low or high white blood cell count, as well as a left shift, are sensitive indicator of a possible bacterial infection.

Question 41

CBC and blood culture:

Answer 41

In many cases occult bacteremia resolves on its own without sequelae; however, there is the possibility that untreated occult bacteremia may go on to seed other sites, such as the meninges or a bone or joint. Risk of disease is low but burden of disease may be high (eg, missed bacteremia progressing to bacterial meningitis). Especially important to obtain a CBC and blood culture when immunization status is unclear.

Question 42

Urinalysis:

Answer 42

A urinalysis, looking for evidence of pyuria and bacteria, should be checked routinely in males less than 6 mo old (less than 12 mo old if uncircumcised) and females less than 12 mo old.

Question 43

Urine culture:

Answer 43

A positive culture is the gold standard for diagnosing infection. A urine culture should be obtained from males less than 6 mo old (less than 12 mo old if uncircumcised) and females less than 12 mo old. Cultures are only as good as the sample, so most pediatricians will catheterize infants and toddlers to obtain the specimen.

Question 44

Lumbar puncture:

Answer 44

The younger the child, the more subtle the signs of meningitis may be. Very young infants (less than 3 mo to under 6 mo) with bacterial meningitis may not show signs of nuchal rigidity and should undergo lumbar puncture for spinal fluid. Strongly consider lumbar puncture after the first seizure in a child less than 12 months. Potentially consider lumbar puncture in children 12 to 18 months. A LP should also be a strong consideration in children older than 6-12 months with atypical seizures, children whose immunization status is incomplete or unknown, or if there is persistent irritability in children slow to return to baseline behavior.

Question 45

How do you best manage a fever?

Answer 45

- If child is uncomfortable, may give NSAID medicines (acetaminophen, ibuprofen) - However, studies show that this does not prevent recurrence of febrile seizure

Question 46

How do you best manage a seizure?

Answer 46

- A child experiencing seizure should be placed on his side to avoid choking on stomach contents or saliva - Keep child in safe setting to minimize risk of injury while seizing - Do not put anything in his mouth - Do not restrain movements - Call 911 if seizure lasts greater than 5 minutes

Question 47

What is anti-seizure prophylaxis?

Answer 47

Should not be used for children with simple febrile seizures due to serious side effects!