FEBRILE SEIZURE
1 yr old presents with fever of 1 day and generalised seizure of 10 minutes duration is brought ER at post ictal state
Febrile 39 0c
No neck stiffness
Throat congested
No dysmorphism
No neurocutaneous markers
What is your assessment ?
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A simple febrile seizure is a primary generalized, usually tonic–clonic, attack associated with fever, lasting for a maximum of 15 min, and notrecurrent within a 24-hr period
Being less than 1 yr meningeal signs are reliable
Younger age < 1 yr increases the risk of recurrences
Duration of <24 hrs increases the risk of recurrences
High grade fever also increases the risk of recurrence
2 yr old develops fever of 39 0c and develops focal seizure on day 3 . it lasted for 30 minutes. Child was seizing when they reached ER_
Febrile
No meningeal signs
No neurocutaneous markers
No dysmorphism
What is your assessment?
Complex febrile seizure
Seizing at 30 minutes -status /prolonged seizure
A lumbar puncture is still recommended in children with a prolonged febrile seizure, as well as in any child with persistent lethargy.
The study, Consequences of Prolonged Febrile Seizures (FEBSTAT), recruited 199 children aged 1 month through 5 years who had a febrile seizure that lasted more than 30 minutes. Children recruited most often had focal seizures that were usually their first febrile seizure
The FEBSTAT study performed baseline EEGs within 72 hours of the episode of febrile status epilepticus. Review of their baseline EEGs showed that there was focal slowing or attenuation in a substantial proportion of children, and the slowing and attenuation were highly associated with MRI evidence of acute hippocampal injury.
Even prolonged febrile seizures do not appear to be associated with adverse cognitive outcomes. In the British Cohort Study, no differences were found between 5-year-olds with and those without febrile seizures, even when the analysis was limited to complex febrile seizures. A study of 27 children with febrile convulsions lasting more than 30 minutes found no differences in cognitive function at 7 years of age between them and their siblings.
3 yr old child with with previous history of febrile seizures develop fever and focal seizures . he has no post ictal deficit
What is his risk of recurrence?
Risk Factors for Recurrence of Febrile Seizures
MAJOR
Age <1 yr
Duration of fever <24 hr
Fever 38-39°C (100.4-102.2°F)
MINOR
Family history of febrile seizures
Family history of epilepsy
Complex febrile seizure
Daycare
Male gender
Lower serum sodium at time of presentation
Having no risk factors carries a recurrence risk of approximately 12%; 1 risk factor, 25-50%; 2 risk factors, 50-59%; 3 or more risk factors, 73-100%.
1 yr old who had febrile seizure ,now develops afebrile seizure focal clonic variety. In the 2 nd yr he develops myoclonus . he is noted to have developmental delay?
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What is your impression?
Is it complex febrile seizure?
Dravet syndrome is the most severe of the phenotypic spectrum of febrile seizure-associated epilepsies. It constitutes a distinct entity in the onset of which is in infancy. Its onset is characterized by febrile and afebrile unilateral clonic seizures recurring every 1 or 2 mo. These early seizures are typically induced by fever, but they differ from the usual febrile convulsions in that they are more prolonged, are more frequent, are focal and come in clusters. Seizures subsequently start to occur with lower fevers and then without fever.
During the 2nd yr of life, myoclonus, atypical absences, and partial seizures occur frequently and developmental delay usually follows. This syndrome is usually caused by a de novo mutation, although rarely it is inherited in an autosomal dominant manner. The mutated gene is located on 2q24-31 and encodes for SCN1A, the same gene mutated in GEFS+ spectrum.
However, in Dravet syndrome the mutations lead to loss of function and thus to a more severe phenotype. There are several milder variants of Dravet syndrome that manifest some but not all of the above features and that are referred to as Dravet syndrome spectrum or Borderland. Mutations in other genes may also cause Dravet syndrome or GEFS+ phenotypes
6 yr old with past history of febrile seizure is developing generalised tonic clonic seizure with out fever. He has family history of febrile and afebrile seizures
What is your assessment?
GEFS+ is an autosomal dominant syndrome with a highly variable phenotype. Onset is usually in early childhood and remission is usually in mid-childhood. It is characterized by multiple febrile seizures and by several subsequent types of afebrile generalized seizures, including generalized tonic–clonic, absence, myoclonic, atonic, or myoclonic astatic seizures with variable degrees of severity. A focal febrile seizures plus epilepsy variant, in which the seizures are focal rather than generalized, has also been described.
1 yr old is admitted with simple febrile seizures is admitted. You have done cbc,RBS,calcium, and LP. You are planning to do lp after imaging. Parents request EEG
Lumbar Puncture
Meningitis should be considered in the differential diagnosis, and lumbar puncture should be performed for all infants younger than 6 mo of age who present with fever and seizure, or if the child is illappearing or at any age if there are clinical signs or symptoms of concern. A lumbar puncture is an option in a child 6-12 mo of age who is deficient in Haemophilus influenzae type b and Streptococcus pneumoniae immunizations or for whom immunization status is unknown. A lumbar puncture is an option in children who have been pretreated with antibiotics
Electroencephalogram
If the child is presenting with the first simple febrile seizure and is otherwise neurologically healthy, an EEG need not normally be performed as part of the evaluation. An EEG would not predict the future recurrence of febrile seizures or epilepsy even if the result is abnormal. Spikes during drowsiness are often seen in children with febrile seizures, particularly those older than age 4 yr, and these do not predict later epilepsy. EEGs performed within 2 wk of a febrile seizure often have nonspecific slowing, usually posteriorly
At times, if the patient does not recover immediately from a seizure, then an EEG can help distinguish between ongoing seizure activity and a prolonged postictal period, sometimes termed a nonepileptic twilight state. EEG can also be helpful in patients who present with febrile status epilepticus because the presence of focal slowing present on the EEG obtained within 72 hr of the status has been shown to be highly associated with MRI evidence of acute hippocampal injury
Blood Studies
Blood studies (serum electrolytes, calcium, phosphorus, magnesium, and complete blood count) are not routinely recommended in the work-up of a child with a first simple febrile seizure. Blood glucose should be determined in children with prolonged postictal obtundation or with poor oral intake (prolonged fasting). Serum electrolyte values may be abnormal in children after a febrile seizure, but this should be suggested by precipitating or predisposing conditions
A low sodium level is associated with higher risk of recurrence of the febrile seizure within the following 24 hr.
Neuroimaging
A CT or MRI is not recommended in evaluating the child after a first simple febrile seizure. Approximately 11% of children with febrile status epilepticus are reported to have (usually) unilateral swelling of their hippocampus acutely, which is followed by subsequent long-term hippocampal atrophy.
Which all infections are common precipitants of febrile seizures and febrile status?
Febrile seizures often occur in the context of otitis media, roseola and human herpesvirus (HHV) 6 infection, shigella, or similar infections, making the evaluation more demanding. In patients with febrile status, HHV-6B (more frequently) and HHV-7 infections were found to account for one-third of the cases
what is the risk of a child developing epilepsy following febrile seizure?
focal febrile seizure
neurodevelopmental disability
recurrent febrile seizure
Risk Factors for Occurrence of Subsequent Epilepsy After a Febrile Seizure
RISK FACTOR RISK FOR SUBSEQUENT EPILEPSY
Simple febrile seizure 1%
Recurrent febrile seizures 4%
Complex febrile seizures (more
than 15 min duration or recurrent
within 24 hr)
6%
Fever <1 hr before febrile seizure 11%
Family history of epilepsy 18%
Complex febrile seizures (focal) 29%
Neurodevelopmental abnormalities 33%
reference
pediatric neurology swaiman 6th edition
nelson text book of pediatrics 20th edition
Superintendent, ICH.