Case Presentation Complex Febrile Convulsion

Faizunnur Erfin 0606103874 Resource Person Dr. Amril Amirman Burhany, Sp.A(K)

Faculty of Medicine, Universitas Indonesia Departemen Ilmu Kesehatan Anak Jakarta

Chapter 1: Literature Review Complex febrile convulsion

Background Generalized convulsionss The term convulsion is synonymous with fit or seizure. Convulsionn are due to synchronous discharge of electrical activity from a number of neurones, and this manifests itself as loss of consciousness and abnormal movements. In a generalized convulsion all four limbas and the face are affected.1 Febrile convulsions, the most common seizure disorder during childhood, generally have an excellent prognosis but may also signify a serious underlying acute infectious disease such as sepsis or bacterial meningitis. Therefore, each child with a seizure associated with fever must be carefully examined and appropriately investigated for the cause of the fever, especially when it is the 1st seizure. Febrile seizures are age dependent and are rare before 9 mo and after 5 yr of age. The peak age of onset is 1418 mo of age, and the incidence approaches 34% of young children. A strong family history of febrile convulsions in siblings and parents suggests a genetic predisposition. Linkage studies in several large families have mapped the febrile seizure gene to chromosomes 19p and 8q1321. An autosomal dominant inheritance pattern is demonstrated in some families.2 CLINICAL MANIFESTATIONS. A simple febrile convulsion is usually associated with a core temperature that increases rapidly to 39C. It is initially generalized and tonic-clonic in nature, lasts a few seconds and rarely up to 15 min, is followed by a brief postictal period of drowsiness, and occurs only once in 24 hr. A febrile seizure is described as complex or complicated when the duration is >15 min, when repeated convulsions occur within 24 hr, or when focal seizure activity or focal findings are present during the postictal period. Some children have a chronic seizure disorder with more seizures during fever. These are not febrile seizures, but are referred to as seizures with fever. Convulsive status epilepticus (one seizure lasting 30 min or multiple seizures during 30 min without regaining consciousness) is often due to central nervous system infection (viral or bacterial meningitis). Approximately 3050% of children have recurrent seizures with later episodes of fever and a small minority has numerous recurrent febrile seizures. Factors associated with increased recurrence risk include age <12 mo, lower temperature before seizure onset, a positive family history of febrile seizures, and complex features. Febrile seizures are not associated with reduction in later intellectual performance, and most children with febrile seizures have only a slightly greater risk of later epilepsy than the general population. Factors that are associated with a substantially greater risk of later epilepsy include the presence of complex features during the seizure or postictal period, a positive family history of epilepsy, an initial febrile seizure before 12 mo of age, delayed developmental milestones, or a pre-existing neurologic disorder. The risk of epilepsy is much higher than in the general population in children with one or more complex febrile seizures, especially if the seizures are focal in children with an
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underlying neurologic disorder. The incidence of epilepsy is >9% when several risk factors are present, compared with an incidence of 1% in children who have febrile convulsions and no risk factors.2 During the acute evaluation, a physician's most important responsibility is to determine the cause of the fever and to rule out meningitis or encephalitis. If any doubt exists about the possibility of meningitis, a lumbar puncture with examination of the cerebrospinal fluid (CSF) is indicated. A lumbar puncture should be strongly considered in children <12 mo of age and considered in those 1218 mo of age, especially if seizures are complex or sensorium remains clouded after a short postictal period.2 Seizure-induced CSF abnormalities are rare in children and all patients with abnormal CSF after a seizure should be thoroughly evaluated for causes other than seizure. The possibility of viral meningoencephalitis should also be kept in mind, especially that caused by herpes simplex. Viral infections of the upper respiratory tract, roseola (and nonroseola human herpes virus 6 and 7 infections), and acute otitis media are most frequently the causes of febrile convulsions. Aside from glucose determination, laboratory testing such as serum electrolytes and toxicology screening should be ordered based on individual clinical circumstances such as evidence of dehydration. An electroencephalogram (EEG) is not warranted after a simple febrile seizure but may be useful for evaluating patients with complex or atypical features or with other risk factors for later epilepsy. Similarly, neuroimaging is also not useful for children with simple febrile convulsions, but may be considered for children with atypical features, including focal neurologic signs or pre-existing neurologic deficits.2 TREATMENT. Routine management of a normal infant with simple brief febrile convulsions includes a careful search for the cause of the fever and reassurance and education of the parents. Although antipyretics have not been shown to prevent seizure recurrences, active measures to control the fever, including the use of antipyretics, may reduce discomfort and are reassuring. In a setting where support for ventilation can be provided, consideration should be given to treating seizures lasting >5 min with a benzodiazepine as a first-line therapy as described in Chapter 593.8 . Prolonged anticonvulsant prophylaxis for preventing recurrent febrile convulsions is controversial and no longer recommended for most children. Antiepileptics such as phenytoin and carbamazepine do not prevent febrile seizures. Phenobarbital prevents recurrent febrile seizures but may also decrease cognitive function in treated children compared with untreated children. Sodium valproate is also effective for prevention of febrile seizures, but the potential risks of the drug do not justify its use in a disorder with an excellent prognosis regardless of treatment. The incidence of fatal valproate-induced hepatotoxicity is highest in children <2 yr of age. If parental anxiety is very high, oral diazepam may be used as an effective and safe method of reducing the risk of recurrence of febrile seizures. At the onset of each febrile illness, oral diazepam, 0.3 mg/kg q8h (1 mg/kg/24 hr), is administered for the duration of the illness (usually 23 days). The side effects are usually minor, but symptoms of lethargy, irritability, and ataxia may be reduced by adjusting the dose. Another approach for selected patients with recurrent complex febrile seizures is to prescribe diazepam in the form of a gel that can be given rectally at the time of a seizure in a dose of approximately 0.5 mg/kg for children aged 25 yr. This will usually terminate the seizure and prevent recurrence over 12 hr. Preventive anticonvulsant treatment
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or treatment after the seizure has not been shown to reduce the risk of later epilepsy in higher risk patients.2 The prognosis of children with simple febrile seizures is excellent. Intellectual achievements are normal. Many children have further febrile seizures, but the development of epilepsy (afebrile seizures) is rare. Febrile seizures recur in 50% of children who have their first febrile seizure at younger than 1 year of age and in 28% of children who have their first seizure at older than 1 year of age. About 10% of children with febrile seizures have three or more recurrences. The risk of multiple recurrences is greater in infants with onset in the first year. Children with complex febrile seizures have only a 7% risk of having further complicated febrile seizures. The risk of epilepsy in most children with febrile seizures is no greater than the general population (approximately 1%). Factors that increase the risk for the development of epilepsy include abnormal neurologic examination or development, family history of epilepsy, and complex febrile seizures. The probability of developing epilepsy is 2% if one risk factor is present and 10% if two or three risk factors are present.3

Chapter II Case Illustration PATIENTS IDENTITIY Name Sex Address Age Ethnicity Religion Date of admission Medical record no. Payment method : Child Nayla : Girl : Jl. Musyawaroh No. 14 Kebon Jeruk, Jakarta Barat : 16 months old : Betawi : Islam : 4th October 2010 (2.30 am) : 79 75 85 : Jamkesmas

PARENTS IDENTITY Father Name Age Education Occupation Religion Suku Mr. A 35 years old High school graduate Entepreneur Islam Javanese Mother Mrs. E 32 years old Junior high graduate House wife Islam Javanese

Income

Rp. 2.5000.000,-/month

None

Parent-child relationship: biologic child

ANAMNESIS The information from anamenesis was based on alloanamnesis to the mother and father on 4th October 2010, information from RSAB Harapan Kita. Chief Complaint Seizure 30 minutes before hospital admission.

History of Present Illness 12 hours before admission, the child suddenly had a fever, and her mother gave her a sanmol syrup. A fever was subsided, but about 2 hours later the fever was occur again. The child had a cough too, and she had a yellow sputum. The child was conscious. There is no serumen and liquid appears from ear. There is no diarrhea and vomit. 7 hours before admission, her mother realize that the patient was being seizure, type of seizure is tonic clonic, Duration of seizure about 10 minutes and after had a seizure the child cry spontaneusly. But the mother is still panic, and she go to the clinic near her house, and got a dumin for her child. 4 hours before admission, fever was appears and then the patient had a seizure again,with a same type tonic clonic, duration of seizure about 3 minutes and after had a seizure the child cry spontaneusly. 30 minutes before admission, fever was appears and then the patient had a seizure again,with a same type tonic clonic, duration of seizure about 5 minutes and but after had a seizure the child was unconscious, and the her mother bring her to the emergency RSAB Harapan Kita.

History of Past Illness At 8 months old, patient got seizure once, duration 5 minutes, the seizure was same like this time (with fever) and got paracetamol to reduce fever. History of Family Illness Mother had diagnosed with febrile convulsion when she was child.

History of Pregnancy Patient mother was healthy throughout her pregnancy. Antenatal visit was irregular. Spontaneous birth, no cyanosis, no icteric, spontaneously cried.
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History of Delivery Patient was born with midwifes help, birth spontaneously, normal, at term, and cried spontaneously. There were no pale, yellow or blue. Birth weight was 3100 gram and birth lenght is 48 cm.

History of Growth, Development, and Puberty Rolling over: at 5 months old. Sitting down: at 8 months old Crawling: at eight months old Standing up: at 12 months old Walking: (-).

History of Feeding Patient had breastfed until 3 months ago. Additionally, since 10 months ago patient also drinks formula milk. She started to eat fruits at the age of 2 months old. Bubur susu at 5 months old. At 1 year old, patient started to eat rice with vegetables on the side.

History of Immunization Patient completed the basic immunization program.

History of Maternal Reproduction Patient is the second child in the family. The age of the mother was 21 when she was pregnant.

PHYSICAL EXAMINATION (Monday, October 4th 2010) General Condition Compos mentis, Irritable Vital Sign Blood Pressure: 100/70 mmHg HR RR : 136 x/minute, regular, adequate, equal : 36 x/minute, regular, abdominotorakal

Temp. : 39.1oC axilla Anthropometric Data Body Weight Body Height Nutritional Status : 8 kg : 71 cm : BW/A = 8/10.6 x 100% = 75.5% BH/A = 71/79 x 100% = 89.8 % BW/BH = 8/10.9 x 100% = 73.4%, z-score between -1 and -2 SD Height age 9 m.o Clinical interpretation: mild to moderate malnutrition Head circumference: 44 cm (normocephalic) Upper arm circumference: 14 cm General Status Head: deformity (-), fontanel closed, sinus pain (-) Hair: hair distribution are equal, hair could not easily pulled Eyes: anemic conjuctiva -/-, icteric sclera -/-, sunken eyes -/Nose: secret -/-, septum deviation (-) Throat: uvula at the middle, tonsil T2/T2, hyperemic (+), edema (-), PND (-) Teeth and mouth: cyanosis (-), good hygiene, oral thrush (-), carries dentis (-) Neck: trachea in the middle, lymph nodes enlargements (-)

Chest: symmetric on static and dynamic, no retraction Heart: ictus cordis is palpated in 5th ICS of left midclavicle line, 1st and 2nd heart sound are normal, murmur (-), gallop (-) Lung: symmetric on static and dynamic, symmetric expansion, right fremitus = left fremitus, sonor/sonor, vesicular +/+, rales -/-, wheezing -/Abdomen: supple, flat, pain on palpation (-), liver and spleen were impalpable, balotement -/, CVA pain -/- intestinal sound (+) normal 1 x/ 5 seconds, good turgor Extremity: warm extremity, CRT <2 second. LABORATORY EXAMINATION (3rd October 2010) Complete blood Hb: 10.7 g/dL Ht: 33 vol% Leu: 10.500/uL Diff count: -/-/-/77/20/3 % Thrombocyte: 159.000 ui Glucose test 136 mg/dl Electrolyte (6th October 2010) Complete blood Hb: 10.8 g/dL Ht: 33 vol% Leu: 6.500/uL Diff count: -/-/-/31/63/6 % Thrombocyte: 123.000 ui

MCV: - CU microns MCH: - pg MCHC: %

MCV: - CU microns MCH: - pg MCHC: %

(7th October 2010) Complete blood Hb: 11 g/dL Ht: 34 vol% Leu: - uL Diff count: Thrombocyte: 95.000 ui

MCV: - CU microns MCH: - pg MCHC: %

Summary Child,a girl 16 months old, came to hospital with a convulsion 30 minute before admission. There were high fever, cough, unconscious when she had a convulsion, 3 times in 24 hours, the type is tonic clonic and after had a convulsion, she was conscious.. From physical examination her temperature is 39c. . Wasting and baggy pants (-). From laboratory examination got trombositopeni. The patient was diagnosed with complex febrile convulsion and mild moderate malnutrition.

WORKING DIAGNOSIS 1. Complex febrile convulsion 2. Mild to moderate malnutrition

MANAGEMENT Lumbar Puncture Glucose test Electrolyte analysis Dumin (paracetamol) supp 120 mg KAEN 1B 960 mL/24 hours 10 dpm Diazepam 10 mg supp per rectal Diazepam 3 x 0.8 mg oral Monitoring vital sign Diet 10.9 x 100 = 1100 kcal/24 hours

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Chapter III Case Discussion

The patient is a 16 months old girl with a sudden convulsion since 30 minutes before hospital admission. Later, this patient is diagnosed as complex febrile convulsion and mild-moderat malnutrition.

Diagnosis Discussion The diagnosis of complex febrile convulsion was based on the anamnesis, physical examination. From the anamnesis, it was found that the patient has sign of convulsion, and three times in 24 hours, the type of convulsion is tonic clonic, and before had a convulsion, she had a fever, during the convulsion, and patient was unconscious. From physical examination, there is a fever, the temperature about 39c. The laboratory examination also revealed an abnormality, trombositopenia, from 159.000 in 1st day, 123.00 in 3rd day, 95.000 in 4th day. There is no hemaconcentration. There is also another diagnosis accompanying a complex febrile convulsion, which is mildmoderate malnutrition. The diagnosis of the mild-moderate malnutrition is mostly based on the antropometric measurement. The BW/BH showed that the patient has a mild-moderate malutritional status. Moreover, the parents also stated that she doesnt eat much. Treatment Discussion The management treatment, the patient must have a lumbar puncture, because we have to know is there any bacterial or viral infection in serebrospinal fluid. A blood glucose test and electrolyte blood analysis if there is an intracranial causes. Paracetamol oral was given for maintaining the temperature, and if she still has a fever, we can give her a paracetamol supp per rectal. Intra venous line therapy was given KAEN 1 B for maintanance fluid body and to reduce a fever, 10 drops per minute. And therapy for convulsion, she got a diazepam per oral three times a day 0.8 mg, and if the convulsion occurs, we can give her a diazepam per rectal 10 mg. Nutritional Discussion Here is the nutritional status of the patient: BW/A = 8/10.6 x 100% = 75.5% BH/A = 71/79 x 100% = 89.8 % BW/BH = 8/10.9 x 100% = 73.4 %

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From the calculation above, we can see that the patient has mild-moderate malnutrition status. The ideal body weight for the height of 71 cm is 10.9 kg. Moreover, the height of 71 cm is actually the height of 9 months old. Therefore, the height age of the patient is 9 months old. The calorie requirement for 9 months old child is 110 kcal/kgBW/day. From above data, we can calculate the daily calorie requirement, being the ideal body weight of 10.9 multiplied by the calorie requirement of a 9 months old child, 110 kcal/kgBW/day. Therefore, the total calorie is 1199 kcal/day.

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References 1. Grace M Young. Pediatrics, Complex febrile convulsion. 2009. Downloaded from http://emedicine.medscape.com/article/801117-overview 2. Febrile Seizures. In Kliegman: Nelson Textbook of Pediatrics. 2007. Saunders, Elsevier. 3. Febrile seizures. In Nelson Essentials of Pediatrics ed 5th. 2007. WB Saunders Publisher.

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