UNIVERSITY OF NORTHERN PHILIPPINES

College of Medicine
Vigan City, Ilocos Sur

A Requirement

Presented to

ILOCOS TRAINING AND REGIONAL MEDICAL CENTER

DEPARTMENT OF PEDIATRICS

By

GROUP No. 02

BALTAZAR, ALYSSA MARIE L.

BARTOLOME, APPLE ANNE MICHELLE B.
BASILIO, ALESSANDRO L.
BODA, UTSAV BHARATBHAI
BUMATARIYA, DIVYESH JAGDISH
CHANDRA PRAKASH, BOOPATHI

A.Y 2020 – 2021

Group Number: 02
Date: SEPTEMBER 07, 2020

ADMITTING DIAGNOSIS

According to the data presented in the case, our patient has history of fever and sore throat, with PE
findings of Tachycardia, Tachypnea and fever and has supraclavicular and suprasternal retractions,
Capillary refill time >2 seconds & grade 3 bipedal edema. Since the seizures are following the febrile
period and doesn’t seem to be directly related to any other causes, it leads us to arrive at admitting
diagnosis of SIMPLE FEBRILE SEIZURE SECONDARY TO ACUTE TONSILOPHARYNGITIS.

PATHOPHYSIOLOGY

Retrieved from: https://calgaryguide.ucalgary/simple-febrile-seizure-pathogenesis-and-clinical-findings

Febrile seizures are seizures that occur between the ages of 6 and 60 mo (peak 12-18 mo) with a
temperature of 38°C (100.4°F) or higher, that are not the result of CNS infection or any metabolic
imbalance, and that occur in the absence of a history of prior afebrile seizures.
A simple febrile seizure is a primary generalized, usually tonic-clonic, attack associated with fever,
lasting for a maximum of 15 min, and not recurrent within a 24-hr period. A complex febrile seizure is
more prolonged (>15 min), and/or is focal, and/or recurs within 24 hr.
Febrile status epilepticus is a febrile seizure lasting longer than 30 min. Most patients with simple
febrile seizures have a very short postictal state and usually return to their baseline normal behavior and
consciousness within minutes of the seizure.
Febrile infection–related (or refractory ) epilepsy (FIRES) is a very different disorder seen
predominantly in older (>5 yr) usually male children and associated with an encephalitis-like illness but
without an identifiable infectious agent. Children with FIRES were previously normal but subsequently
develop difficult-to-treat epilepsy. Between 2% and 5% of neurologically healthy infants and children
Group Number: 02
Date: SEPTEMBER 07, 2020

experience at least one, usually simple, febrile seizure. Simple

febrile seizures do not have an increased risk of mortality even though they are concerning to
the parents.
Complex febrile seizures may have an approximately 2-fold long-term increase in mortality rates, as
compared with the general population, over the subsequent 2 yr, probably secondary to a coexisting
pathology. There are no long-term adverse effects of having one or more simple febrile seizures.
Compared with age-matched controls, patients with febrile seizures do not have any increase in the
incidence of abnormalities of behavior, scholastic performance, neurocognitive function, or attention.
Children who develop later epilepsy, however, might experience such difficulties. Febrile seizures
recur in approximately 30% of those experiencing a first episode, in 50% after two or more episodes, and
in 50% of infants younger than 1 yr of age at febrile seizure onset. Several factors such as, age <1 yr,
duration of fever <24 hrs and fever >38 o may affect the recurrence risk. Although approximately 15% of
children with epilepsy have had febrile seizures, only 5% (range 1–33%, dependent on risk factors) of
children who experience febrile seizures proceed to develop epilepsy later in life.

MECHANISM OF FEVER IN CHILDREN

When the body is introduced to the

pyrogens, either exogeous or endogenous,
the immnune cell of the body tries to
overcome their local physiologic effects
and their toxic materials. To achieve this,
the immune cells such as, macrophages
and NK-cells with help of other immune
cells, release the prostaglandins that create
inflammatory effects at local tissue and
allow more immune cells to the primary
exposed site.

Pyrogenic cytokines such as IL-1, IL-

6, and TNF are released from these cells
and enter the systemic circulation.
Although these circulating cytokines lead
to fever by inducing the synthesis of
PGE2, they also induce PGE2 in
peripheral tissues. The increase in PGE2
in the periphery accounts for the
nonspecific myalgias and arthralgias that
often accompany fever. It is thought that
some systemic PGE2 escapes destruction
by the lung and gains access to the
hypothalamus via the internal carotid.

Retrieved_from:https://d3i71xaburhd42.cloudfront.net/24609b8531e1cea2d9e2
dcbcddb9f48facbfa7dd/2-Figure1-1.png
When the prostaglandins reaches the hypothalamus of the brain while circulating through the
bloodstream, they affect the thermo-regulatory set point. The thermoregulatory set point is elevated after
Group Number: 02
Date: SEPTEMBER 07, 2020

the primary effects of the prostaglandins. It is an autonomous

response of the body to fight against the infection or the toxins and it’s harmful effects to the
body tissues.

However, it is the elevation of PGE2 in the brain that starts the process of raising the hypothalamic
set point for core temperature. By the Heat production and heat conservation mechanisms, the body
generates and keeps more heat inside the body, thus presenting with fever.
Cytokines produced in the brain may account for the hyperpyrexia of CNS hemorrhage, trauma, or
infection. Viral infections of the CNS induce microglial and possibly neuronal production of IL-1, TNF,
and IL-6. The cytokines produced in the CNS can raise the hypothalamic set point, bypassing the
circumventricular organs. CNS cytokines likely account for the hyperpyrexia of CNS hemorrhage,
trauma, or infection.

SIMPLE VS COMPLEX SEIZURES

WOULD A LUMBAR TAP BE INDICATE IN THIS CASE? WHY?

In this case, a lumbar puncture is not indicated as it is reserved for all infants younger than 6
mo of age who present with fever and seizure, if the child is ill-appearing, or at any age if there
are clinical signs or symptoms of concern. (In such cases, Meningitis should be considered in the
differential diagnosis.)

A lumbar puncture is an option in a child 6-12 mo of age who is deficient in Haemophilus influenzae
type b and Streptococcus pneumoniae immunizations or for whom the immunization status is unknown.
A lumbar puncture is an option in children who have been pretreated with antibiotics. In patients
presenting with febrile status epilepticus, a nontraumatic lumbar puncture rarely shows cerebrospinal
fluid (CSF) pleocytosis (96% have < 3 nucleated cells in the CSF) with a concurrently normal CSF
protein and glucose. Pleocytosis suggests bacterial or viral infection.

WOULD ANTI-SEIZURE MEDICATIONS BE INDICATED IN THIS CASE?

In this case, anti-seizure medications are not indicated.

In general, anti-epileptic therapy, continuous or intermittent, is not recommended for children with
one or more simple febrile seizures. Parents should be counseled about the relative risks of recurrence of
febrile seizures and recurrence of epilepsy, educated on how to handle a seizure acutely, and given
emotional support. If the seizure lasts for longer than 5 min, acute treatment with lorazepam, midazolam,
or diazepam is needed.
Rectal diazepam is often prescribed to families to be used at home as a rescue medication if a febrile
seizure lasts longer than 5 min. Alternatively, buccal or intranasal midazolam may be used. In cases of
frequently recurring febrile seizures, intermittent oral clonazepam (0.01 mg/kg every 8-12 hr up to a
maximum dose of 1.5 mg/day) or oral diazepam (0.33 mg/kg every 8 hr) can be given during febrile
Group Number: 02
Date: SEPTEMBER 07, 2020

illnesses. Such therapies help reduce, but do not eliminate, the risks
of recurrence of febrile seizures. Historically, continuous therapy with the AEDs phenobarbital
or valproic acid was occasionally used to prevent febrile seizures.
However, in the vast majority of cases, use of continuous therapy is not justified, due to the risk of
side effects and lack of demonstrated long-term benefits, even if the recurrence rate of febrile seizures is
expected to be decreased by these drugs.
Antipyretics can decrease the discomfort of the child but do not reduce the risk of having a recurrent
febrile seizure. Chronic antiepileptic therapy may be considered for children with a high risk for later
epilepsy.
The possibility of future epilepsy does not change with or without antiepileptic therapy. Iron
deficiency is associated with an increased risk of febrile seizures, and thus screening for that problem and
treating it appears appropriate.

REFERENCES

 American Academy of Pediatrics. Clinical practice guideline— febrile seizures: guideline

for the neurodiagnostic evaluation of the child with a simple febrile seizure

 https://www.semanticscholar.org%2Fpaper%2FPathophysiology-and-management-of-
fever.-Dalal-Zhukovsky

 Nelson textbook of pediatrics, 21st edition.

 Offringa M, Newton R, Cozijnsen MA, Nevitt SJ. Prophylactic drug management for febrile
seizures in children. Cochrane Database Syst Rev . 2017

 Oluwabusi T, Sood SK. Update on the management of simple febrile seizures: emphasis on
minimal intervention. Curr Opin Pediatr . 2012

 Patel AD, Vidaurre J. Complex febrile seizures: a practical guide to evaluation and
treatment.

Noted:

Mary Grace Padilla, MD, DPPS

Liaison Officer
Group Number: 02
Date: SEPTEMBER 07, 2020

Navid Roodaki, MD
Chief Resident (Clinical)