Case II – NeurologyDr. K. Krishnamurthy

Vasha Ramgobin.Neil Roopchan.

Valmiki Seecheran.

Year V MBBS.

Case summary.• The emergency department (ED) notifies you that one of your patients is

being evaluated for new-onset seizures. The 2 year old boy was in his normal state of good health until this morning. When he complained of a headache and then fell to the floor. While waiting for the ED physician to come to the phone, you review the patient’s chart and find that he has had normal development. His family history is significant for a seizure of unknown etiology that his father had at age 4 years. According to ED physician, the boy’s mother saw jerking of both arms and legs. When the ambulance arrived 5 minutes later, the child had stopped jerking but was not arousable; his heart rate was 108 bpm, respiratory rate 16 breaths/min, blood pressure 90/60 mmHg, and temperature 104oF (40o). His blood sugar level was 135 mg/dL. By the time the child arrived to the ED, he was awake and he recognized his parents. His physical examination in the ED is normal, as are his complete blood count and urinalysis.

Objectives.

• What is the most likely diagnosis?• What is the best management for this

condition?• What is the expected course of this condition?• List factors that include the risk of further

seizure activity.

Patient history.• Demographics.

– Name – John Doe.– Age – 2 year old.– Gender – Male.

• Presenting complaint.– New onset seizures.– Disinterested in reaching for toys.

• History of presenting complaint.– Previously good health until this morning.– Complained of headaches and then fell to the floor.– His mother reported jerkings of both arms and legs. 5 minutes later, the child had stopped jerking but

was not arousal.– At arrival of A&E, child was awake and recognized his parents.

• Past medical history.– Normal developmental chart.

• Family history.– +ve family history of seizures of unknown aetiology.– His father had seizures at age four (4).

Patient history.

• Vitals.– HR – 108bpm.– RR – 16bpm.– BP – 90/60 mmHg.– Temperature – 40.0 Celsius. – Blood sugar – 135mg/dl.

• All physical examinations were normal. • FBC & Urinalysis was normal.

Diagnosis.

• Febrile seizures– A seizure occurring in the absence of a CNS infection with an elevated

temperature in a child between 6 months and 6 years.

• Simple febrile seizure– Seizure lasts < 15 minutes without focal or lateralizing signs/ sequalae. – If more than one seizure occurs in a brief period, the total episode

lasts less than 30 minutes.• Complex febrile seizure

– Seizure lasts > 15 minutes and may have lateralizing signs .– If several seizure occur in a brief period, the entire episode may last

for more than 30 minutes.

Diagnosis.

• If neurological examination are abnormal, or seizure occur several days in the illness, a lumbar puncture may be necessary.

• Bedside investigations. (NB – unreliable in children < 1 year)– Brudzinski sign – patient supine, passive neck flexion results

in involuntary knee and hip flexion.– Kernig’s sign – patient supine, leg flexed at hip, knee at 90

degrees, pain is induced with leg extension.• Lumbar puncture generally indicated for patients < 1

year.

Management.• A diagnosis of FS can only be made after considering CNS infection as a

cause.• Self-limited.

– If longer than 5 minutes, can be interrupted with lorazepam/ diazepam.– No need for anti-convulsants.– Airway management is a priority.

• Parental education.– 6 months to 6 years. – 5% of children.– Non-fatal.– Genetic basis. (10-20% increase with a first degree relative).

• Injury prevention.• Fever control.

– Acetaminophen.

Expected course.

• Prognosis is generally good, children will not develop neurologic/developmental consequences.

• Children < 12 months at time of their first seizure have a 50% to 65% chance of another febrile seizure. Older children have a 20% to 30% of reoccurrence.

• Outgrow the condition by 5-6 years of age.

Thank you.