CASE PRESENTATION

1. CASE PRESENTATION Maria Angelica U. Veloso

2. Identifying Data Name: MV Age:1 Sex: Male Nationality: Filipino Religion: Roman Catholic Address: Taguig Chief informant: Mother and Father Reliability: Fair

3. Chief Complaint Seizure (Few mins PTA, lasting approximately 5 mins)

4. 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

5. HPI Day of admission • Cough still present • Fever • (T max = 38.2 C) • Temporarily lysed with paracetamol • Still with good activity and good appetite

6. 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

7. Review of Systems (-) Weakness, loss of appetite, colds, dyspnea, vomiting, diarrhea or urinary changes

8. Past Medical History • No history of head trauma • First seizure occurrence • Asthma • Ventolin nebulization • With previous hospitalizations last year

9. 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

10. 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

11. 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

12. Nutritional History • Breastfed until 1 month then began taking formula (Enfalac) • Not yet weaned • Currently on pure formula milk diet

13. 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

14. 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

15. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. Physical Exam Motor: Spontaneous active movement on all extremities Sensory: Intact Absent Babinski, No ankle clonus, DTRs ++ (-) Nuchal rigidity, (-) Brudzinski, (-) Kernig’s

26. 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

27. Working Impression Benign Febrile Convulsion secondary to Pneumonia

28. Differentials • Complex febrile seizure • CNS Infection • Electrolyte imbalance

29. 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

30. 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

31. Course in the Wards – Day 1

32. Course in the Wards – Day 2

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

34. 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

36. 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

37. 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.

38. 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

41. 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

42. 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

43. 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

44. Work Up

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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).