Pediatrics · Year 3 · from Pediatrics

Case 1: Febrile Seizure

Patient Demographics

  • Age: 18-month-old male
  • Sex: Male

Chief Complaint

"My son had a seizure during his fever."

History of Present Illness

An 18-month-old previously healthy male is brought to the emergency department after experiencing a generalized tonic-clonic seizure at home. The mother reports that the child had been fussy with rhinorrhea and low-grade fever (38.2°C) for the past day. This morning, his temperature rose rapidly to 39.5°C, and within 30 minutes he suddenly stiffened his whole body, then began jerking his arms and legs rhythmically. The episode lasted approximately 2 minutes, after which he was drowsy but responsive. This is his first seizure. There is no history of head trauma. His father had febrile seizures as a child. The child is fully vaccinated and has had normal development.

Physical Examination

  • General: Drowsy but arousable, mildly irritable toddler
  • Vital signs: Temp 38.8°C, HR 130 bpm, RR 28/min, BP 90/55 mmHg
  • HEENT: Rhinorrhea, mildly erythematous oropharynx, bilateral TMs erythematous with decreased mobility, no bulging fontanelle, no meningeal signs
  • Cardiovascular: Regular rate and rhythm, no murmur
  • Respiratory: Clear to auscultation
  • Neurologic: Symmetric pupils, reactive to light, moves all extremities equally, normal tone, no focal deficits, no meningeal signs (negative Kernig and Brudzinski)

Workup

  • Point-of-care glucose: 95 mg/dL (normal)
  • Clinical assessment: Appearing well after postictal period resolved, no signs of meningitis

Diagnosis

Simple febrile seizure with acute otitis media

Clinical Reasoning

This presentation is classic for a simple febrile seizure: generalized seizure lasting less than 15 minutes, occurring once in 24 hours, in a neurologically normal child aged 6 months to 5 years, with fever and no evidence of CNS infection. The family history of febrile seizures supports the diagnosis. The source of fever is bilateral acute otitis media. Because he is over 12 months old, fully vaccinated, has no meningeal signs, and returned to baseline, lumbar puncture is not indicated. EEG and neuroimaging are not recommended for simple febrile seizures.

Management

  1. Treat underlying infection: Amoxicillin for acute otitis media
  2. Antipyretics: Acetaminophen or ibuprofen for comfort (though antipyretics do not prevent febrile seizures)
  3. Parent education:
  • Febrile seizures are common (2-5% of children) and benign
  • Risk of recurrence is approximately 30%
  • Simple febrile seizures do not increase epilepsy risk above baseline 1%
  • First aid: place child on side, do not put anything in mouth, time the seizure
  1. Rescue medication: Consider prescribing rectal diazepam (0.5 mg/kg) for future seizures lasting >5 minutes
  2. Return precautions: Return for seizures lasting >5 minutes, focal features, or signs of meningitis

Clinical Image

Image Description: EEG recording showing generalized spike-wave discharges, demonstrating the typical electroencephalographic patterns seen in seizure disorders.

Source: Wikimedia Commons URL: https://commons.wikimedia.org/wiki/File:Spike-waves.png License: CC BY-SA 3.0

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