Seizures Febrile

^^^^ I. Problem. A 2-year-old boy who attends day care is brought to the emergency department with a fever and a history of seizure-like activity.

II. Immediate Questions

A. Did patient have a seizure? The first step is to decide if patient actually had a seizure. It is important to obtain a history from someone who witnessed the event. This may be difficult if seizure occurs when parents or other caretakers are not present. Ask for a description with special attention to extremity movements, eye deviations, lip smacking, and cyanosis; this information usually allows clinician to determine if child actually experienced a seizure.

B. What type of febrile seizure occurred? Febrile seizures are classified as either simple (typical) or complex. A simple febrile seizure lasts less than 15 minutes, is generalized in onset, and occurs only once in a 24-hour time period. In contrast, a complex febrile seizure lasts longer than 15 minutes, is focal, or there is more than one seizure in 24 hours.

C. Does patient have a history of seizures? A child with a prior history of nonfebrile seizures does not undergo the same workup or treatment as an otherwise healthy child. Similarly, children with known CNS abnormalities, developmental delay, and metabolic disorders are not included in the definition of febrile seizures.

D. Are there any signs of CNS infection? It is of extreme importance to differentiate seizure with fever and febrile seizures. Meningitis and encephalitis are two potentially life-threatening infections that commonly present with seizure and fever.

E. Is there a history of trauma? Head trauma is a common occurrence in young children. It is important to elicit any such history in a child presenting with seizure and fever, because these children will require a different evaluation.

F. Any toxic ingestion? Children younger than 6 years of age account for more than half of poisonings in any given year. Questions regarding possible drug exposure at home or where child is cared for are essential.

III. Differential Diagnosis. Febrile seizures occur in infancy or early childhood, usually between 3 months and 5 years of age. The seizure activity is associated with fever but lacks evidence of intracranial infection or defined cause. Seizures with fever in children who have suffered a previous nonfebrile seizure are excluded. However, it is important to remember that fever is very common in this age group and that presence of fever may be unrelated to cause of the seizure. A. Infection. CNS infections are one of the most common causes of seizure with fever. Bacterial or viral meningitis or encephalitis must be considered. In addition, Shigella gastroenteritis and roseola as well as other infectious etiologies may present with seizure as a symptom.

B. Trauma. Recent head injury, with or without loss of consciousness, can lead to seizures. Nonaccidental trauma should also be considered in this age group as a cause of seizures with incidental fever.

C. Toxins. Many drug exposures may lead to seizure activity. Certain toxic ingestions commonly present with seizure and fever, including cocaine, tricyclic antidepressants, and amphetamines. In addition, children with a history of seizure disorder may have anticonvulsant levels that are too high or too low, leading to seizures with incidental fevers.

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