Case 19 Flashcards
What is on the differential diagnosis for a febrile seizure?
CNS infection (meningitis/encephalitis), Idiopathic epilepsy, Ingestion/poisoning, Head trauma
What are the findings from testing with a febrile seizure?
CBC - Normal. CSF - Normal without organisms.
What are some causes of unresponsiveness in a child?
Seizures, Syncope due to breath-holding spells, infection (meningitis/encephalitis), toxic ingestions/poisoning, head trauma with loss of consciousness, intracranial processes (tumor/hemorrhage), intussusception.
Seizure causes:
Include metabolic disturbances, head trauma, genetic syndromes, developmental abnormalities, fever, idiopathic.
Syncope due to breath-holding spells:
- Common between ages 1 and 3 years
- May be cyanotic or pallid
- Episodes quickly self-resolve; no postictal state
Infection (meningitis/encephalitis):
- 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.
Toxic ingestions/poisoning:
- Most commonly seen between 9 mo-3 yrs
- Various medications may cause unresponsiveness (eg, opiates, benzodiazepines, clonidine, oral diabetic agents)
Intussusception:
- 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
Seizures:
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.
Generalized tonic-clonic seizure:
- 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
Absence epilepsy (petit mal seizures):
- 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
Simple partial seizures:
- Motor signs in a single extremity or one side of the body
- Focal onset seizure activity may spread to become generalized
Complex partial seizures:
- 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
What are conditions that mimic seizures?
Motor tics, myoclonus, gastroesophageal reflux (sandifer’s syndrome), pseudo seizure.
What is the etiology of febrile seizures?
- 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
What is the epidemiology for febrile seizures?
- 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
Classification of febrile seizures:
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
What is the recurrence risk for febrile seizures:
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.