CASE REPORT

Complex Febrile Seizure

Presenters Day/ Date Supervisor

: Ika Nopa Nst; Siti Rizky A Nst : Monday / May 14th 2012 : dr. Hj Sri Sofyani, Sp. A (K)

CHAPTER 1 INTRODUCTION

1.1.

Background Febrile convulsions, or febrile seizures (FS), are seizures that occur on the rise in body

temperature caused by the extracranial process.1 Expert opinion about the age of the patient during a febrile seizure are not same. Most expert argue that febrile seizure occur at children aged between one months to five years old.2 According to American Academy of Pediatrics (AAP) the youngest age of febrile seizures is 6 months old.3 Most of 90% patients with febrile seizures occur in children younger than five years old.Most febrile seizures occur in children aged between six months to twenty two months. The highest insiden of febrile seizure is at 18 months. Incidence of febrile seizure in worldwide is 114%. In everycountry , the incidence and prevalence of febrile seizure is different.In Japan incidence of febrile seizure is rangers from 8.3% - 9.9% . In United States and Europe prevalence of febrile seizure is 2 - 5 %. In Asia prevalence of febrile seizure is 2 fold higher than prevalence in united states and Europe.4 Febrile seizures are classified as either simple or complex. Simple febrile seizures consist of a brief (lasting less than 10 minutes) tonic-clonic convulsion which occurs only once within a 24-hour period. There are no focal features and it resolves spontaneously.

Conversely, complex febrile seizures are prolonged (greater than 10-15 minutes), focal, or multiple and recurrent within the same febrile illness over a 24-hour period. While the majority of febrile seizures are simple (70-75%), 9-35% of febrile seizures are complex.10 Prognostic of patient with febrile seizure is good. The mortality rate of patients with febrile seizure is only 0.64% 0.75 %. Most of patients with febrile seizure have complete recovery and a small fraction develop into epilepsy (2-7%). Four percent of patient with febrile seizures were significantly impaired behavior and decreased levels of intelegence.5

1.2.

Objective This paper is done in order to complete the task in following the doctor's professional

education program in the department of pediatrics. In addition, providing knowledge to the author and readers about complex febrile seizure.

CHAPTURE 2 LITERATURE REVIEW FEBRILE COMPLEX SEIZURE 2.1. Febrile Seizure 2.1.1. Defenition Febrile convulsions, or febrile seizures (FS), are seizures that occur on the rise in body temperature caused by the ekstracranial process.1 The peak occurrence of FS is 18 months, FS are excluded in children with seizures due to a CNS infection, a previous afebrile seizure, or an underlying CNS abnormality. 6 2.1.2. Epidemiology Incidence of febrile seizure in worldwide is 114%. In everycountry , the incidence and prevalence of febrile seizure is different.In Japan incidence of febrile seizure is rangers from 8.3% - 9.9% . In United States and Europe prevalence of febrile seizure is 2 - 5 %. In Asia prevalence of febrile seizure is 2 fold higher than prevalence in united states and Europe. Most of 90% patients with febrile seizures occur in children younger than five years old.Most febrile seizures occur in children aged between six months to twenty two months. The highest insiden of febrile seizure is at 18 months.4 2.1.3. Risk Factor - Family history of febrile seizures - Duration of febrile illness (the shorter the febrile period) - Presence of prior neurological abnormalities - Under five years old 7

2.1.4. Predictors of recurrent febrile seizures include: - A history of focal, prolonged, and multiple seizures. - Influenza A viral infection. - Family history of febrile seizures. - Onset of febrile seizure <12 months of age. - Temperature <40C (<104 F) at time of seizure.
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- And a history of complex, initial febrile seizures..8

2.1.5. Pathophysiology 1. Fever (>38.3C rectal) can decrease gamma aminobutyric acid A (GABA(A)

receptor mediated inhibition to a greater extent than it decreases excitation, which may shift the balance towards excitation and contribute to seizure generation. This appears to be mediated by reducing GABA release from presynaptic terminals, but fever may also decrease post-synaptic GABA(A) receptor function. 2. Fever can decrease the seizure threshold in immature cells. 3. Fever can increase the mobility of ions to the cell. It facilitate the occurrence of depolarization. 4. Sudden increase in body temprature can increase glutamat acid which is excitator. 9

2.1.6. Classification and Clinical Findings a. Simple febrile seizure: In a child who is otherwise neurologically healthy and without abnormality by examination or by developmental history is defined as: - Seizure less than 10 minutes - Single seizure which is generalized or tonic clonic - occurs only once within a 24-hour period b. Complex febrile seizure: - Seizures are prolonged (greater than 10-15 minutes) - Seizures are focal, or multiple - Recurrent within the same febrile illness over a 24-hour period.10 neurological

2.1.7. Differential Diagnose and Diagnose Complex febrile convulsion - Prolonged - Focal features - Seizures recur within 24 hours or same illness - Consider differential diagnoses (Table 1) - Investigate further (eg. LP if suspect CNS infection)

Table 1. Differential diagnoses of fever and convulsions16

Febrile seizures

Simple Complex

Central nervous system infection

Meningitis Encephalitis

Other precipitants of seizures in a child with Systemic illnesses (eg. occult bacteraemia) fever Head trauma Intoxication Electrolyte imbalance Hypoglycaemia

2.1.7.1 Investigations: Routine blood work is not indicated for simple febrile seizures. Laboratory investigations are dictated by the clinical condition of the child and by an appropriate clinical policy for children of that age presenting to the emergency department with fever. - Lumbar Puncture (LP) An LP is not recommended in children considered to be haemodynamically unstable. Strongly consider LP if the child is less than 12 months and consider LP if the child is less than 18 months. LP is recommended if:
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Child has received antibiotics prior to the seizure as partially treated meningitis could be present in children who were on antibiotics prior to the seizure, and in these cases consider an LP regardless of age. Even if an LP is performed and the results are negative, one may consider treatment of meningitis, as cerebrospinal fluid (CSF) may be normal in the early stages of meningitis.

Meningeal signs are present: Meningeal irritation is defined as presence of Brudzinski sign (flexion of the neck causes flexion of the patients hips and knees), Kernig sign (pain elicited with 90 degree hip flexion and knee extension), or neck stiffness in children older than 1 year of age. In
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children 1 year or younger, signs of meningeal irritation are the signs mentioned herein or irritability during manipulation of head or legs by the physician and/or a bulging fontanel.8 It should be stressed that clinical signs of meningitis are insensitive and if the clinician is suspicious that meningitis is present the LP should not be delayed while awaiting for these signs to develop. Imaging Neuroimaging is not indicated after a simple febrile seizure, but could be considered when there are clinical features of a neurological disorder, e.g. micro/macrocephaly, neurocutaneous abnormalities, pre-existing neurological deficit, postictal neurological deficit persisting for more than a few hours, or when there are recurrent complex febrile seizures, particularly where there is doubt whether the seizures are febrile. Magnetic resonance imaging is more sensitive than computed tomography for brain disorders that may present with seizures. Electroencephalography (EEG) EEG does not predict which children progress to a seizure disorder. Epileptiform abnormalities are relatively common in children with benign febrile seizures. EEG has a low sensitivity in children under three years of age following an unprovoked seizure. EEG may have a limited role in the diagnosis of acute encephalopathic disorders if the child remains encephalopathic for longer than normal following a febrile seizure. 9 2.1.8. Treatment 2.1.8.1 Acute Management of Febrile Convulsion: - Maintain a clear airway. - Protect the child from injury. - Place the child in a semi-prone position. - Loosen clothing or remove excess clothing. - Give oxygen if available. - Apply suction for nasal or oral secretions if facility available. - Treat fever by sponging with tepid water and antipyretics (e.g. acetaminophen). - Monitor vital signs. - If facilities and medications are available give :

Short acting anti convulsant for termination of acute seizures Drugs Diazepam Administration Rectal Dose BW < 10 : 5 mg BW> 10 : 10 mg

Diazepam

IV

0.3-0.5 mg/kgbb/kali

Phenytoin

IV

10-20 mg/kgBB /kali

Phenobarbital

IV

10-20 mg/kgBB/kali

2.1.8.2 Hospital Admission Children should preferably be observed for several hours after a febrile convulsion. If they are clinically stable with cause of fever identified and treated, they may be sent home. However, follow-up care must be assured. Hospital admission is individualized. It depends on the experience of the practitioner, specific clinical situation and family circumstances.

2.1.8.3 Management of Fever - There is no evidence that antipyretic treatment prevents the recurrence of febrile convulsions. - Fever should be treated in order to promote the comfort of the child and to prevent dehydration. - Use of antipyretic drug is effective and, paracetamol or ibuprofen is advised. - An adequate fluid intake is advisable. 12 -

2.1.9 Prognosis Prognostic of patient with febrile seizure is good. The mortality rate of patients with febrile seizure is only 0.64% 0.75 %. Most of patients with febrile seizure have complete recovery and a small fraction develop into epilepsy (2-7%). Four percent of patient with febrile seizures were significantly impaired behavior and decreased levels of intelegence.5
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CHAPTER 3 MEDICAL RECORD COMPLEX FEBRILE SEIZURE

3.1.

Objective The aim of doing this paper is to report a case of Complex Febrile Seizure of a 2

month 10 day old boy that was admitted at Pediatrics Department of Haji Adam Malik General Hospital.

3.2

Case MA, 2 month 10 day old, male, weight 4,3 kg, height 55 cm, was admitted to Haji

Adam Malik Hospital at the Infection Unit Pediatric Department on April 09st 2012 with main complaint seizure. It started one weeks ago starting from, seizure three times a day, with duration less than 5 minute. Seizure generalized, with eyes rolling up, jerking extremities, and patient alert after seizure over. Patient experienced fever since one week ago. Fever in high temprature, and decreased with antipiretic drugs.

History of previous illness

:Patient was treated by pediatrician in RSUD Langsa and diagnosed as Complex Febrile Seizure

History of previous medication

: Stesolid syr, Tempra, Transfusi PRC 75cc

Physical Examination Presence Status : sensorium : Alert , temperature: 37,5C. cyanotic (-), edema (-), icteric (-). Body weight (BW): 4,3 kg, body length (BL): 55 cm Head: Eye: Light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra (+/+). Ear/ mouth/ nose: normal. Neck Thorax : Lymph node enlargement (-), nuchal rigidity (-) Anemic (-), dyspnea (-),

: Symmetrical fusiform , retraction (-) HR: 124 bpm, regular, murmur (-) RR : 36 bpm, regular, rales (-) : Soepel, peristaltic (+) N, liver and spleen not palpable
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Abdominal

Inguinal Extremities

: :

Multiple lymph node enlargement (-) Pulse =124 bpm, regular, adequate pressure/volume. Warm acral, CRT < 3 seconds. Baggy pants (-), hypotrophy muscle (-). Physiologic Reflex : APR/KPR (+/+) Pathologic Reflex : (-) Meningeal Reflex : (-)

Genitalia

: Male, within normal limit

Laboratorium: Test (10-4-2012) Complete Blood Count Hemoglobin (Hb) Erytrocyte (RBC) Leukocyte (WBC) Hematocrite Trombocyte (PLT) MCV MCH MCHC RDW MPV PCT PDW Cell Count: Neutrofil Limfosit Monosit Eosinophil Basophil Neutrophil absolute Limfosit absolute Monosit absolute Eosinophil absolute Basophil absolute 34.20 % 47.50 % 15.60 % 1.90 % 0.800 % 3.27x103/L 4.55x103/L 1.40x103/L 0.28x103/L 0.08x103/L 37 80 % 20 40 % 28% 16% 01% 1.9 5.4 x103/L 3.7 10.7 x103/L 0.3 0.8 x103/L 0.20 0.50 x103/L 0 0,1 x103/L Results Normal Value

9.70 g % 3.45 x 106/mm3 9.57 x 103/mm3 29.10 % 265 x 103/mm3 84.30 fL 28.10 pg 33.30 g % 15.80 % 8.50 fL 0.20 % 8.8 fL

10.7 17.1 g % 3.75 4.95 x106/mm3 6.0 17.5 x103/mm3 38 - 52 % 217 497 x103/mm3 93 - 115 fL 29 - 35 pg 28 34 g % 14,9 18,7 % 7,2 10 fL

Differential diagnose : - Complex Febrile Seizure - Anemia

Working diagnose

: Complex Febrile Seizure

Management

IVFD D5% NaCl 0,225% 6 gtt/minute micro Tempra Syr 3 x 0,4 cc Stesolit Syr 2 x 0,5 cth

Investigation planning : Consult to neurology division Consult to hematology division EEG Head CT scan

Follow up: Follow Up April 10th - 14th 2012 S : Fever (-), convulsion (-) O: Sensorium Head : : Alert, weight = 4.3 Kg, Temperature = 37 0C Eye: Light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra (+/+). Ear/ mouth/nose: normal. Neck Thorax : Lymph node enlargement (-), nuchal rigidity (-)

: Symmetrical fusiform , retraction (-) HR: 126 bpm, regular, murmur (-) RR : 30 bpm, regular, rales (-)

Abdominal : Soepel, peristaltic (+) N, liver and spleen not palpable Inguinal : Multiple lymph node enlargement (-) Pulse =126 bpm, regular, adequate pressure/volume. Warm acral, CRT < 3 seconds. Baggy pants (-), hypotrophy muscle (-). Physiologic Reflex : APR/KPR (+/+) Pathologic Reflex : (-) Meningeal Reflex : (-) A : dd/- Complex Febrile Seizure - Anemia - Observasi convulsi
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Extremities :

P : - IVFD D5% NaCl 0,225% 6 gtt/minute micro - Tempra Syr 3 x 0,4 cc - Stesolit Syr 2 x 0,5 cth

Test (14-4-2012) Complete Blood Count Hemoglobin (Hb) Erytrocyte (RBC) Leukocyte (WBC) Hematocrite Trombocyte (PLT) MCV MCH MCHC RDW MPV PCT PDW Cell Count: Neutrofil Limfosit Monosit Eosinophil Basophil Neutrophil absolute Limfosit absolute Monosit absolute Eosinophil absolute Basophil absolute

Results

Normal Value

9.70 g % 3.45 x 106/mm3 9.57 x 103/mm3 29.10 % 265 x 103/mm3 94.30 fL 29.10 pg 33.30 g % 15.80 % 8.50 fL 0.20 % 8.8 fL

10.7 17.1 g % 3.75 4.95 x106/mm3 6.0 17.5 x103/mm3 38 - 52 % 217 497 x103/mm3 93 - 115 fL 29 - 35 pg 28 34 g % 14,9 18,7 % 7,2 10 fL

37.20 % 39.50 % 7.60 % 1.90 % 0.800 % 3.27x103/L 4.55x103/L 0.50x103/L 0.18x103/L 0.08x103/L

37 80 % 20 40 % 28% 16% 01% 1.9 5.4 x103/L 3.7 10.7 x103/L 0.3 0.8 x103/L 0.20 0.50 x103/L 0 0,1 x103/L

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Test(14-4-2012) Analysis of electrolit Calcium (Ca) Natrium (Na) Kalium (K) Phospor Clorida (Cl) Magnesium (Mg) Follow Up April 14th - 18th 2012 S : Fever (-), convulsion (-) O: Sensorium Head : :

Results

Normal Value

8.9 mg/dL 137 mEq/L 4.9 mEq/L 5.7 mEq/L 106 mEq/L 1.75 mEq/L

8.4 10.8 mg/dL 135 -155 mEq/L 3.6-5.5 mEq/L 5.0 -10.8 mEq/L 96-106 mEq/L 1.4 -1.8 mEq/L

Alert, weight = 4.3 Kg, Temperature = 37.70C Eye: Light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra (+/+). Ear/ mouth/nose: normal.

Neck Thorax

Lymph node enlargement (-), nuchal rigidity (-)

: Symmetrical fusiform , retraction (-) HR: 112 bpm, regular, murmur (-) RR : 26 bpm, regular, rales (-)

Abdominal : Soepel, peristaltic (+) N, liver and spleen not palpable Inguinal : Multiple lymph node enlargement (-) Pulse =112 bpm, regular, adequate pressure/volume. Warm acral, CRT < 3 seconds. Baggy pants (-), hypotrophy muscle (-). Physiologic Reflex : APR/KPR (+/+) Pathologic Reflex : (-) Meningeal Reflex : (-) A : dd/- Complex Febrile Seizure - Suspect Anemia - Observasi convulsi

Extremities :

P : - IVFD D5% NaCl 0,225% 6 gtt/minute micro - Tempra Syr 3 x 0,4 cc - Stesolit Syr 2 x 0,5 cth

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Test (18-4-2012) Complete Blood Count Hemoglobin (Hb) Erytrocyte (RBC) Leukocyte (WBC) Hematocrite Trombocyte (PLT) MCV MCH MCHC RDW MPV PCT PDW Cell Count: Neutrofil Limfosit Monosit Eosinophil Basophil Neutrophil absolute Limfosit absolute Monosit absolute Eosinophil absolute Basophil absolute

Results

Normal Value

10.00 g % 3.42 x 106/mm3 7.05 x 103/mm3 28.40 % 517 x 103/mm3 94.00 fL 29.40 pg 34.00 g % 15.40 % 7.60 fL 0.39 % 7.7 fL

10.7 17.1 g % 3.75 4.95 x106/mm3 6.0 17.5 x103/mm3 38 - 52 % 217 497 x103/mm3 93 - 115 fL 29 - 35 pg 28 34 g % 14,9 18,7 % 7,2 10 fL

37.80 % 39.80 % 7.30 % 5.70 % 0.400 % 1.95x103/L 3.79x103/L 0.40x103/L 0.47x103/L 0.03x103/L Results

37 80 % 20 40 % 28% 16% 01% 1.9 5.4 x103/L 3.7 10.7 x103/L 0.3 0.8 x103/L 0.20 0.50 x103/L 0 0,1 x103/L Normal Value

Test(18-4-2012) Analysis of electrolit Calcium (Ca) Natrium (Na) Kalium (K) Phospor Clorida (Cl) Magnesium (Mg)

8.7 mg/dL 137 mEq/L 4.9 mEq/L 6.2 mEq/L 104 mEq/L 1.75 mEq/L

8.4 10.8 mg/dL 135 -155 mEq/L 3.6-5.5 mEq/L 5.0 -10.8 mEq/L 96-106 mEq/L 1.4 -1.8 mEq/L

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Follow Up April 19th - 23th 2012 S : Fever (-), convulsion (-) O: Sensorium Head : : Alert, weight = 4.3 Kg, Temperature = 36.60C Eye: Light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra (-/-). Ear/ mouth/nose: normal. Neck Thorax : Lymph node enlargement (-), nuchal rigidity (-)

: Symmetrical fusiform , retraction (-) HR: 120 bpm, regular, murmur (-) RR : 32 bpm, regular, rales (-)

Abdominal : Soepel, peristaltic (+) N, liver and spleen not palpable Inguinal : Multiple lymph node enlargement (-) Pulse =120 bpm, regular, adequate pressure/volume. Warm acral, CRT < 3 seconds. Baggy pants (-), hypotrophy muscle (-). Physiologic Reflex : APR/KPR (+/+) Pathologic Reflex : (-) Meningeal Reflex : (-)

Extremities :

A : dd/- Complex Febrile Seizure - Anemia - Observasi convulsi

P : - IVFD D5% NaCl 0,225% 6 gtt/minute micro - Tempra Syr 3 x 0,4 cc - Stesolit Syr 2 x 0,5 cth

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Follow Up April 24th - 25th 2012 S : Fever (-), convulsion (-) O: Sensorium Head : : Alert, weight = 4.3 Kg, Temperature = 36.60C Eye: Light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra (-/-). Ear/ mouth/nose: normal. Neck Thorax : Lymph node enlargement (-), nuchal rigidity (-)

: Symmetrical fusiform , retraction (-) HR: 120 bpm, regular, murmur (-) RR : 32 bpm, regular, rales (-)

Abdominal : Soepel, peristaltic (+) N, liver and spleen not palpable Inguinal : Multiple lymph node enlargement (-) Pulse =120 bpm, regular, adequate pressure/volume. Warm acral, CRT < 3 seconds. Baggy pants (-), hypotrophy muscle (-). Physiologic Reflex : APR/KPR (+/+) Pathologic Reflex : (-) Meningeal Reflex : (-) A : - Complex Febrile Seizure

Extremities :

P : - IVFD D5% NaCl 0,225% 6 gtt/minute micro - Tempra Syr 3 x 0,4 cc - Stesolit Syr 2 x 0,5 cth

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Refference 1. Ikatan Dokter Anak Indonesia. Unit Kerja Koordinasi Neurologi. Konsensus penatalaksanaan kejang demam. Badan Penerbit IDAI 2006. 2. ILAE. Guidelines for epidemiologic studies on epilepsy. Epylepsia 1993; 34: 592596. 3. American Academy of Pediatrics. Practice parameter: the neurodiagnostic evaluation of the child with a first simple febrile seizure. Pediatrics 1996;97:76975. 4. Hauser WA. The prevalence and incidence of convulsive disorders in children. Epilepsia 1994;35:S16. 5. Knudsen FU. Febrile seizures: treatment and prognosis. Epilepsia 2000;41:29. 6. Offringa M, Moyer VA. Evidence based paediatrics: evidence based management of seizures associated with fever. BMJ 2001;323:11114. 7. Madeleine Grace M. Sosa, MD., FPPS, FPNA,FCNSP, MSCE.Febril Seizure, College of Medicine, Dasmarinas, Cavite Consultant De La Salle Health Science Institute, 2011. 8. Berg AT, Shinnar S, Darefsky AS, et al. Predictors of recurrent febrile seizures: a prospective cohort study. Arch Pediatr Adolesc Med 1997;151:3718. 9. Nelson KB, Ellenberg JH. Prognosis in children with febrile seizures. Pediatrics. 1978;61:720-727. 10. Tonia Jones, Steven J. Jacobsen. Childhood Febrile Seizures: Overview and Implications.2007.available from www.medsci.org. 11. Rosman NP. Evaluation of the child who convulses with fever. Pediatr Drugs 2003;5:45761. 12. V Wong, Mhk Ho, Np Rosman, Y Fukuyama. Clinical Guideline on Management of Febrile Convulsion. HK J Paediatr (new series) 2002;7:143-151

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