Lauren Kinneman DO, Inova Fairfax Medical Center
With Eiman Abdulrahman MD, Children’s National Medical Center

The Case
2 yo F presents with a complex febrile seizure. This case’s questions focused on the choice of a second-line anti-epileptic and the decision to perform an additional workup in the ED.

Here’s How You Answered Our Questions

The patient returns to normal mental status but spikes a higher fever, and is found to have a leukocytosis:

The choice of second-line AED was split down institutional lines, and seemed to be determined by familiarity with the drug and ease of access.

Most of the participants in our discussion agreed that an LP was indicated, but disagreed on the exact indication. Reasons that the were cited included the height of the fever, the leukocytosis, and the fact that the seizure was a complex febrile seizure instead of a simple febrile seizure.

Denouement
An LP was performed in the ED after the patient spiked a fever, and the results were normal. The patient was admitted to the ICU step-down unit. She had a normal MRI brain the following day. The patient had no further seizure activity and her EEG had no findings concerning for an underlying seizure disorder. Her fevers continued, and she had a single episode of diarrhea, leading to an ultimate diagnosis of viral gastroenteritis. The patient’s symptoms had resolved at discharge. She is scheduled for follow-up with an outpatient neurologist.

Teaching Point
Choice of a second-line AED is up for debate, and for now, institutional preferences still govern which is given. This research question is currently being evaluated by the Established Status Epilepticus Treatment Trial (ESETT), which compares fosphenytoin, valproic acid, and levetiracetam.