Febrile Seizure Case File

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Eugene C. Toy, MD, Barry C. Simon, MD, Terrence H. Liu, MD, MHP, Katrin Y. Takenaka, MD,
Adam J. Rosh, MD, MS

Case 34
A 16-month-old child is brought in by EMS after a witnessed tonic-clonic event at home by his
mother. The mother, a 33-year-old G2 woman, reports that he was born vaginally at term after an
uneventful pregnancy. His birth weight was 3700 g, and he was discharged on the second hospital
day. The mother noted that the child has been well appearing, is not taking any medications and
there had been no recent travel. He had been active for the past week with no apparent complaints.
The mother thinks the seizure lasted about 5 minutes but it ceased by the time EMS arrived at the
home. The vital signs on the chart include a temperature of 38.4°C (101.1°F) (rectal), a heart rate of
130 beats per minute, a respiratory rate of 24 breaths per minute, and a systolic blood pressure of
100 mm Hg. On initial evaluation, the child is well appearing, well-perfused, and in no respiratory
distress. His mental status is back to baseline per the mother, and on further evaluation, the child
has no rashes or murmurs but is noted to have a bulging erythematous tympanic membrane.
Acetaminophen is ordered and the child is observed and reevaluated several times over the next
couple of hours. No laboratory studies are ordered initially.

⯈ What is the most likely diagnosis?

⯈ What is the next step in management of this patient?

ANSWER TO CASE 34:

Febrile Seizure

Summary: This is a 16-month-old child with a febrile seizure and acute otitis media. The
combination of a relatively brief seizure in a febrile child in this age group who awakens back to
baseline is consistent with a diagnosis of febrile seizure. Uncomplicated presentations require a
thorough history and physical examination but rarely any additional testing. The presence of a focal
infection like otitis media is common but not essential for the diagnosis. Providing the child returns
to a baseline playful state, admission to the hospital is not necessary.

 Most likely diagnosis: Simple febrile seizure and acute otitis media

 Next step in management: Medication to reduce the fever followed by a period of
observation and reevaluation

ANALYSIS
Objectives

1. Learn the specific definition of a simple febrile seizure

2. Understand current standards for an age-based approach to the evaluation of a simple febrile
seizure in the pediatric patient.
 3. In cases of concurrent infection, specifically otitis media (OM), determine the need for
further evaluation and/or testing in a simple febrile seizure.

Considerations
This infant has experienced a witnessed seizure at home and is noted to be febrile but well
appearing and back at his baseline in the emergency department, and without neurologic deficits.
As with all sick emergency department patients the evaluation begins with assessment of airway,
breathing, and circulation. After the initial assessment, resuscitation and stabilization, etiology for
the seizure must be investigated. This subject can be complex considering the large number of
potential causes. The greatest immediate threat and concern is the possibility of CNS infection.
Infectious causes must be addressed before less acute etiologies are considered.

Approach To:
Febrile Seizures

DEFINITIONS

SIMPLE FEBRILE SEIZURE: The definition for a simple febrile seizure is very specific: age
between 6 months and 60 months, generalized tonic-clonic convulsions, spontaneous cessation of
convulsion within 15 minutes, return to alert mental status after convulsion, documentation of fever
(>38.0°C), one convulsion with a 24-hour period, and absence of neurologic abnormality on
examination.

COMPLEX FEBRILE SEIZURE: This heterogeneous group is beyond the scope of this chapter.
The causes, presentations, assessments, and treatments are broad and complex. A standard
treatment recommendation does not exist and the clinician must evaluate and treat the child with a
complex febrile seizure on a case-by-case manner.

WELL-APPEARING INFANT: An infant who appears to both caretaker and health care
practitioner to interact appropriately for age, has no increased work of breathing, has normal skin
color, and no evidence of dehydration on the clinical examination.

ACUTE OTITIS MEDIA: Bacterial (suppurative) infection of middle ear fluid indicated by acute
onset of signs and symptoms accompanied by a middle ear effusion.

CLINICAL APPROACH
A simple febrile seizure is a traumatic event for the caregiver, and in almost all cases, the child will
be brought in by ambulance, with the emergency medicine physician evaluating the patient after the
tonic clonic activity has ceased. If the child does not appear toxic, distressed, or hemodynamically
unstable, a period of observation is recommended. During this period (usually under 1 hour), the
clinician should have a discussion with the caregiver and EMS regarding the duration of the event,
recent illnesses, and new medications. Additional useful history includes any possible exposures to
chemicals or medications in the household and if there exists a family history of seizure disorders.
Also, documentation of a fever greater than 38.0°C should be obtained, and antipyretic medications
can be administered (oral or rectal based on the infants mental status).

A thorough physical examination should be performed, looking specifically for any source of
infection and clinical signs that are worrisome for bacterial meningitis (petechial rash, nuchal
rigidity, failure to fully engage or to return to baseline level of awareness, etc). The child’s entire
body should be examined for any signs of trauma or abuse such as old ecchymoses, scratches, or
scars. The provider should observe the interaction between the child and care giver to raise or
lowers ones suspicion for possible abuse.

For infants that meet the strict definition of a simple febrile seizure, further testing (serum
electrolytes, glucose, lumbar puncture, and neuroimaging) is not warranted. Multiple retrospective
studies have demonstrated the extremely low incidence of bacterial meningitis in children with a
simple febrile seizure and no clinical signs of meningitis. Unfortunately, since the clinical
presentation of bacterial meningitis can be more subtle in children younger than 12 months of age,
some experts recommend lumbar puncture even for simple febrile seizures in this population (6
months to 12 months).

Infants with concurrent infections (bacterial enteritis, urinary tract infection, or otitis media) with a
simple febrile seizure should be treated for the underlying illness, not changing the standard
management. This child was found to have a case of acute otitis media (AOM).

Acute Otitis Media

The diagnosis of AOM requires a middle ear effusion and signs of middle ear inflammation. The
disease exists on a spectrum with otitis media with effusion, which lacks a bacterial infection or
inflammation. Diagnosis of a middle ear effusion can be confirmed on otoscopy by finding bubbles
or an air-fluid level and a tympanic membrane that is abnormally colored (not translucent), opaque,
and/or not mobile with pneumatic pressure. Acute inflammation can either be confirmed by a
history of fever and ear pain (or tugging) or direct visualization of a bulging and red tympanic
membrane.

Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis are

thought to cause over 90% of cases of AOM; however, current vaccine patterns may alter future
etiologies. Complications of AOM are rare, but include hearing loss, tympanic membrane
perforation, and mastoiditis. Of most concern in this case would be the rare complication of
intracranial extension causing meningitis, brain abscess, or central venous thrombosis. These
complications must be entertained if AOM is encountered in the setting of a seizure, especially if
the child experienced a complex febrile seizure.

There exists much controversy over when to treat AOM with antibiotics. Most professional
guidelines recommend any child younger than the age of 2 be treated with antibiotics and children
older than the age of 2 may be treated with a “watchful waiting” approach if they have mild or
moderate symptoms. Amoxicillin remains the drug of choice. The widespread use of antibiotics in
the developed world is widely thought to be responsible for the low incidence of severe
complications of AOM seen in the ED.
Risk of Seizure Recurrence
One-third of children who have a simple febrile seizure will experience another by the age of 6
years old. Children who experience a simple febrile seizure have a small increase in their likelihood
of developing epilepsy, but the risk is still only 1% in children that have had a simple febrile
seizure.

Prevention and Treatment

Antibiotic and/or antipyretic therapy has not been shown to decrease the recurrence rates of simple
febrile seizures. Caretakers can often feel overwhelmed in an effort to reduce the fever to prevent
another seizure and must be reassured that such measures have not been shown to reduce
recurrence. Continuous antiepileptic medications (eg, valproic acid, phenobarbital, etc.) are not
recommended for first-time febrile seizures.

Case Resolution
The toddler discussed above is observed in the emergency department for 1 hour. He is noted to be
playful, active, and in no distress. After a careful physical examination, the child is discharged
home with his mother to follow-up with his pediatrician. Parents should be instructed to return to
the emergency department immediately for repeat seizure, change in behavior, vomiting, etc. An
expectation should be shared that the AOM should improve within 72 hours of antibiotic treatment,
and if not, they should return to their pediatrician or the emergency department. As with any
pediatric patient, an attempt should be made to contact the patient’s primary pediatrician prior to
leaving the ED.