Hot Seat Case # 112: 12 mo male with seizure-like activity
Posted on: April 26, 2018, by : Lauren Kinneman
Lauren Kinneman, DO Inova Children’s Hospital
with Kathleen Brown, MD Children’s National Medical Center
12 month old full term male brought in by EMS for concern of a seizure and rash. The mother described that she noticed a “red bump” on his chest in the morning that has spread to his entire body throughout the day. While playing with his blocks at home, he had an episode where he appeared unresponsive, staring with arms flexed persistently. The event lasted about 10-20 seconds, the patient appeared to be sleepy, but then returned to baseline shortly thereafter. Immediately prior to arrival, as EMS was transporting the child, he had another event lasting about 1 minute with arms stiffening and staring.
PMHx: full term, no prior seizures, patient with eczema
FHx: no seizure disorder, no febrile seizures
Meds: None
Allergies: NKDA
ROS: Denies fever prior to EMS arrival, no vomiting, no diarrhea, no increased work of breathing, no cough, no travel, never had rash before
Vital Signs: T103 P140 R32 BP 100/60 100% RA
General: Alert. Crying in parents arms, does not appear toxic or sleepy
Skin: rash as seen (below), neg nikolsky sign, no dermatographism
Head: Normocephalic. atraumatic.
Neck: No lymphadenopathy
Eye: no conjunctivitis, pupils 3mm and reactive b/l,
Ears, nose, mouth and throat: Oral mucosa moist, no ulcerations or lesions, tms clear bilateral, no swelling of lips
Cardiovascular: Regular rate and rhythm. No murmur.
Respiratory: Lungs are clear to auscultation. respirations are non-labored.
Gastrointestinal: Soft. Nontender. Non distended. No organomegaly.
Neurological: Alert. No focal neurological deficit observed. Patient’s strength appears normal, moves all extremities.
Extremities: No swelling of hands or feet
Please comment why or why not in the section below.
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The rash appears to have the target like appearance of erythema multiforme. When I think of associated infectious causes – HSV and mycoplasma come to mind (along with a lengthier list of ID and non-ID causes). With that I would pause – could this be HSV? Does not sound like an encephalitic child, and 12 months would be an unusual age to acquire HSV. I would thus be tempted to observe the child, see if they defervesce and remain well appearing (no neck stiffness, not acting encephalopathic, no mucosal involvement) and then call this EM, with a febrile seizure without doing an LP or CT.
I completely concur with Caleb! This certainly looks like erythema multiforme (EM) to me. The differential includes urticaria and serum sickness (but the child lacks acral edema, joint involvement and dermatographism; also the acute fever >39C is more consistent with EM). During the observation period, I’d serially watch how the rash progresses. In EM, the lesions once they appear, stay fixed for days to typically 2-3 weeks. In urticarial and serum sickness, the lesions are evanescent (coming and going in different areas often over several hours), and are sometimes responsive to antihistamines. Remember urticarial and serum sickness reactions are due to Type I (IgE-mediated) and Type III (immune complex) hypersensitivity reactions, whereas the pathophysiology of EM is quite distinct.
As Caleb also notes, there is a classic association with HSV infection and EM. So, could this child’s presentation with acute, febrile seizure be c/w with acute HSV meningoencephalitis? Unlikely, as this child’s mental status has returned to normal. Remember, hemorrhagic necrosis of the brain/meninges from HSV that presents with seizures will lead to a persistently toxically ill-appearing, encephalopathic child. They don’t just get better in the ED setting!