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What is on the differential diagnosis for a febrile seizure?

CNS infection (meningitis/encephalitis), Idiopathic epilepsy, Ingestion/poisoning, Head trauma


What are the findings from testing with a febrile seizure?

CBC - Normal. CSF - Normal without organisms.


What are some causes of unresponsiveness in a child?

Seizures, Syncope due to breath-holding spells, infection (meningitis/encephalitis), toxic ingestions/poisoning, head trauma with loss of consciousness, intracranial processes (tumor/hemorrhage), intussusception.


Seizure causes:

Include metabolic disturbances, head trauma, genetic syndromes, developmental abnormalities, fever, idiopathic.


Syncope due to breath-holding spells:

-Common between ages 1 and 3 years
-May be cyanotic or pallid
-Episodes quickly self-resolve; no postictal state


Infection (meningitis/encephalitis):

-Up to 20-40 percent of children with meningitis can present with seizure activity
-Children with encephalitis will frequently present with fever and seizure
-Enteroviral and herpes simplex virus infections are typical pathogens for encephalitis.


Toxic ingestions/poisoning:

-Most commonly seen between 9 mo-3 yrs
-Various medications may cause unresponsiveness (eg, opiates, benzodiazepines, clonidine, oral diabetic agents)



-Lethargy with a near-unresponsive state may be seen between episodes of colicky pain
-Dehydration due to vomiting and third-spacing of fluids may lead to mental status changes



Result of excessive neuronal activity in the brain. Types include generalized tonic-clonic seizure, absence epilepsy (petit mal seizures), simple partial seizures, complex partial seizures.


Generalized tonic-clonic seizure:

-Most common type in children
-Begins abruptly with tonic (rigid) stiffening of all extremities and upward deviation of the eyes
-Clonic jerks of all extremities follow the tonic phase
-Finally, child becomes flaccid; urinary incontinence may occur


Absence epilepsy (petit mal seizures):

-Generalized seizure, but consciousness is regained more quickly than seen in a generalized tonic-clonic seizure
-Seen in children starting around age 3
-Characterized by loss of environmental awareness and automatisms
-Not associated with loss of tone
-May be precipitated by hyperventilation or photic stimulation


Simple partial seizures:

-Motor signs in a single extremity or one side of the body
-Focal onset seizure activity may spread to become generalized


Complex partial seizures:

-Alteration of consciousness is hallmark feature
-Signs and symptoms tend to localize around the eyes, the mouth, and the abdomen
-Commonly accompanied by automatisms, quasi-purposeful motor or verbal behaviors that are repeated inappropriately
-Lasts 30 sec to 2 min and are associated with postictal phase
-Secondary generalization can occur


What are conditions that mimic seizures?

Motor tics, myoclonus, gastroesophageal reflux (sandifer's syndrome), pseudo seizure.


What is the etiology of febrile seizures?

-Typically a benign and self-limited illness like a viral infection causes a fever that triggers a seizure in a susceptible host (young child, positive family history, etc)
-With more serious CNS infection (such as meningitis or encephalitis), the infection itself causes both fever and seizure.
-Prolonged fever prior to the seizure - especially with irritability or inconsolability - is an indication of a more serious CNS condition causing the seizure


What is the epidemiology for febrile seizures?

-One of the most common reasons for seizures in children
-Febrile seizures occur in children ages 6-60 mo at a frequency of 2-4 percent and tend to occur early in the febrile illness (often on the first day)
-Febrile seizures are hereditary, but mode of inheritance is unclear


Classification of febrile seizures:

Simple febrile seizure: More common, last less than 15 min, occur once in a 24 hr period, generalized.
Complex febrile seizure: Less common, last greater than 15 min, occur more than once in 24 hr period, focal


What is the recurrence risk for febrile seizures:

If a child has a first febrile seizure before age 12 mo, the recurrence risk for a second febrile seizure is about 50 percent. If first seizure is after 12 mo of age, the recurrence risk is about 30 percent. Parents should be reassured that recurrent, simple febrile seizures have no long-term effects on child development.


What is the risk of epilepsy in a patient with febrile seizures?

-Risk of developing epilepsy in children with simple febrile seizures is slightly increased above the 0.5-1 percent baseline population risk.
-Epilepsy more common among children with early, recurrent febrile seizures, especially if there is a family history of epilepsy
-Children with complex febrile seizures and those with pre-existing developmental abnormalities are at increased risk


Causes of fever without a source:

Viral infection, Occult bacteremia, UTI, Bacterial meningitis


Viral infection:

Many common viral infections (eg enterovirus, adenovirus) may cause significant fever in a young child without any additional clinical signs or symptoms (eg congestion, cough, diarrhea, or rash)


Occult bacteremia:

-Occult bacteremia may also cause fever without additional clinical signs or symptoms
-Febrile children ages 3-36 mo without a discernible focus of infection may have an "occult" bacteremia, usually caused by Strep pneumo or Hemophilus influenza type B.
-Since the intro of the protein-polysaccharid conjugate pneumococcal vaccine (PCV-7), the rates of invasive pneumococcal infections have declined. And Hemophilus influenzae, type B - once a feared pathogen- is now uncommon in the US due to universal vaccination.
-Undiagnosed, the child with occult bacteremia is at risk for the development of a more serious bacterial infection, such as meningitis or osteomyelitis, through bacterial seeding of these distant sites.



-Common cause of fever in children
-Because small children cannot complain of dysuria, frequency or costoverterbral angle (CVA) tenderness, UTI must be ruled out by laboratory testing.
-Clinical practice guidelines suggest when it is appropriate to obtain a urine specimen in the workup of a fever without a source.


Bacterial meningitis:

One of the most potentially serious infections in infants and children.


What is the epidemiology of bacterial meningitis?

Increasingly uncommon due to immunization (and herd immunity), but potentially devastating.


What is the etiology of bacterial meningitis?

-Bacterial meningitis in immunized children 2 mo to 12 years of age is usually due to Step pneumo or Neisseria meningitides.
-In younger infants, gram negative organisms, such as Escherichia coli, and organisms like Group B strep (strep agalactiae) need to be considered


How does bacterial meningitis present?

-May present with increasing lethargy and irritability, as well as signs of meningeal irritation (nuchal rigidity or meningismus).
-Alternatively, non-specific findings, including fever (in 90-95 percent of cases), anorexia, poor feeding, symptoms of an upper respiratory infection, myalgia, and tachycardia may predominate.


How do you treat bacterial meningitis?

-In cases in which meningitis is highly suspected, antibiotics are generally given empirically as soon as the CSF culture is obtained (and in severe cases, even beforehand).
-Start with high-dose IV antibiotics directed at the most likely organisms (usually a 3rd ben cephalosporin and vancomycin). Then tailor antibiotics based on sensitivities.
-Treatment duration: 7-14 days


What are complications of bacterial meningitis?

-Stroke, subdural effusions, and syndrome of inappropriate anti-diuretic hormone (SIADH) secretion
-Developmental delay, seizures, and hearing loss
-Unusual for treated meningitis to be fatal


What are the bacterial meningitis findings in CSF?

Decreased CSF glucose. Decreased CSF glucose: blood glucose ratio. Increased CSF protein. Increased WBC count. Increased percentage of polymorphonuclear cells in CSF WBCs.