2. CASE
• The emergency department (ED) notifies you that one of your
patients is being evaluated for new onset seizures. The 2 year
old boy was in his normal state of good health until this
morning. When he complained of a headache and then fell to
the floor. While waiting for the ED physician to come to the
phone, you review the patient’s chart and find that he has had
normal development. His family history is significant for a
seizure of unknown etiology that his father had at age 4years.
According to ED physician, the boy’s mother saw jerking of
both arms and legs. When the ambulance arrived 5 minutes
later the child had stopped jerking but was not arousable. His
heart rate was 108 bpm, Resp rate 16, BP 90/60 mmHg, temp
104 F (40C). His blood sugar level was 135mg/dL. By the time
the child arrived to ED he was awake and recognized his
parents. His physical examination in the ED was normal, as are
his Complete blood count and urinalysis.
3. IMPORTANT POINTS
• Age
• Normal state of good health
• Normal development
• Family history significant for seizures
• Generalized tonic clonic seizure
• Elevated temperature
• Other investigations normal
4. QUESTIONS
• What is the most likely diagnosis?
• What is the best management for this condition?
• What is the expected course of this condition?
• List the factors that increase the risk of further seizure
activity
5. MOST LIKELY DIAGNOSIS?
• Simple febrile seizure
• Diagnostic Criteria:
-The setting is fever in a child aged 6 months to 5 years
-The single seizure is generalized and lasts less than 15
mins
-The child is otherwise neurologically healthy and without
neurological abnormality by examination or developmental
history
-Fever (and seizure) is not caused by meningitis,
encephalitis or other illnesses affecting the brain
6. ADDITIONALLY…
• Most common seizure disorder in childhood
• Considered a genetic disorder however pattern of
inheritance has not been described
• Most commonly presents as tonic clonic seizure
7. IMMEDIATE MANAGEMENT
• In diagnosing this condition, physician should rule out any other
causes of the seizure
• After, diagnosis the focus is on diagnosing cause of fever
• No blood studies are specific unless patient also has diarrhea
or vomiting (electrolyte studies)
• No imaging is indicated
• On the basis of risk/benefit analysis, neither long term or
intermittent anticonvulsant therapy is indicated for children who
have experienced one or more simple febrile seizure
• Oral diazepam can reduce the risk of subsequent febrile
seizures, because it is intermittent, this therapy has the fewest
adverse effects. If preventing febrile seizures is essential, this
would be the treatment of choice
• Antipyretic medication
8. POSSIBLE PROCEDURE
• Strongly consider lumbar puncture in children younger
than 12 months, because the signs and symptoms of
bacterial meningitis may be minimal or absent in this age
• LP should be considered in children aged 12-18 months,
because the signs of bacterial meningitis are subtle
• For children older than 18 months, the decision to perform
lumbar puncture rests on the clinical suspicion of
meningitis
9. LONG TERM MANAGEMENT
• Most important aspect is PARENTAL COUNSELLING
• This can be a traumatizing experience for parents so they
must be reassured that their child will most likely have a
good outcome
10. EXPECTED COURSE OF CONDITION
• Children with a previous simple febrile seizure are at
increased risk of recurrent febrile seizure, this occurs in
one third of cases
• Children younger than 12 months at the time of first
simple febrile seizure have a 50% probability of having a
second. After 12 months the probability decreases to 30%
• Children who have simple febrile seizures are at an
increased risk for epilepsy. The rate of epilepsy by aged
25 is about 2.4%, which is about twice the risk of normal
• No literature supports the hypothesis that simple febrile
seizures lower intelligence, cause learning disability or
associated with increased mortality
11. RISK FACTOR FOR FIRST FEBRILE
SEIZURE
• Family history of febrile seizures
• Delayed development
• Low sodium levels
• Very high fever
12. RISK FACTOR FOR RECURRENCE OF
FEBRILE SEIZURES
• Young age
• Family history of febrile seizures
• Short duration of fever before the initial seizure
• Relatively low fever at the time of initial seizure
• Possible family history of afebrile seizure
13. RISK FACTORS FOR DEVELOPMENT
OF EPILEPSY FOLLOWING FEBRILE
SEIZURES
• Suspect or abnormal development before the first seizure
• Family history of afebrile seizures
• Complex first febrile seizure
14. ETIOLOGY
• Most febrile illnesses associated with febrile seizures are
due to common infections such as
-tonsillitis
-Upper respiratory tract infections
-otitis media
Children of pre school age are subject to frequent
infections and accompanying high fevers, in combination
with a relatively low seizure threshold, allows the common
occurance of febrile seizures
15. PATHOPHYSIOLOGY
• Unknown
• However, increased susceptibility to febrile seizures
associated with specific interleukin alleles (Tsai et al 2002,
Kanemoto 2003) are being studied as well as relative lack
of myelination in immature brain (Hirtz and Nelson 1983)
and impaired thermoregulatory mechanisms
(McCaughran and Schechter 1983)
• Recently documented pathogen associated with febrile
seizure is human Herpes virus type 6 (Suga 2000) and
the direct viral invasion of the brain causes the seizures,
and the virus can be reactivated when there is fever
16. CONCLUSION
• Febrile seizures are now recognized as a benign
syndrome determined largely by genetic factors,
manufactured by an age related susceptibility to seizures
that is eventually outgrown.
• Fortunately, the majority of children who have febrile
seizures will require no treatment other than parental
reassurance and will have a good outcome.
