Febrile
fits
HISTORY
|
Introduction Ian
is a 20-month old Chinese boy, previously well, now presenting with
an episode of fit. |
The
type of fits commonly found in Ian�s age group (between 6 months to 5
years) is febrile fits. Less likely to be due prenatal (e.g. intrauterine
infections, cerebral malformation), perinatal (e.g. hypoxia) or postnatal
events (e.g. kernicterus) as child is previously well and because of his
age. |
|
History of presenting complaint The
fit occurred at 3:00 am in the morning preceded 6 hours by a fever, Tmax
39 degrees celsius (measured at home by mother with a mercury thermometer)
of one-day duration. Paracetamol was given but the fever did not subside
and Ian was brought to the A&E Department of KK Hospital and
subsequently admitted. Ian
had a 4-day duration of diarrhoea and 2-day duration of vomiting and poor
feeding. The diarrhoea is watery and does not contain blood or mucus. The
vomiting is non-bilious and consists of ingested feeds. He
has no headache, confusion, photophobia, neck stiffness or rash on his
body. |
Suggests
that the fit may be precipitated by the fever as it occurs within 12 hours
of onset of the fever and is greater than 38.5 degrees celsius, the
threshold temperature at which fits are precipitated. The
fever is probably part of an inflammatory response to a viral
gastroenteritis whose symptoms first appeared 4 days ago. Unlikely
to be a CNS infection, e.g. meningitis, encephalitis. |
|
Nature of fit Ian�s
fit was witnessed by his mother who was sleeping by his side. Ian
was sleeping soundly then. The fit was not preceded by any prodromal
symptoms such as irritability or pallor. The
fit began with uprolling of eyes, foaming at mouth followed by tonic
spasms of all 4 limbs and uncontrollable jerking. The entire episode
lasted no more than 5 minutes. There
is only one episode of fit. There were no subsequent fits. Ian
appeared drowsy after the fit and returned to sleep.
There were no focal neurological signs or sensorial defect such as
confusion, vomiting or paralysis. |
Fits
more likely to be a generalized seizure, unlikely to be partial. Suggests
a generalized tonic-clonic seizure. Fit into the picture of a febrile fit.
Likely
to be a simple febrile fit. Likely
to be a simple febrile fit. Unlikely to be a complex febrile seizure or
epilepsy. This affects management later as complex fits is one of the
indications for anticonvulsant therapy. |
|
Past history There
is no past history of head trauma, hospital admissions or afebrile
seizures. There
is no past history of any medical problems or diseases. There
is no family history of fits. Ian
is a full-term baby and is delivered by normal vaginal delivery. He was
never warded in the paediatrics ICU. Birth and development history are
unremarkable. Ian
is not on any long-term medications. |
Fits
are unlikely to be caused by an underlying neurological pathology or any
chronic diseases or metabolic derangements, e.g. hypoglycaemia as Ian was
previously a healthy child. This affects management later as a history of
afebrile seizures and a positive family history for fits are some
of the indications for anticonvulsant therapy. Rule
out drugs, e.g. phenothiazines as a possible precipitant of the fits. |
CLINICAL EXAMINATION
|
General inspection Ian
is alert, comfortable at rest and is playing with his older brother. He
maintains eye contacts when spoken to and is able to respond to sounds and
bright objects. He
does not have any dysmorphic features or skin rashes. He is sitting on the
bed and his behavior is like any other normal child. |
Ian�s
condition is stable and he does not have any neurological syndromes or
disorders. Too well to have meningitis or encephalitis. Rule
out neurocutaneous diseases such as tuberous sclerosis and other
syndromes, e.g. Down�s. |
|
Parameters Anthropometric
data all between 50th and 75th percentile. |
Consistent
with a healthy child with no previous serious medical problem or chronic
illness. |
|
Vital signs Respiratory
rate: 30 bpm Heart
rate: 120 bpm Temperature:
36.7C Blood
pressure: 120 / 80 mmHg. |
His
vital signs are stable. |
|
Neurological Examination Cranial
nerves: there are no visual field defects, loss of visual acuity and there
are no cranial nerve palsies. Motor:
the tone and power are within normal range, reflexes are brisk and there
are no signs of upper motor neuron lesions such as ankle clonus or upgoing
plantars. |
Unlikely
to be an underlying intracranial pathology such as a tumor. |
|
Systemic review Examination
of other systems is unremarkable. There are no signs of infection such as
respiratory crackles, ear discharge or injected tonsils. |
Exclude
presence of previously undetected systemic diseases which may have
contributed to the fits. |
SUMMARY
Ian
is a 20-month Chinese boy, previously well, now presenting with a single episode
of generalized tonic-clonic fits lasting 5 minutes, occurring 6 hours after the
onset of a high fever more than 39C possibly due to an uncomplicated viral
gastroenteritis of 4-day duration. Clinical examination reveals no remarkable
neurological or systemic findings.
Clinical
diagnosis: Simple febrile fits.
INVESTIGATIONS
The
aim of the following investigations is to find out about the nature of the
infection, the presence of any electrolytes imbalance which may require
correction and presence of undiagnosed metabolic derangements, e.g. IDDM. As the
clinical diagnosis is simple febrile fits, other diagnostic investigations such
as skull X-ray, CT head and EEG are not indicated at the present moment unless
Ian�s condition deteriorate subsequently.
|
Investigations |
Indications |
|
Full
blood count |
Total
white and differential count to differentiate between a viral and
bacterial infection. |
|
U&E |
Check
electrolytes levels. |
MANAGEMENT
Symptomatic
The
management of Ian is mainly symptomatic to lower the fever and to control any
recurrent fits. As his condition is stable now, treatment is not necessary.
However should his fever and fits recur again, I would administer paracetamol,
e.g. tablet 120mg, depending on the temperature and advise parents to control
fever by sponging. I would administer intra-rectal valium to control the fits
should they recur, using IV valium only if the former is not effective.
Anticonvulsant medication
They
are not indicated in Ian�s case as:
�
The fit is a simple febrile fit. It is not complex and does not have
atypical features such as postictal neurological signs.
�
There is no evidence of presence of structural brain damage in Ian, e.g.
cerebral palsy.
�
There is no previous afebrile seizures.
�
There is no abnormal development antedating the first fit.
�
There is no family history of afebrile fit or epilepsy.
Education of parents
Ian�s
parents will naturally be anxious about their son�s education. I would first
reassure them that Ian�s condition is benign and is not life-threatening
before telling them more about the prognosis of febrile fits and risks for
possible future recurrences in order to allay their fears and concerns. I would
explain in detail to them that anticonvulsant medications are not needed in
Ian�s case and he will be monitored for one or two more days and he will be
discharged after the fever subsides and there are no recurrence of fits or
evolvement of other abnormal neurological signs, e.g. Todd�s paralysis.
I
would educate Ian�s parents of the following:
Prognosis of febrile fits:
�
Good mental development: Ian�s �IQ� will not be affected in any way
by the fits.
�
Few have neurological deficits: It is highly unlikely that Ian will have
any neurological problems later on in life.
�
Recurrence rate of 50% after the 1st seizure: Inform parents of the
possibility of Ian having another fit and to assure them that the condition is
unlikely to be severe and to teach them on what to do during a recurrence of the
fits � isolating the child, giving intrarectal valium.
�
Multiple recurrences in 5 � 10%.
�
Frequency of future epilepsy in 2 � 5%: Ian parents� should be
informed of the likelihood of Ian developing epilepsy in the future but should
be reassured that the possibility is very low.
CONCLUSION
Febrile
fits are common recurrences in the wards. It is important to provide symptomatic
treatment for the fever and to control the fits, after which a thorough clinical
review and investigations must be conducted to distinguish a simple febrile fits
to other types of fits caused by an intracranial pathology. Though febrile fits
are generally benign conditions with no long-term sequelae or complications, the
parents will naturally be worried and frightful at the sight of their child
fitting. Time must be spent to talk to the parents in order to find out about
their fears and concerns, to rectify and misunderstanding and to properly
educate them on the nature and prognosis of this condition.