Ryan Em C. DalmanMD MBA “Co-co-co-com Bulsyon!” “ehem…”

 Objectives  Case Presentation  Case Discussion

 Present a case of Simple Febrile Seizures  Discuss the pathophysiology and management of Simple Febrile Seizures

Patient History

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

 “Combulsyon” (Convulsions)

 Fever – intermittent, undocumented  No associated symptoms  Convulsions  Consult at Angono Hospital  38.4 o C  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

 Undocumented Fever  Convulsions  2-3 minutes  Prompted consult 7 hours PTA hence admitted

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

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

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

 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

 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

Pneumonia (Aug, 2009) No Tuberculosis, Asthma, Trauma No previous surgeries No previous hospitalizations No Allergies

 BCG – 1 dose  DPT – 3 doses  Hep B – 3 doses  Measles – 1 dose

 Stands alone  Throws toys  Obeys commands or requests  Attempts to use a spoon

 PTB – father  No diabetes, hypertension, heart disease, cancer, stroke, kidney disease, asthma, or allergies

 Father works for Reagent, in the packaging department  Mother is a housewife  They live in a makeshift house in Pasig City

 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

Physical Exam

 awake, active, with good cry but consolable  in cardiorespiratory distress

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

 Light brown  No rashes, hemorrhages, scars  Dry  good skin turgor  CRT 1-2 seconds

Head normocephalic no lesions, fontanels closed Eyes anicteric sclerae, 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

Neck with cervical lymphadonapathy no nuchal rigidity Chest adynamic precordium no heaves, thrills, or lifts, PMI at 4 th 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

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

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

Sensory turns to pain Motor 5/5 on all extremities DTR ++ on all extremities

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

Admitting Impression, Salient Features, Differentials, Course in the Ward

 Benign Febrile Seizure secondary to pneumonia

 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

BFC 2 o to PNBacterial Meningitis 13 month old++ Intermittent fever++ Convulsions (2 episodes (different febrile episodes; 2-3 mins; general tonic-clonic) ++ Unproductive cough and colds++/- Tachypneic; tachycardic++ Bilateral lung crackles+- Normal neurologic examination+-

BFC 2 o to PNViral Encephalitis 13 month old++ Intermittent fever++ Convulsions (2 episodes (different febrile episodes; 2-3 mins; general tonic-clonic) ++ Unproductive cough and colds+- Tachypneic; tachycardic+- Bilateral lung crackles+- Normal neurologic examination++/-

ER T: 40.1 o CCR: 138RR: 35 awake, in mild cardiorespiratory distress rales on bilateral lung fields D5LR Paracetamol 10mkd

ER CBC: normal Urinalysis: pus cells – 2-4

1 st Hospital Day SOAP -Good suckT: 36.5 o C CR: 120 RR: 36 -Awake, with good cry -In mild cardiorespiratory distress -no seizures -With febrile episodes -No retractions -Fine crackles, bilateral -She is afebrile but has febrile episodes recorded -Patient is tachycardic and tachypneic. -IV Fluids -Ampicillin -Paracetamol for fever -monitor vital signs -diet as tolerated -for CSF culture

2 nd Hospital Day SOAP T: 37.6 o C CR: 110RR: 34 -with good cry -In mild cardiorespiratory distress -no seizures -No retractions -Fine crackles, bilateral -still no episodes of seizures and fever -still tachypneic -Continue medications -monitor vital signs -diet as tolerated -for CSF culture

3 rd Hospital Day SOAP T: 36.6 o C CR: 108 RR: 30 -not in cardiorespiratory distress -no seizures -No retractions -Fine crackles, bilateral Chest X-Ray -bilateral lung PN w/ non-specific lymphadenopathy suggest follow- up study after treatment to r/o primary infection PTB -absence of seizures -responding well to medications -the patient is no longer tachypneic -with no more febrile episodes -continue medications -monitor vital signs -Diet as tolerated -For CSF culture -For PPD

5 th Hospital Day SOAP T: 36.9 o C CR: 110 RR: 29 -Awake, with good cry -not in cardiorespiratory distress -No retractions -Fine crackles, bilateral - No more febrile episodes and not tachypneic (day3) -responding well to medications -resolution stage -switch to oral medication -Monitor vital signs -diet as tolerated -follow up CSF culture

6 th Hospital Day SOAP T: 37.0 o C CR: 105 RR: 24 -Awake, with good cry -not in cardiorespiratory distress -no seizures -No retractions -Fine crackles, bilateral CSF analysis -clear, sugar 3.3s (N), protein 27.6 (N), cell count 0 -no more seizure episodes -resolution stage of pneumonia -CSF analysis rules out meningitis May go home -amoxicilliln 50mk/day

 Benign Febrile Convulsion secondary to Pneumonia

Simple Febrile Seizures  Ages 3 months – 6 years  Axillary temperature 37.8 o C 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

 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 % for China. Nooruddin R Tejani, MD, Assistant Professor, Department of Emergency Medicine, SUNY Health Sciences Center Brooklyn; Director, Pediatric Emergency Medicine, Downstate Medical Center

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

 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

 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

 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

 Electroencephalogram (EEG)  Should not be routinely requested in children with a benign febrile seizure  There is no evidence that EEG can predict future incidence of epilepsy  Presence of abnormalities in the EEG does not change the recommendation the use of anticonvulsants CPG on First Simple Febrile Seizure

 Simple febrile seizures may slightly increase the risk of developing epilepsy, but they have no adverse effects on behavior, scholastic performance, or neurocognition.  Children with febrile seizures have a slightly higher incidence of epilepsy compared with the general population (2% vs 1%).