Hot Seat #174: 4 year old with febrile seizure
Posted on: August 18, 2021, by : Haroon Shaukat MD
Rachel Hatcliffe, MD, Children’s National Medical Center
HPI:
4.5 year old female with history of prior febrile seizure presents to the emergency room after a 5-10 minute seizure in the setting of one day of fever. Earlier this morning she had one episode of NBNB emesis and was found to have fever to 39.3C. Her father gave a dose of ibuprofen with subjective improvement. Later in the day she was playing with a sibling when she had a generalized tonic-clonic seizure with shaking of bilateral upper extremities and eye deviation to the right. Father gave rectal Diastat and brought patient to the ED. Denies cough, congestion, abdominal pain, diarrhea, or dysuria. Patient is toilet trained and voids independently. Father is concerned patient is not yet at baseline mental status.
PMHx: Febrile seizure x1 in past (2 months ago)
Meds: Rectal Diastat prn
All: None
FH: No family hx of epilepsy
SH: Lives with parents and two siblings. Both siblings currently have URI sx.
Imm: Has not received 4 yo vaccines yet, but otherwise UTD
Exam:
VS: Temp 36.7 HR 109 RR 20 BP 103/78, SpO2 99% on RA
General: Sleepy but arousable
Skin: No rash, warm.
Head: Atraumatic, normocephalic.
Neck: Supple, no nuchal rigidity, no significant lymphadenopathy
Eyes: PERRL, EOMI, normal conjunctiva
ENMT: oral mucosa moist, no pharyngeal erythema
CV: RRR, cap refill <2s in distal extremities
Resp: CTAB, no increased . No crackles, wheezes or rales.
GI: Soft, non-tender, non-distended.
Neuro: CN II-XII intact, moves all extremities. Responds to light touch in all extremities. Patient is arousable but refuses to ambulate.
Father is very concerned and expresses fear about the possibility of repeat seizures at home. He reports patient is still more sleepy than normal and requests more tests to find out the source of the fever.
You obtain CBC, BMP, UA and covid swab. WBC 7, H/H 13.9/39.1, Plt 231, 80% pmns. CMP wnl. Clean catch UA with neg blood/protein, neg ketones, neg nitrites, 3+ LE, 2 RBC, 15 WBC, no epithelial cells, rare bacteria. Covid negative. The patient remains afebrile in ED and returns to neurologic baseline.
The patient is discharged home without antibiotics. No urine culture is added prior to discharge. Father calls the ED a few days later and reports that the child has had persistent fever with Tmax 39.5. No additional seizures. He reports patient has had some congestion, but otherwise denies vomiting, diarrhea, abdominal pain, dysuria. Pt is eating and drinking normally but appears slightly more fatigued than normal.
They return to the ED and on arrival VS: 39.3, HR 115 BP 110/76, RR 24. Pt is alert and interactive, no respiratory distress. Abdomen is soft, non-tender. No neck pain/stiffness. You give Tylenol and obtain repeat Urine testing in the ED. Clean catch UA shows: neg blood/protein, neg ketones, neg nitrites, 2+ LE, 3 RBC, 9 WBC, no epithelial cells, no bacteria.
The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.
Managing parent expectations is probably the most effort we put into patient care. While critical care seems like it’s much of our time (and maybe more exciting), you all know that it’s only occasional patients and we often make quick decisions and move on to manage the majority of patients. I’ve found that most parents, when a bit of sit-down time is spent with them, can often be quite comfortable with little intervention, especially when presented in the positive light of less doing to your child. While we may empower our residents to these discussions, if you think about residency, it was always let’s move to the next task, so again they may not spend sufficient time, unless coached to really think about how/what they are going to say and ensure of course that they have bought into your plan, whether it’s a limited workup or no workup when the parent is looking for an extensive workup. And, again, extensive may be relative and what we think of as limited may be more than sufficient to satisfy the parents’ desire.
As a nice study showed some years ago, sitting down at the patient bedside (however, wherever we can do that) does really create a perception that you have spent more time with the patient/family than if you are standing for the same amount of time. Take a break, sit down, talk to the family and you may really be pleasantly surprised that they are also ok with doing less.
I’m wondering why this child is still having high grade fevers (>39C) “a few days later”. It’s unlikely an untreated UTI as the urine only has 9 WBC/hpf on the repeat sample. Were there additional studies obtained on the 2nd visit other than the urine, such as a repeat COVID test or blood cultures?
A consideration during the initial presentation when the patient was refusing to ambulate would be a hip/ joint physical exam. Even though eventually patient was ambulating fine. Also wonder how many days of high fevers this child had.
I’m thinking of the differential of fever and pyuria– bacterial, but culture is negative; viral, such as adenovirus; inflammatory, such as KD/MIS-C. Want to review history for symptoms of KD and look on exam for signs of KD to decide if this workup is needed. Agree with the comment above about sitting down to discuss the prognosis of fever in a well-appearing child. And it is helpful to reach out to the PMD to have this family followed closely over the next days.