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TRANSCRIPT
CASE REPORT
Complex Febrile Seizure
Presenters : Ika Nopa Nst; Siti Rizky A Nst
Day/ Date : Monday / May 14th 2012
Supervisor : 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 1–14%. 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.
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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.
.
2
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 1–14%. 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 <40°C (<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 (>38.3°C 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 neurological
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
2.1.7. Differential Diagnose and Diagnose
Table 1. Differential diagnoses of fever and convulsions16
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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)
Febrile seizures Simple
Complex
Central nervous system infection Meningitis
Encephalitis
Other precipitants of seizures in a child with
fever
Systemic illnesses (eg. occult bacteraemia)
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:
- 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 patient’s 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
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
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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 Administration Dose
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Diazepam
Diazepam
Phenytoin
Phenobarbital
Rectal
IV
IV
IV
BW < 10 : 5 mg
BW> 10 : 10 mg
0.3-0.5 mg/kgbb/kali
10-20 mg/kgBB /kali
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
CHAPTER 3
7
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. Anemic (-), dyspnea (-),
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 : Lymph node enlargement (-), nuchal rigidity (-)
Thorax : Symmetrical fusiform , retraction (-)HR: 124 bpm, regular, murmur (-)RR : 36 bpm, regular, rales (-)
Abdominal : Soepel, peristaltic (+) N, liver and spleen not palpable
Inguinal : Multiple lymph node enlargement (-)
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Extremities : 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) Results Normal ValueComplete Blood Count
Hemoglobin (Hb) 9.70 g % 10.7 – 17.1 g %Erytrocyte (RBC) 3.45 x 106/mm3 3.75 – 4.95 x106/mm3
Leukocyte (WBC) 9.57 x 103/mm3 6.0 – 17.5 x103/mm3
Hematocrite 29.10 % 38 - 52 %Trombocyte (PLT) 265 x 103/mm3 217 – 497 x103/mm3
MCV 84.30 fL 93 - 115 fLMCH 28.10 pg 29 - 35 pgMCHC 33.30 g % 28 – 34 g %RDW 15.80 % 14,9 – 18,7 %MPV 8.50 fL 7,2 – 10 fLPCT 0.20 %PDW 8.8 fL
Cell Count:
Neutrofil 34.20 % 37 – 80 % Limfosit 47.50 % 20 – 40 %Monosit 15.60 % 2 – 8 %Eosinophil 1.90 % 1 – 6 % Basophil 0.800 % 0 – 1 % Neutrophil absolute 3.27x103/µL 1.9 – 5.4 x103/µL Limfosit absolute 4.55x103/µL 3.7 – 10.7 x103/µL Monosit absolute 1.40x103/µL 0.3 – 0.8 x103/µL Eosinophil absolute 0.28x103/µL 0.20 – 0.50 x103/µL Basophil absolute 0.08x103/µL 0 – 0,1 x103/µL
Differential diagnose : - Complex Febrile Seizure
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- 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 : Alert, weight = 4.3 Kg, Temperature = 37 0C
Head : Eye: Light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra
(+/+). Ear/ mouth/nose: normal.
Neck : Lymph node enlargement (-), nuchal rigidity (-)
Thorax : 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 (-)
Extremities : 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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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) Results Normal ValueComplete Blood Count
Hemoglobin (Hb) 9.70 g % 10.7 – 17.1 g %Erytrocyte (RBC) 3.45 x 106/mm3 3.75 – 4.95 x106/mm3
Leukocyte (WBC) 9.57 x 103/mm3 6.0 – 17.5 x103/mm3
Hematocrite 29.10 % 38 - 52 %Trombocyte (PLT) 265 x 103/mm3 217 – 497 x103/mm3
MCV 94.30 fL 93 - 115 fLMCH 29.10 pg 29 - 35 pgMCHC 33.30 g % 28 – 34 g %RDW 15.80 % 14,9 – 18,7 %MPV 8.50 fL 7,2 – 10 fLPCT 0.20 %PDW 8.8 fL
Cell Count:
Neutrofil 37.20 % 37 – 80 % Limfosit 39.50 % 20 – 40 %Monosit 7.60 % 2 – 8 %Eosinophil 1.90 % 1 – 6 % Basophil 0.800 % 0 – 1 % Neutrophil absolute 3.27x103/µL 1.9 – 5.4 x103/µL Limfosit absolute 4.55x103/µL 3.7 – 10.7 x103/µL Monosit absolute 0.50x103/µL 0.3 – 0.8 x103/µL Eosinophil absolute 0.18x103/µL 0.20 – 0.50 x103/µL Basophil absolute 0.08x103/µL 0 – 0,1 x103/µL
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Test(14-4-2012) Results Normal Value
Analysis of electrolit
Calcium (Ca) 8.9 mg/dL 8.4 – 10.8 mg/dL
Natrium (Na) 137 mEq/L 135 -155 mEq/L
Kalium (K) 4.9 mEq/L 3.6-5.5 mEq/L
Phospor 5.7 mEq/L 5.0 -10.8 mEq/L
Clorida (Cl) 106 mEq/L 96-106 mEq/L
Magnesium (Mg) 1.75 mEq/L 1.4 -1.8 mEq/L
Follow Up April 14th - 18th 2012
S : Fever (-), convulsion (-)
O: Sensorium : Alert, weight = 4.3 Kg, Temperature = 37.70C
Head : Eye: Light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra
(+/+). Ear/ mouth/nose: normal.
Neck : Lymph node enlargement (-), nuchal rigidity (-)
Thorax : 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 (-)
Extremities : 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
P : - IVFD D5% NaCl 0,225% 6 gtt/minute micro
- Tempra Syr 3 x 0,4 cc
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- Stesolit Syr 2 x 0,5 cth
Test (18-4-2012) Results Normal ValueComplete Blood Count
Hemoglobin (Hb) 10.00 g % 10.7 – 17.1 g %Erytrocyte (RBC) 3.42 x 106/mm3 3.75 – 4.95 x106/mm3
Leukocyte (WBC) 7.05 x 103/mm3 6.0 – 17.5 x103/mm3
Hematocrite 28.40 % 38 - 52 %Trombocyte (PLT) 517 x 103/mm3 217 – 497 x103/mm3
MCV 94.00 fL 93 - 115 fLMCH 29.40 pg 29 - 35 pgMCHC 34.00 g % 28 – 34 g %RDW 15.40 % 14,9 – 18,7 %MPV 7.60 fL 7,2 – 10 fLPCT 0.39 %PDW 7.7 fL
Cell Count:
Neutrofil 37.80 % 37 – 80 % Limfosit 39.80 % 20 – 40 %Monosit 7.30 % 2 – 8 %Eosinophil 5.70 % 1 – 6 % Basophil 0.400 % 0 – 1 % Neutrophil absolute 1.95x103/µL 1.9 – 5.4 x103/µL Limfosit absolute 3.79x103/µL 3.7 – 10.7 x103/µL Monosit absolute 0.40x103/µL 0.3 – 0.8 x103/µL Eosinophil absolute 0.47x103/µL 0.20 – 0.50 x103/µL Basophil absolute 0.03x103/µL 0 – 0,1 x103/µL
Test(18-4-2012) Results Normal Value
Analysis of electrolit
Calcium (Ca) 8.7 mg/dL 8.4 – 10.8 mg/dL
Natrium (Na) 137 mEq/L 135 -155 mEq/L
Kalium (K) 4.9 mEq/L 3.6-5.5 mEq/L
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Phospor 6.2 mEq/L 5.0 -10.8 mEq/L
Clorida (Cl) 104 mEq/L 96-106 mEq/L
Magnesium (Mg) 1.75 mEq/L 1.4 -1.8 mEq/L
Follow Up April 19th - 23th 2012
S : Fever (-), convulsion (-)
O: Sensorium : Alert, weight = 4.3 Kg, Temperature = 36.60C
Head : Eye: Light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra
(-/-). Ear/ mouth/nose: normal.
Neck : Lymph node enlargement (-), nuchal rigidity (-)
Thorax : 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 (-)
Extremities : 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 : 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 : Alert, weight = 4.3 Kg, Temperature = 36.60C
Head : Eye: Light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra
(-/-). Ear/ mouth/nose: normal.
Neck : Lymph node enlargement (-), nuchal rigidity (-)
Thorax : 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 (-)
Extremities : 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
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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