CRSFebrile Seizure

Explanation

There are no localising signs. The rapid return of consciousness, normal optic discs and normal neurological examination, plus clear absence of cardiovascular and respiratory signs make raised intracranial pressure unlikely. In addition, there are no features of meningism, such as neck stiffness and persisting decreased level of consciousness.

Mild tachypnoea is not uncommon in febrile children and does not indicate an underlying pneumonia if there are no other localising features on lung auscultation. Enlarged and red tonsils do not necessarily mean the child has tonsillitis and are very common findings in viral illnesses. Tonsillitis is usually due to bacterial infections (Group A Streptococcus) and is a condition of school-aged children rather than infants. The tympanic membranes are infected, as is common with viral upper respiratory tract infections and do not indicate a diagnosis of acute otitis media, which requires three components to be present:

• symptoms,
• middle ear fluid and
• tympanic membrane changes.

Lack of meningism, i.e., neck stiffness and his looking well, are against meningitis but do not exclude it. The focus for his fever is a viral upper respiratory tract infection.

Explanation

No investigations are required at this stage other than checking the blood sugar level. The seizure could be secondary to an underlying condition resulting in hypoglycaemia (such as an endocrinopathy), or due to poor oral intake and increased consumption of glucose due to the intercurrent febrile illness, or due to the seizure itself. There are no indications for brain imaging, EEG or urine metabolic screening.

It is not unreasonable to perform EUC and Ca in children with recurrent seizures with no other explanation, however, febrile seizures are VERY common and salt imbalances from inherited metabolic defects are VERY, VERY rare!

References

Teran CG, Medows M, Wong SH. Rodriguez L, Varghese R. Febrile seizurescurrent role of the laboratory investigation and source of the fever in the diagnostic approach. Pediatric Emergency Care. 2012; 28(6)493-7. opac.library.usyd.edu.au/record=b4309712~S4

Explanation

No investigations are required for simple febrile seizures, other than investigating the cause of the fever. The likelihood of finding an abnormality on brain imaging in a child with simple febrile seizures approximates 0%. The children who are most likely to have an abnormality on brain imaging are children with focal features, significant developmental delay, neurocutaneous lesions or abnormal head circumference. Individual café au lait spots and strawberry naevi are common findings in children, as are febrile seizures. Therefore, there will be many children with both skin lesions and febrile seizures. However, if there are multiple café au lait spots or multiple strawberry naevi, you should consider neurogenetic disorders and the possibility of malformations in the brain causing seizures.

A family history of febrile seizures is commonly found, once you question the parents in detail (and the parents have time to ask their parents!). Focal features on history or examination require further investigation. The radiation risk from a head CT scan in this age group should be considered before ordering neuroimaging.