Case Report : Complex Febrile

Seizure due to Acute Rhinopharyngitis

Presented by: Diska AstariniSupervisor: dr. Sumardi Fransiskus, M.biomed, Sp.A

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Patient Identity

• Name : DPP

• Sex : Male

• Age : 1 year 5 month

• Religion : Catholic

• Address : Rantau village,Monterado

• Date of birth : 3 October 2013

• Date of : 17 March 2015

hospitalization

History Taking

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Main Complaint

a 1 year old boy was brought to the

emergency room of Abdul Aziz

Hospital on March, 17th , 2015 due

to seizure 4 hours before the

hospitalization

•1 week before

• Cough• Rhinorhea

•1 days before

• Fever• No

temperature was documented

• Temporarily relieved by Paracetamol syrup

•7 hours before

• 1st seizure• Lasted for <5

minutes• Eyes rolling

upward + rhytmic jerking of the upper and lower extremities

• crying after the seizure and then sleep

•4 hours before

• 2nd seizure• < 10

minutes• 4 limbs

jerky movement

• Regain consciousness and crying after the seizure

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Systemic review

▫Pasient didn’t complain about

dyspnea, chill, bruised, epistaxis,

gums bleeding or joint swelling.

▫Defecation and urinate pattern was

the same as usual

Body Systems Complaints

General No weight loss, no loss of appetite

Cardiovascular No Leg Swelling, No Chest Pain, no palpitation, no shortness ofbreath

Respiratory No shortness of breath, no noisy breathing, cough, rhinorhea, no hemoptisis

Gastrointestinal No diarrhea, no hematemesis, no constipation

Genitourinary No increase in freqency of micturation, no dysuria, no incontinence, no flank pain no hematuria

CNS No LOC after attack, no headache , no history of trauma

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Past Medical History

• Never had history of the seizure with or

without fever before.

• Never had been hospitalized or

undergone any surgery before.

• Had no long term illnesses

• Never had history of alergy, asthma

Family’s medical history

• Patient’s father had history of febrile

seizure during his childhood lives

• No epilepsy history in the family

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History of mother’s pregnancy

• Never consumed “jamu” or other

drugs without doctor prescription

• Never had fever , hypertension or

fluor albus

• ANC every month at midwife’s clinic

Birth history

• He was born full term by spontaneous

vertex presentation, delivery at home

supported by midwife, crying

immediately. The birth weight was 2800

gr. The delivery was uncomplicated and

there was no resuscitation required

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Feeding history

• 0-4 month: breast milk only

• 4-10 month: breast milk + formula milk +

porridge

• 10 month : started to eat rice same with

other’s family menu.

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Immunization History

Patient’s mother said that the basic

immunizations were complete . The

last immunization he took when his

age was 9 month

Developmental History

• All the developmental parameters were

normal according to statement of

patient’s mother. Patient look normal and

the developmental progress was the same

as other child around.

Social & Environmental History

• Patient is the only child. He lives with

his parents and his grandmother. None

of them was having fever or cough

before the patient even got one.

Genogram

70 yr 61 yr

35 yr 30 yr 23 yr

45 yr 42 yr

19 yr 15 yr 12 yr 7 yr

1 year 5 month

: patient

: another family with febrile seizure history

Physical Examination

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General appearance:Concious and alert

Look hurts a little more

Well nourished

Vital Sign• BP : 80/60 mmHg

• RR : 104 bpm

• HR : 38 bpm

• T : 38,1o C

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Antropometri• Height : 79 cm• Weight : 9 kg

• W/A : normal• H/A : normal• W/H : normal

Systemic Examination

• Cardiovascular : NAD

• Abdominal : NAD

• CNS : NAD

• Urogenital : NAD

• Respiratory:

Nose : Discharge (+)

pharynx : Reddish (+)

Lung : Wheezing (-/-), Crackles (-/-)

NEUROLOGY EXAMINATION

• Cranial nerve : there was no

nystagmus. All cranial nerve were

intact

• Muscle tone: No hypotonia and

hypertonia

• Signs of meningeal irritation: no

neck stiffness, negative brudzinski‘s

and kernig’s sign

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Laboratory Finding

Parameter Standard 17/03/15

WBC

RBC

HGB

MCV

MCH

RDW

HCT

PLT

WIDAL

3.6-11.0 gr/l

4.20-6.20 x 106/l

11.7-17.3 g/dl

80-100 fl

26-34 pg

10,5-14,5 fl

38.0-54-0 %

150-440 x 103/l

Negatif

6,9 x 103 gr/l

4,80x 106/l

11,5 g/dl

67,0 fl

24,1 pg

11,1 % fl

32,2 %

428 x 103/l

O (Negatif)

H(Negatif)

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Diagnosis

•Complex Febrile Seizure due to

Acute Rhinopharyngitis

Planning

• Electrolyte serum

• Glucose

• Lumbal Puncture (recommended)

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Treatment

• ABC

• Bed rest

• Diet

• Drink warm fluids

• Avoid smoky environment

• Education to parents

• IVFD D5 ¼ NS 20 dpm mikro

+ oral intake fluid 73cc/day

• Inj. Diazepam IV 3 mg (if

seizure only)

• Inj. Metamizole 3x 90 mg

(T>38,5 ◦C)

• Diazepam per rectal 4,5 mg/

8 hours (T>38,5 ◦C)

• Paracetamol syrup 3x ¾

cthcc

• Ambroxol syrup 2x ½ cth

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Prognosis

•Quo ad Vitam : Bonam

•Quo ad Functionam : Bonam

•Quo ad Sanactionam : Dubia

Ad Bonam

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Case Analysis

27Anamnesis

Theory

“Seizure occuring in association with fever in children between 6 month and 60 month of age, absence of intracranial infection, metabolic disturbance or other metabolic disorder.”

(Pedoman Pelayanan Medis IDAI,2009)

Patient• 1 year 5 month old boy • More than 1 seizure attack

within 24 hours• Duration 5-10 minutes• Cough, rhinorrea, fever • No neurological deficit after

seizure• No evidence of intracranial

pathology or any metabolic derangement

Patient

• More than 1 seizure attack within 24 hours

• Duration 5-10 minutes • No neurological deficit

after seizure

• No evidence of intracranial pathology or any metabolic derangement

Theory“Classification of Febrile Seizures:

Simple (all of the following)• Duration of less than 15 minutes• Generalized • No previous neurologic

problems • Occur once in 24 hours

Complex (any of the following) 

• Duration of more than 15 minutes

• Focal• Recurs within 24 hours.”

(Graves,2012)

Physical Examination

•Patients

• T: 38,1oC

• Nose: discharge (+)

• mouth: Pharynx : Reddish• Neurology examination:

Normal• Meningeal’s sign (-)

•Theory

• Temperature: fever

• Mental state: normal

• Cranial nerves are intact

• Neurology examination:

normal

• Meningeal’s sign: (-)

• Extracranium Infection

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Laboratory Finding

PatientNormal level of :

• WBC

• Platelet

• Hemoglobin

• RBC

• Malaria: Negative

• Widal : Negative

Theory

• Laboratory studies are not routinely recommended unless clinically indicated.

• Any labs performed to identifying a source of fever

• LP : 12-18 Month are recommended

• EEG : not routinely recommended

(Seinfeld,2014)

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Diagnosis PatientHistory taking: • 1 year 5 month old boy got

more than 1 seizure attack within 24 hours associated with fever, >15 minutes, no neurological deficit after seizure and there’s no evidence of intracranial pathology. History of febrile seizure in family.

Physical examination: • No neurological abnormality, no

neck stiffness, upper respiratory tract infection

Laboratory Finding• No abnormality detected

Theory• A seizure occuring in the

absence of CNS infection nor

caused by metabolic imbalance

with an elevated temperature in

a child between 6 months and 5

years

• Family history of seizure

• no neurological abnormality

before and after the seizure

• Frequency <4 times a year• (Pedoman Pelayanan Medis IDAI,2009)

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Treatment

•Patient• IVFD D5 ¼ NS 20 dpm mikro +

oral intake fluid 73cc/day

• Inj. Diazepam IV 3 mg (if

seizure only)

• Inj. Metamizole 3x 100 mg

(T>38,5 ◦C)

• Diazepam per rectal 4,5 mg/ 8

hours (T>38,5 ◦C)

• Paracetamol drop 3 x ¾ cth

• Ambroxol drop 3x ½ cth

Theory• Maintain ABC

• Anticonvulsant control

seizure

• Antipiretic Control fever

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Prognosis

Patient

• Quo ad vitam : Bonam

• Quo ad Functionam: Bonam

• Quo ad Sanactionam : Ad

Bonam

Theory• Generally, patients with febrile

seizure have a good

prognosis.

• mortality from febrile seizures

is very rare

• febrile seizures reoccur

frequently

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Thank you