Febrile Seizures: A Case Discussion

1. “Co-co-co-com Bulsyon!” “ehem…” Ryan Em C. Dalman MD MBA - 070070 Febrile Seizures: A Case Discussion

2. Outline • Objectives • Case Presentation • Case Discussion

3. Objectives • Present a case of Simple Febrile Seizures • Discuss the pathophysiology and management of Simple Febrile Seizures

4. Case Presentation Patient History

5. General Data • CM • 1-year-old born on 4/4/2009 • Female • Admitted for the first time • Roman Catholic • Lives in Manggahan, Pasig City

6. Chief Complaint • “Combulsyon” (Convulsions)

7. History of Present Illness • Fever – intermittent, undocumented • No associated symptoms • Convulsions • Consult at Angono Hospital • 38.4oC • CBC: normal • Urinalysis: WBC (6-8)  pyuria • Dx: UTI • Rx: Paracetamol 10 mk/dose and cotrimoxazole 50 mk/day • Unproductive cough and colds 1 day PTA

8. History of Present Illness • Undocumented Fever • Convulsions • 2-3 minutes • Prompted consult 7 hours PTA hence admitted

9. Review of Systems General: no weight loss, no change in appetite Cutaneous: no lesions, no pigmentation, no hair loss, no pruritus HEENT: no redness no aural discharge no neck masses no sore throat

10. Review of Systems Cardiovascular: no easy fatigability, or fainting spells Gastrointestinal: no vomiting, no loose bowel movements, no constipation Genitourinary: no genital discharge, no pruritus no problems in urination Endocrine: no polyuria, polydypsia, no heat/cold intolerance

11. Review of Systems Muskuloskeletal: no joint or muscle swelling, no limitation of movement, no stiffness Hematopoietic: no easy bruisability, or bleeding

12. Maternal and Birth History • Born full term via NSD to a 31 year old G4P3 (3013) by an obstetrician at PCGH • with complete prenatal consults • No intake of any medications except for multivitamins • No maternal illnesses • No complications at birth

13. Nutritional History • Breastfed from birth to the present • No formula given • Supplementary foods were given at 6 month old • Current diet • Breast milk 4-5 bottles a day • Rice + (chicken, vegetables, w/ soup) 3x a day • Bread every morning

14. Past Medical History Pneumonia (Aug, 2009) No Tuberculosis, Asthma, Trauma No previous surgeries No previous hospitalizations No Allergies

15. Immunizations • BCG – 1 dose • DPT – 3 doses • Hep B – 3 doses • Measles – 1 dose

16. Developmental History • Stands alone • Throws toys • Obeys commands or requests • Attempts to use a spoon

17. Family History • PTB – father • No diabetes, hypertension, heart disease, cancer, stroke, kidney disease, asthma, or allergies

18. Personal and Social History • Father works for Reagent, in the packaging department • Mother is a housewife • They live in a makeshift house in Pasig City

19. Environmental • Not exposed to environmental hazards like chemicals, pollution, cigarette smoking, etc • House prone to flooding • Has their own toilet • Water comes from Manila Waters • Drinking water from faucet boiled for 5 minutes

20. Case Presentation Physical Exam

21. General Survey • awake, active, with good cry but consolable • in cardiorespiratory distress

22. Vital Signs/ Anthropometrics Vital signs Temperature – 37.5oC CR – 140 (70-110) RR – 36 (20-30) Anthropometrics Weight: 7.1 kg (<5th) Length: 75cm (50th) HC: 42cm (<5th) CC: 45 cm AC: 42 cm

23. Skin • Light brown • No rashes, hemorrhages, scars • Dry • good skin turgor • CRT 1-2 seconds

24. HEENT Head normocephalic no lesions, fontanels closed Eyes anictericsclerae, pink palpebral conjunctiva pupils 2-3mm Ears cone of light present inferomedially on both ears no discharge noted Nose septum medline, moist mucosa Throat mouth and tongue moist no TPC

25. Chest and Lungs Neck with cervical lymphadonapathy no nuchal rigidity Chest adynamicprecordium no heaves, thrills, or lifts, PMI at 4th ICS MCL regular rate, normal rhythm no murmurs Lungs symmetrical chest expansion, no retractions Equal vocal fremiti all lung fields resonant on percussion harsh breath sounds with bilateral fine crackles

26. Abdomen/ Perineum Abdomen globular, no scars, no lesions normoactive bowel sounds tympanitic on all quadrants no tenderness on all quadrants no masses, no organomegally liver edge palpated kidneys and spleen not appreciated

27. Neurologic Examination Glasgow Coma Scale verbal response: 5 eye opening: 4 motor response: 6 total: 15 Cerebrum awake and active Cerebellum no nystagmus, tremors, or abnormal movements

28. Neurologic Examination Sensory turns to pain Motor 5/5 on all extremities DTR ++ on all extremities

29. Neurologic Examination Cranial Nerves I: not elicited II: 2-3mm pupils, equally reactive to light III,IV,VI: EOM’s intact V: corneal reflex present V1, V2, V3 intact (turns to touch) VII: no facial asymmetry VIII: turns to sound IX, X: gag reflex present XI: turns head from side to side XII: tongue midline

30. Case Presentation Admitting Impression, Salient Features, Differentials, Course in the Ward

31. Admitting Impression • Benign Febrile Seizure secondary to pneumonia

32. Salient Features • 13 month old, female • Fever (intermittent, undocumented) • Convulsion • 2-3 minutes • General tonic-clonic • Unproductive cough and colds • Tachypneic, tachycardic • Bilateral lung crackles • Normal neurologic exam

33. Differential Diagnosis

34. Differential Diagnosis

35. Course in the Ward ER T: 40.1 oCCR: 138RR: 35 awake, in mild cardiorespiratory distress rales on bilateral lung fields D5LR Paracetamol 10mkd

36. Course in the Ward ER CBC: normal Urinalysis: pus cells – 2-4

37. Course in the Ward 1st Hospital Day

38. Course in the Ward 2nd Hospital Day

39. Course in the Ward 3rd Hospital Day

41. Course in the Ward 5thHospital Day

42. Course in the Ward 6th Hospital Day

43. Final Diagnosis • Benign Febrile Convulsion secondary to Pneumonia

44. Case Discussion

45. Definition/ Clinical Manifestations Simple Febrile Seizures • Ages 3 months – 6 years • Axillary temperature 37.8oC or greater • Generalized tonic-clonic seizures • Less than 15 minutes • Does not recur within the same febrile illness • Normal neurologic exam • No underlying CNS infection or abnormality CPG on First Simple Febrile Seizure

46. Incidence • 2% - 5% have febrile seizures by 5 years old (US) • 5% -10% for India, 8.8% for Japan, 14% for Guam,0.35% for Hong Kong, and 0.5-1.5% for China. Nooruddin R Tejani, MD, Assistant Professor, Department of Emergency Medicine, SUNY Health Sciences Center Brooklyn; Director, Pediatric Emergency Medicine, Downstate Medical Center

47. Pathophysiology High frequency burst of action potentials Increase neuronal excitability Endogenous Pyrogens (interleukin 1 beta) Spread of seizure activity! Loss of surround inhibition Seizure propagation American Epilepsy Society – 10/04

48. Diagnostics • Lumbar puncture should be performed in all children below 18 months for benign febrile convulsions • For >/= 18months, it is recommended in the presence of clinical signs of meningitis • Neuroimaging studies should not be routinely performed in children for benign febrile seizures CPG on First Simple Febrile Seizure

49. Treatment • Antipyretic use • Used to lower fever and should not be relied upon to prevent the recurrence of febrile seizures • Antiepileptic drug use (continuous anticonvulsant) • Not recommended in children after a simple febrile seizure. • It can reduce the recurrence of febrile seizures, but its adverse side effects do not warrant their use in this benign disorder CPG on First Simple Febrile Seizure

50. Treatment • Antiepileptic drug use (intermittent anticonvulsant) • Not recommended for the prevention of recurrent febrile seizures • There is no difference in the risk of seizure recurrence in children receiving intermittent diazepam and placebo CPG on First Simple Febrile Seizure