CASE • FATIMA MEMORIAL HOSPITAL, LAHORE

DISCUSSION
IDENTIFICATION

Age: 11 months
Sex: male
Weight: 7.7kg
PRESENTING COMPLAIN

Fever for 1 day

Two episodes of fits in one day

HISTORY OF PRESENT ILLNESS
•Patient was in usual state of health 1 day ago when he developed
fever at 5 am, (not recorded by parents) sudden in onset, not
associated with rigors and chills relieved by taking syrup Panadol, given
after an hour.
•Then there was second spike of fever at around 8 am. This spike of
fever was associated with an episode of seizure.
•Generalized tonic clonic seizures for 1 minute associated with rolling
of eyes upwards, resolved spontaneously not associated with tongue
bite and frothing from the mouth.
HISTORY OF PRESENT ILLNESS
•They took him to Ittefaq hospital, where fever was documented as
103 F. They gave him medication and discharged.​
•There was another episode of seizure around 2pm associated with
fever (102). It was the same as last episode and resolved within 1
minute.
•Parents again took him to ittefaq hospital but could not be admitted
due to non-availability of bed.​
•No h/o of trauma, recent travel and sick contacts at home.
 PAST MEDICAL HISTORY
BIRTH HISTORY: MILESTONES:
Pre-natal: uneventful with regular Neck holding: 6 months
check ups Sitting: 7-8 months without support
Natal: full-term, SVD, 3.5 kg birth Walking: using a walker now (11
weight months)
Post-natal: stayed in nursery due
to aspiration for 1 day
PAST MEDICAL HISTORY
NUTRITION: IMMUNIZATION:
Breastfeeding and formula milk  Vaccination is according to EPI
in first 6 months
ALLERGIES
Weaning started at 6 months No h/o of allergic reactions
Eating all varieties of foods
MEDICATIONS
now
none
FAMILY HISTORY

Non-consanginous marriage

No significant family history

DIFFERENTIAL DIAGNOSIS
Benign febrile seizures or convulsions
Metabolic: hypoglycemia, hypocalcemia, hyponatremia
CNS: infection (meningitis, encephalitis, abscess), traumatic head injury,
hemorrhage, intracranial malignancy
Seizure mimics: breath holding spells, shaking chills, syncope
Idiopathic epilepsy and epileptic syndromes
Others: neurocutaneous syndromes, Arteriovenous malformation (AVM),
accidental drug ingestions
GENERAL PHYSICAL EXAMINATION
Alert, responsive and cooperative child to examination
Weight: 7.7kg CNS: no signs of meningeal
irritation
Head circumference: 44 cm
Height: 73 cm CVS: s1+s2+0
Vitals: B.P 100/60 Temp 98 F Resp: nvb+0
RR 40/min HR 130bpm Abd: soft and non-tender, bowel
sounds audible
Throat: congested
No signs of child abuse
TREATMENT
Admit Inj. N/S + 5% D/W + 2cc
KCL/100ml - I/V@21cc/hr.
Pass I/V line
Inj. Oxidil (Ceftriaxone) 200mg
Monitor vitals 2 hourly IVXBD
NPO-TFO Inj. Provas (Paracetamol) 80ml IV 4
hourly
INVESTIGATIONS
WBC 25.10 Serum Magnesium 1.95
Neutrophils 75 Serum phosphate 4.74
Lymphocytes 20 Calcium total 9.90
Hb 12.8 BSR 84mg/dl
Platelets 418,000
CRP 8.3
PROVISIONAL DIAGNOSIS

ATYPICAL or COMPLEX FEBRILE SEIZURES

DISCHARGE AND FOLLOW UP

Reassurance of parents

Safety netting
 WHAT IS A SEIZURE?
SEIZURE: Transient occurrence of signs and/or symptoms
due to abnormal excessive neuronal brain activity
Can be symptom of
acute insult to the brain such as alcohol CNS infection
and illicit drug use/ withdrawal
brain injury/abnormality (tumor, Fever
trauma, vascular)
Medications Metabolic (hypoglycemia, electrolyte
abnormalities, liver/renal failure)
Epilepsy
FEBRILE SEIZURES
A febrile seizure is a convulsion in a child caused by a spike in body
temperature, often from an infection. They occur in young children
with normal development without a history of
neurological symptoms.
OR
As defined by the American Academy of Pediatrics (AAP), febrile
seizures, occur in the absence of intracranial infection, metabolic
disturbance, or history of afebrile seizures and are classified as
simple or complex
 CLASSIFICATION
SIMPLE/TYPICAL (70-80%)
All of the following
Duration <15 min(95% <5min)
Generalized tonic-clonic
No recurrence in 24 h period
No neurological impairment or
developmental delay before or
after seizure
COMPLEX/ATYPICAL (20-30%)
At least one of the following
Duration > 15 min
Focal onset or focal features during
seizure
Recurrence seizures(1 in 24 h period)
Previous neurological impairment or
neurological deficit after seizure
EPIDEMIOLOGY

Most common cause of seizure in children (3-5% of children)

Gender: Male > Female

Age: 6 months - 6 years.

PATHPHYSIOLOGY
Although the exact mechanism of simple febrile seizures is unknown,
it is thought to be multifactorial, with genetic and environmental
factors having been shown to contribute to its pathogenesis
Febrile seizures may occur before or soon after the onset of
fever, with the likelihood of seizure increasing with the child's
temperature and not with the rate of temperature rise
Causes (in order of decreasing frequency): viral infections; otitis
media; tonsillitis; UTI; gastroenteritis; LRTI; meningitis; post
immunization.
ETIOLOGY OF FEVER
oINFECTIONS: anatomic approach (CNS, ears, upper and lower
respiratory tract, GI, GU, skin, soft tissue, bones and joints etc.)
oAUTOIMMUNE: mainly autoimmune (JIA, IBD, SLE, etc.)
oMALIGNANCY: childhood cancers (leukemia, lymphoma,
neuroblastoma, etc.)
oMISCELLANEOUS: dehydration, drug and toxins, post-
immunization etc.)
RISK FACTORS
Developmental delay
Discharge from a neonatal unit after 28 days
Daycare attendance
viral infections
a family history of febrile seizures
certain vaccinations
possibly iron and zinc deficiency
 WORKUP
 HISTORY: determine focus of
fever, description of seizure
(prolonged postictal phase and
focal symptoms), medications,
trauma history, development,
family history
 PHYSICAL EXAM: LOC, signs of
meningitis, neurological exam,
head circumference, focus of
infection
SEPTIC WORKUP to find the source of
infection including LP
 if suspecting meningitis
 incomplete or unknown immunization
status
strongly consider if child < 12 mo;
consider if child is 12-18 mo;
only if meningeal signs present if child>
18mo
 EEG/CT/MRI brain not warranted unless
atypical febrile seizure or abnormal neurologic
findings
ADMIT IF
Complex seizure, the child was drowsy before the seizure, is
irritable, systemically unwell or 'toxic', and/or the cause of the fever
is unclear
Symptoms/signs of meningitis; petechial rash; recent or current
treatment with antibiotics (may mask symptoms/signs of
meningitis); or aged <18mo (meningitis have non-specific signs)
The cause of the fever requires hospital management in its own
right
 Early review by a doctor is not possible, inadequate home
circumstances, or the carer is anxious or unable to cope
 MANAGEMENT OF FITTING CHILD
Ensure that the airway is clear
Loosen tight or restrictive
clothing
Put your child on his or her
side so that he or she won't
choke on saliva or vomit
Don’t restrain your child's
movements during the seizure
Try to remain calm
Time the duration of the seizure
Call emergency if the seizure lasts
more than 10 minutes or is
accompanied by a stiff neck,
vomiting or breathing problems
Don’t try to lower your child's fever
by placing him or her in a cold bath,
especially during a seizure
ACUTE TREATMENT OF FEBRILE STATUS EPILEPTICUS
Although most febrile seizures have resolves by the time
of presentation, physicians should be prepared to treat
patients with febrile status epilepticus.
Febrile status epilepticus is continuous seizure for more than 30
minutes without neurological recovery
In acute setting, intravenous lorazepam (Ativan) in a dose of 0.1 mg
per kg is the treatment of choice for acute tonicclonic pediatric seizures
or buccal midazolam​
RISK FACTORS FOR FUTURE EPILEPSY AFTER
A FEBRILE SEIZURE
Family history of epilepsy
Complex febrile seizure (multiple complex features are a possible
risk factor. In one study, children with complex febrile seizure feature
had a risk of 6 to 8 %)
Neurodevelopmental abnormality (e.g., cerebral palsy,
hydrocephalus)
Fever duration <1 hour before seizure onset
PARENTS EDUCATION
•Very small risk of developing epilepsy
•9% in child with multiple risk factors
•2% in child with typical febrile seizure​
•1% in general population​
RECURRENCE
Parents should be warned that febrile seizure reoccur frequently.

33% chances of recurrence (75% mostly within 1 year of first seizure

and in children < 1 yr old.

Risk of recurrence is similar between simple and complex febrile

seizures
PROPHYLAXIS
Prophylaxis with antiepileptic drugs (phenobarbital and valproic
acid) not recommended because of associated adverse effects, the
burden of long term compliance, and a lack of data showing a
reduced risk of future epilepsy with prevention of recurrent simple
febrile seizures
If high risk for recurrent of prolonged seizures, give rectal diazepam
or sublingual lorazepam
MANAGEMENT
Counsel and reassure parents
Febrile seizures do not cause brain damage
Antipyretics and fluids for comfort (though neither prevent seizure)
Treat underlying cause of fever
Inform daycare or school
Follow up with in 2 weeks
WHEN TO REFER
Afebrile seizure
If diagnosis of febrile seizure is in doubt
Recurrent febrile convulsions
Child is at increased risk of epilepsy e.g coexistent neurological or
development condition
History of epilepsy in a first degree relative
Parents are anxious despite reassurance or request referral
 QUESTIONS PARENTS MAY ASK
What causes febrile seizures?
If my child has a febrile seizure, does that mean that he or she has
epilepsy?
What are the chances of developing epilepsy after having febrile
seizure?
Can febrile seizures be prevented or avoided?
REFERENCES
OXFORD Handbook of general practice
TORONTO NOTES 2018
www.aafm.org (American academy of family physicians)
www.medscape.com