Neurology · Year 3 · from Neurology

Case 3: Febrile Seizure with Parental Anxiety

Patient Demographics

• Age: 14 months old
• Sex: Female

Chief Complaint

Parents in emergency department: "She had a seizure! Is she going to be okay? Does she have epilepsy?"

History of Present Illness

Baby Emma is a 14-month-old girl brought to the emergency department after having a seizure at home approximately 1 hour ago. Her parents describe that she developed a fever (101.8F at home) earlier today with runny nose and fussiness - they assumed she was getting a cold. While her mother was holding her, Emma's eyes suddenly rolled back, her body stiffened, and then her arms and legs began shaking rhythmically. Her lips appeared slightly blue. The episode lasted approximately 2-3 minutes, after which she was drowsy and irritable for about 15 minutes but then returned to her baseline. She has not had another episode. She has never had a seizure before.

Past Medical History

• Healthy infant
• Born full term, no complications
• Immunizations up to date
• No developmental concerns

Family History

• Mother had febrile seizures as a child (2 episodes, outgrew them)
• No epilepsy in family

Physical Examination in ED

Vital Signs: Temp 102.4F (39.1C), HR 140, RR 30, SpO2 99%

General: Alert, interactive, appropriate for age; no longer drowsy

HEENT:

• TMs: Right TM erythematous and bulging consistent with acute otitis media
• Pharynx: Mild erythema
• No meningismus

Neurological:

• Alert, smiling at parents
• Normal tone and strength
• No focal deficits
• Normal fontanelle (soft, flat)

Skin: No rash

Clinical Image

Image: Comparison chart showing the distinguishing features between simple febrile seizures (generalized, <15 minutes, single in 24 hours) and complex febrile seizures (focal features, >15 minutes, or multiple in 24 hours).

Image Source: Wikimedia Commons Attribution: Medical education, Public Domain URL: https://commons.wikimedia.org/wiki/File:Febrile_seizure_types.png

Assessment and Diagnosis

Simple Febrile Seizure

• Age: 14 months (within typical range: 6 months - 5 years)
• Generalized tonic-clonic seizure
• Duration: <15 minutes (2-3 minutes)
• Single episode in 24 hours
• No focal features
• Source of fever identified: Acute otitis media

Criteria Met for Simple Febrile Seizure:

Workup for Simple Febrile Seizure

Lumbar Puncture: NOT indicated

• Child is well-appearing, immunized, no meningeal signs
• LP is not routinely recommended for simple febrile seizures in well-appearing children 6-12 months who are immunized
• For this 14-month-old who is well-appearing and immunized, LP is not necessary

EEG: NOT indicated

• Does not predict recurrence or future epilepsy
• Not helpful in management

MRI: NOT indicated

• No focal features or concern for structural lesion

Routine Labs: NOT necessary for simple febrile seizure

• Can consider if source of fever unclear

Parent Counseling (Critical Component)

Understanding the Event: "Emma had what we call a febrile seizure. These happen in about 2-5% of healthy children between 6 months and 5 years old. They are triggered by fever, not by how high the fever is, but often by how rapidly the temperature rises. Febrile seizures run in families, and since you (mom) had them, Emma has a higher chance."

Prognosis: "I know this was terrifying to watch, but I have reassuring news:

• Simple febrile seizures do NOT cause brain damage
• Simple febrile seizures do NOT cause developmental problems
• Most children outgrow them by age 5
• The risk of developing epilepsy is slightly higher than average (about 2-4%) but still low - most children with febrile seizures NEVER develop epilepsy"

Recurrence Risk: "About 30-35% of children will have another febrile seizure, usually within the first 1-2 years. Risk factors for recurrence include:

• Young age at first seizure (Emma is 14 months - moderate risk)
• Family history of febrile seizures (YES - her mother)
• Lower temperature at time of seizure

The more risk factors, the higher the chance of recurrence."

What to Do If It Happens Again:

1. Stay calm
2. Place her on her side on a safe surface (floor, bed)
3. Do NOT put anything in her mouth
4. Time the seizure
5. If it lasts more than 5 minutes, call 911
6. If she turns blue or has trouble breathing, call 911
7. After the seizure, she may be sleepy - this is normal

Fever Management: "Treating fever with acetaminophen or ibuprofen will make her more comfortable but does NOT prevent febrile seizures. Don't feel guilty if you 'missed' treating a fever - it wouldn't have prevented this."

When to Seek Care:

• Seizure lasts >5 minutes
• Multiple seizures in one day
• Focal seizure (one-sided)
• Not back to baseline within 30-60 minutes
• Signs of meningitis (stiff neck, persistent lethargy, severe headache, rash)

Management Plan

For Acute Otitis Media:

• Amoxicillin 90 mg/kg/day divided twice daily for 10 days

For Febrile Seizure:

• No daily anticonvulsant medication indicated
• Prophylactic antiepileptics NOT recommended for simple febrile seizures

Rescue Medication:

• Rectal diazepam (Diastat) 0.5 mg/kg prescribed for use if seizure lasts >5 minutes
• Instructions provided on administration
• Prescription for future febrile illnesses

Follow-Up:

• With pediatrician in 1-2 days to ensure ear infection improving
• Return to ED if seizure recurs during this illness

Follow-Up (Phone Call Next Day)

• Fever improving on antibiotics
• No further seizures
• Parents feeling more confident about management
• Plan to follow up with pediatrician tomorrow

Teaching Points

1. Simple febrile seizures are BENIGN - do not cause brain damage or developmental problems

1. No workup needed for classic simple febrile seizure in a well-appearing, immunized child

• No LP, EEG, or imaging routinely indicated

1. Simple vs. Complex febrile seizure:

• Simple: Generalized, <15 min, single in 24h
• Complex: Focal features, >15 min, OR multiple in 24h
• Complex febrile seizures have slightly higher epilepsy risk

1. Recurrence risk is about 30-35% - higher if young age, family history, low temperature at seizure

1. Prophylactic antiepileptics are NOT recommended for simple febrile seizures - risks outweigh benefits

1. Parent education and reassurance are the most important interventions

1. Rescue medication (rectal diazepam) can be prescribed for prolonged seizures

Key Teaching Points Summary

Infantile Spasms (West Syndrome)

• Neurological emergency - early treatment improves outcomes
• Triad: Spasms + hypsarrhythmia + developmental regression
• Vigabatrin first-line for TSC-associated cases
• ACTH first-line for non-TSC cases
• Look for ash-leaf spots (TSC)

Duchenne Muscular Dystrophy

• X-linked; affects boys; CK massively elevated
• Gower's sign and calf pseudohypertrophy are classic
• Corticosteroids prolong ambulation
• Cardiac and pulmonary monitoring essential
• Genetic counseling for family

Febrile Seizures

• Simple febrile seizures are benign - no workup needed
• 2-4% risk of future epilepsy (still low)
• 30-35% recurrence risk
• Parent reassurance is the primary intervention
• No prophylactic antiepileptics indicated

All cases for this lecture as Markdown