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CASE PRESENTATION. Maria Angelica U. Veloso. Identifying Data. Name: MV Age: 1 Sex: Male Nationality: Filipino Religion: Roman Catholic Address: Taguig Chief informant: Mother and Father Reliability: Fair. Chief Complaint. Seizure (Few mins PTA, lasting approximately 5 mins).

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CASE PRESENTATION

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Case presentation

CASE PRESENTATION

Maria Angelica U. Veloso


Identifying data

Identifying Data

Name: MV

Age:1

Sex: Male

Nationality: Filipino

Religion: Roman Catholic

Address: Taguig

Chief informant: Mother and Father

Reliability: Fair


Chief complaint

Chief Complaint

Seizure (Few mins PTA, lasting approximately 5 mins)


History of present illness

History of Present Illness

1 week PTA

  • Coughing episodes, productive

  • No dyspnea, wheezing, colds

  • Consult done  Salbutamol nebulization 3 times a day and Prednisone 3 mL OD, which offered some relief


Case presentation

HPI

Day of admission

  • Cough still present

  • Fever

    • (T max = 38.2 C)

    • Temporarily lysed with paracetamol

    • Still with good activity and good appetite


Case presentation

HPI

Few minutes PTA

  • Seizure

    • Sudden onset without aura

    • Upward rolling of eyeballs, stiffening of extremities, pooling of saliva, frothing around the mouth and generalized cyanosis

    • No vomiting, loss of consciousness or incontinence

    • Lasted around 5 minutes

    • Post ictally upward staring

    • No recurrence

  • Immediate consult and subsequent admission


Review of systems

Review of Systems

(-) Weakness, loss of appetite, colds, dyspnea, vomiting, diarrhea or urinary changes


Past medical history

Past Medical History

  • No history of head trauma

  • First seizure occurrence

  • Asthma

    • Ventolin nebulization

    • With previous hospitalizations last year


Past medical history1

Past Medical History

Previous hospitalizations:

- URTI x 2 (Aug 2010)

- AGE (2011)

Previous surgeries: None

Allergies: None

Immunization history:

- BCG, Hepa B x 3, DPT + OPV x 3, Measles

- No HiB, MMR, Varicella, Pneumococcal, Rotavirus


Family history

Family History

  • Asthma  Maternal aunt

  • Brother had a cough few days before which was treated with antibiotics

  • No history of febrile seizures, epilepsy

  • No HTN, DM, heart disease


Birth and maternal history

Birth and Maternal History

  • Born full term via NSD to a 31 y/o G3P3 (3003)

    • Unrecalled BW; No complications; Good activity, cry and color

    • NBS done

  • Planned pregnancy

  • Regular PNCU

  • No maternal illnesses/vices during pregnancy


Nutritional history

Nutritional History

  • Breastfed until 1 month then began taking formula (Enfalac)

  • Not yet weaned

  • Currently on pure formula milk diet


Developmental history

Developmental History

Gross Motor: Walks well alone

Adaptive Fine Motor: Throws toys, drinks from cup

Language: Obeys commands or requests, can say mama and dada

Personal Social: Does nursery games, helps dress himself, does not attempt to feed himself with a spoon

 At par for developmental age


Environment and social history

Environment and Social History

  • Lives with 4 others in a well lit but not well ventilated home, which is quite small

  • Water source: Delivered mineral water

  • Daily garbage collection

  • No smokers at home but some neighbors burn wood for cooking

  • No pets but some neighbors raise pigs

  • Mother is a housewife

  • Father is a TMC employee

  • Patient is active and playful despite being asthmatic


Physical exam

Physical Exam

General Survey: Awake, Alert, Irritable, Not in cardiorespiratory distress

Vital Signs: HR - 161, RR - 40, BP – 90/70, Temperature – 38.6 degrees C, Height – 80 cm, Weight – 12 kg, HC – 46 cm, CC – 50 cm, AC – 53 cm


Physical exam1

Physical Exam

HEENT: Normocephalic, Closed fontanelles; Anicteric sclerae, Pink palpebral conjunctivae; No nasal discharge; Dry lips, moist buccal mucosa, and tongue; No TPC, (-) CLAD, Supple neck


Physical exam2

Physical Exam

Chest/Lungs: Equal chest expansion, No retractions, Harsh breath sounds, Bibasal rales

CVS: Adynamic precordium, Tachycardic, Regular rhythm, Distinct heart sounds, Good S1 and S2; (-) Murmurs, (-) S3 or S4; PMI at 5th ICS MCL


Physical exam3

Physical Exam

Abdomen: Globular without any visible masses or scars; Normoactive bowel sounds; (-) Obliteration of Traube’s space; Soft, (-) Masses or organomegaly upon palpation, (-) Tenderness


Physical exam4

Physical Exam

GU: Grossly normal male external genitalia

DRE: Not done

Skin/Extremities: Good skin color and turgor; (-) Pallor, (-) Cyanosis, (-) Jaundice (-) Edema; Full and equal pulses; Good capillary refill


Physical exam5

Physical Exam

Neurologic:

GCS 15, Irritable

VII – No facial asymmetry

VIII – Lateralizes/Localizes sound

IX, X – Intact gag reflex and swallowing

XI – Moves shoulders

XII – Tongue midline

Cranial nerves

I – Not assessed

II, III, IV, VI – Pupils 3 mm equally brisk and reactive to light, Able to track objects, No ptosis

V – Able to bite down hard on tongue depressor


Physical exam6

Physical Exam

Motor: Spontaneous active movement on all extremities

Sensory: Intact

Absent Babinski, No ankle clonus, DTRs ++

(-) Nuchal rigidity, (-) Brudzinski, (-) Kernig’s


Salient features

Salient Features

  • 1/M

  • 1 week of productive cough

  • Fever

  • 1 seizure episode lasting 5 minutes without recurrence

  • First occurrence and no family history of febrile seizures or epilepsy

  • Bilateral rales

  • Essentially normal neurologic exam without nuchal rigidity or meningeal signs


Working impression

Working Impression

Benign Febrile Convulsion secondary to Pneumonia


Differentials

Differentials

  • Complex febrile seizure

  • CNS Infection

  • Electrolyte imbalance


Diagnostics at the er

Diagnostics at the ER

CBC

Hgt 90 mg/dL

Na 136

K 3.9

Ionized Ca 5.36

O2 sat 93%  98%

CXR

Consider interstitial pneumonia, bilateral

133

605

18.3

0.39

0.77/0.16/

0.07/0


Treatment

Treatment

  • Admit

  • Diet as tolerated

  • Monitor VS q 4 and I&O q shift

  • IVF: D5IMB 500 mL x 10 hours (maintenance + 10%)

  • Paracetamol 120mg/5mL, 5 mL every 4 hours for T >/= 37.8 C

  • Salbutamol nebulization once every 6 hours with chest clapping after every other nebulization

  • Standby diazepam 3 mg IV for frank seizures > 5 mins

  • Ampicillin 300 mg IV every 6 hours

  • Zinc 10mg/5mL twice a day for 14 days

  • Standby O2

  • Seizure precaution

  • Refer to neurology


Course in the wards day 1

Course in the Wards – Day 1


Course in the wards day 2

Course in the Wards – Day 2


Seizures

Seizures

  • Transient occurrence of signs and/or symptoms resulting from abnormal excessive or synchronous neuronal activity in the brain


Seizures1

Seizures

  • Either:

  • Focal (partial)  initial activation of a system of neurons limited to part of one cerebral hemisphere

  • Generalized  synchronous involvement of all of both hemispheres


Febrile seizures

Febrile Seizures

  • Occur between the age of 6 and 60 months

  • Temperature of 38°C or higher

  • Not the result of central nervous system infection or any metabolic imbalance

  • Occur in the absence of a history of prior afebrile seizures


Simple or complex

Simple or Complex?

Simple

  • Primary generalized

  • Usually tonic-clonic, attack associated with fever

  • Lasts for a maximum of 15 min

  • No recurrence within 24 hours

Complex

  • More prolonged (>15 min)

  • Focal

  • Recurs within 24 hours

    Febrile status epilepticus febrile seizure lasting >30 min.


Febrile seizures1

Febrile Seizures

  • Between 2% and 5% of neurologically healthy infants and children experience at least 1

  • Do not have an increased risk of mortality

  • No long-term adverse effects of having ≥1 simple febrile seizures (No brain damage)

  • Only 2-7% of children who experience febrile seizures proceed to develop epilepsy later in life


All in the family

All in the family

  • In many families, the disorder is inherited as an autosomal dominant trait

  • Multiple single genes causing the disorder have been identified

  • In most cases the disorder appears polygenic, and the genes predisposing to it remain to be identified


Genes genes genes

Genes, genes, genes

  • Identified single genes include FEB 1, 2, 3, 4, 5, 6, and 7 genes on chromosomes 8q13-q21, 19p13.3, 2q24, 5q14-q15, 6q22-24, 18p11.2, and 21q22

  • Only the function of FEB 2 is known: it is a sodium channel gene, SCN1A


Some syndromes

Some syndromes

  • Almost any type of epilepsy can be preceded by febrile seizures

  • Afew epilepsy syndromes typically start with such

  • Generalized epilepsy with febrile seizures plus(GEFS+)

  • Severe myoclonic epilepsy of infancy (SMEI, also called Dravet syndrome)

  • And, in many patients, temporal lobe epilepsy secondary to mesial temporal sclerosis


Work up

Work Up


Lumbar puncture

Lumbar Puncture

  • Recommended in children <12 mo of age after their first febrile seizure to rule out meningitis

  • Especially important if the child has received prior antibiotics  mask clinical symptoms of the meningitis

  • The presence of an identified source of fever, such as otitis media, does not eliminate the possibility of meningitis


Lumbar puncture1

Lumbar Puncture

  • Seizures are the major sign of meningitis in 13-15% and 30-35% of such children have no other meningeal signs

  • American Academy of Pediatrics (AAP)  strongly recommends LP in infants <1 yr of age because other signs of the infection might not be present


Lumbar puncture2

Lumbar Puncture

  • A child between 12 and 18 mo of age should also be considered  Clinical symptoms of meningitis may be subtle in this age group

  • For children >18 mo of age  indicated in the presence of clinical signs and symptoms of meningitis (e.g., neck stiffness, Kernig sign, Brudzinski sign) or if the history and/or physical examination otherwise suggest intracranial infection


Electroencephalogram

Electroencephalogram

  • Not needed if the child is presenting with his or her first simple febrile seizure and is otherwise neurologically healthy

  • Would not predict the future recurrence of febrile seizures or epilepsy even if the result is abnormal

  • Spikes during drowsiness are often seen in children with febrile seizures, particularly those >4 year old, and these do not predict later epilepsy


Case presentation

EEG

  • Often have nonspecific slowing, if performed within 2 weeks usually posteriorly. Thus, in many cases, if an EEG is indicated, it is delayed until or repeated after >2 weeks have passed

  • Generally restricted to special cases in which epilepsy is highly suspected

  • Should be used to delineate the type of epilepsy rather than to predict its occurrence


Case presentation

EEG

  • Should be performed for at least 30 min in wakefulness and in sleep  avoid misinterpretation and drawing of erroneous conclusions

  • At times, if the patient does not recover immediately from a seizure, it can help distinguish between ongoing seizure activity and a prolonged postictal period -- nonepileptic twilight state (NETS).


Neuroimaging

Neuroimaging

  • According to the AAP  a CT or MRI is not recommended after a first simple febrile seizure

  • Patients with febrile status epilepticus have been reported to have swelling of their hippocampus acutely and subsequent long-term hippocampal atrophy. These patients may be candidates for neuroimaging, because they may be at risk for later temporal lobe epilepsy


Remember

Remember…

  • The work-up of children with complex febrile seizures needs to be individualized

  • This can include EEG and neuroimaging, particularly if the child is neurologically abnormal

  • Patients with febrile status epilepticus  swelling of their hippocampus acutely and subsequent long-term hippocampal atrophy which puts them at risk for later temporal lobe epilepsy


Treatment1

Treatment

  • In general, antiepileptic therapy, continuous or intermittent, is not recommended for children with one or more simple febrile seizures

  • Counseling on the relative risks of recurrence of febrile seizures and recurrence of epilepsy, how to handle a seizure acutely plus emotional support


Treatment2

Treatment

  • If the seizure lasts for >5 min  acute treatment with diazepam, lorazepam, or midazolam

    • Rectal diazepam is often prescribed

    • Buccal or intranasal midazolam may be used and is often preferred by parents

    • IV benzodiazepines, phenobarbital, phenytoin, or valproate may be needed in the case of febrile status epilepticus


Treatment3

Treatment

In the vast majority of cases it is not justified to use these medications for intermittent therapy  Risk of side effects and lack of demonstrated long-term benefits, even if the recurrence rate of febrile seizures is expected to be decreased


Treatment4

Treatment

Antipyretics

  • Can decrease the discomfort of the child but do not reduce the risk of having a recurrent febrile seizure (seizure often occurs as the temperature is rising or falling)


Treatment5

Treatment

  • Chronic antiepileptic therapy may be considered for children with a high risk for later epilepsy

  • Currently available data indicate that the possibility of future epilepsy does not change with or without antiepileptic therapy

  • Screen for iron deficiency, as it has been shown to be associated with an increased risk of febrile seizures


Prognosis

Prognosis

  • Benign events with excellent prognosis


The end

THE END


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