# Clinical Cases: Pediatric Neurology

## 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
4. **Rescue medication:** Consider prescribing rectal diazepam (0.5 mg/kg) for future seizures lasting >5 minutes
5. **Return precautions:** Return for seizures lasting >5 minutes, focal features, or signs of meningitis

### Clinical Image
![EEG spike-wave pattern](case_01_image.jpg)

**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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## Case 2: Status Epilepticus

### Patient Demographics
- **Age:** 5-year-old female
- **Sex:** Female

### Chief Complaint
"She's been seizing for 10 minutes and won't stop."

### History of Present Illness
A 5-year-old female with known epilepsy (childhood absence epilepsy diagnosed 1 year ago, on ethosuximide) is brought by EMS with ongoing generalized tonic-clonic seizure activity. According to the mother, the child was watching television when she suddenly fell to the floor and began having a generalized seizure. The seizure has been continuous for approximately 15 minutes. EMS administered rectal diazepam 0.5 mg/kg en route 5 minutes ago, but seizure activity continues. The mother reports the child had a viral illness last week and has been vomiting, which may have affected her medication absorption. She has never had a generalized tonic-clonic seizure before; her typical seizures are brief staring spells.

### Physical Examination
- **General:** Actively seizing with generalized tonic-clonic movements
- **Vital signs:** Temp 37.2°C, HR 160 bpm, RR 32/min, SpO2 88% on room air, BP 100/60 mmHg
- **HEENT:** Cyanosis around lips, clenched jaw
- **Neurologic:** Continuous generalized tonic-clonic activity, pupils mid-sized and reactive

### Workup
- **Point-of-care glucose:** 72 mg/dL (low-normal)
- **ABG:** pH 7.22, pCO2 48 mmHg, pO2 65 mmHg
- **Serum ethosuximide level:** 28 mcg/mL (therapeutic 40-100)
- **CBC:** WBC 8,500/μL, Hgb 12.2 g/dL
- **CMP:** Na 138, K 3.8, BUN 12, Cr 0.4
- **CT head (after seizure control):** Normal

### Diagnosis
**Convulsive status epilepticus in a patient with childhood absence epilepsy, likely precipitated by subtherapeutic medication level**

### Clinical Reasoning
Status epilepticus is defined as a seizure lasting more than 5 minutes or multiple seizures without return to baseline. This child has been seizing for 15 minutes despite initial benzodiazepine treatment, representing established status epilepticus. The subtherapeutic ethosuximide level (due to poor absorption during viral illness) likely contributed to breakthrough seizure activity. Notably, ethosuximide only treats absence seizures; this patient has likely developed generalized tonic-clonic seizures, suggesting evolution of her epilepsy syndrome or a secondary generalized tonic-clonic seizure.

### Management
1. **ABCs:** Supplemental oxygen, suction, position for airway protection
2. **Repeat benzodiazepine:** Lorazepam 0.1 mg/kg IV (given at time 15 min)
3. **Second-line agent (at 20 min if seizure continues):** Fosphenytoin 20 PE/kg IV or Levetiracetam 60 mg/kg IV
4. **If refractory (>40 min):** Prepare for anesthetic doses of midazolam infusion, propofol, or pentobarbital; intubation; ICU admission
5. **Post-seizure workup:** EEG monitoring, review medication regimen
6. **Long-term management:** Consider adding a broad-spectrum AED (e.g., valproate) that covers both absence and GTC seizures; optimize medication adherence

### Clinical Image
![EEG patterns in epilepsy](case_01_image.jpg)

**Image Description:** EEG recording demonstrating epileptiform activity, illustrating the electroencephalographic findings used in diagnosing and monitoring seizure disorders.

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