interesting case of an infant with fever with seizures

1. Presented by Dr Gururaja R
MD,DNB
Pediatrician

2.  Vivaan, 42 days old male infant
 first child of non consanguineous marriage
 Brought with h/o fever of 3 days duration
 And abnormal body movements of one day
duration

4.  Fever low grade, intermittent
 Abnormal body movements in the form of
tonic movement of right hand and right leg
with deviation of face and eyes to right side
 Baby had four episodes such abnormal body
movements during fever

5.  SEIZURE?
 CONVULSION?
 EPILEPSY?

6.  SEIZURE –
abnormal, involuntary, paroxysmal
Motor/sensory/autonomic activity
Due to abnormal electrical discharges from
brain
CONVULSION – Motor manifestation of seizure
EPILEPSY – two or more UNPROVOKED seizures
more than 24 hour apart

7. Is it seizure or seizure like activity?
Alteration in motor activity
Alteration in level of consciousness

8.  Is it Febrile seizure?
 Simple/Complex
 Febrile seizures are common in 6 months to 5 yrs
of age
 Generalized seizures during fever
 Single episode
 Lasts < 15 minutes

9.  Parents denied any history of trauma to head
 Antenatal period – uneventful
 Term delivery, LSCS done for non progression of labour
 AGA;B Wt- 3kg
 Cried immediately after birth
 No NICU admission
 Exclusively breastfed and he was feeding well
 Immunisation – up to date

10.  42 days old male infant only child of non
consanguineous marriage brought with
history of fever of 3 days duration and
multiple episodes of right sided focal
seizures
 Antenatal, perinatal and neonatal period-
normal

11.  An infant with fever of short duration and
seizures
 What are the possibilities?
 Infection-CNS/Sepsis
 Structural abnormalities in CNS
 Hypoglycemia
 Hypocalcemia
 Hypomagnesemia
 Hypo/hypernatremia
 Inborn errors of metabolism

12.  Focal cortical dysplasias
 Lissencephaly
 Polymicrogyria
 Sturge-weber syndrome
 Tuberous sclerosis

13.  Pyridoxine deficiency
 Biotinidase deficiency
 Neuronal ceroid lipofusinosis
 Mitochondrial disorders
 Gangliosidosis GM2

14.  Fever with seizure
 CNS infection is MOST IMPORTANT CAUSE
 However metabolic and dyselectrolytemias
should be ruled out
 Infant of this age may not show typical signs
of meningitis as his CNS is immature

15.  Clinical examination in between seizures was normal
 Baby was hemodynamically stable
 Head circumference – 41cms(>3SD)
 No facial dysmorphism
 No skin rash
 AF – normal
 No signs of meningial irritation
 No focal neurological deficits
 Other systemic examination – UNREMARKABLE

16.  Only significant finding noticed during
examination was macrocephaly

17.  Defnition – head circumference >2SD
 Growth charts used to know normal range for
age

18.  Familial
 Hydrocephalus
 Subarachnoid cyst
 Subdural effusion
 Dandy Walker cyst

19.  Hydrocephalus
 Subdural effusion

20.  42 days old male infant only child of non
consanguineous marriage brought with
history of fever of 3 days duration and
multiple episodes of right sided focal
seizures
 Antenatal, perinatal and neonatal period-
normal
 Macrocephaly

21.  Bacterial meningitis with subdural effusion
 CNS TB with hydrocephalus
 Congenital intrauterine infections with
hydrocephalus

22.  CBC – normal
 MP-negative
 Blood sugar- normal
 Electrolytes – normal
 CRP – Negative
 RFT/LFT – NAD
 Urine RE – NAD
 Blood C/S- NAD
 Urine C/S- NAD

23.  Lumbar puncture
 Neuroimaging
 EEG

24.  Lumbar puncture or Neuroimaging?
 In raised ICT – Lumbar puncture carries the
risk of brain stem herniation
 Either fundoscopy or neuroimaging- first
done
 Followed by lumbar puncture

25.  CT or MRI?
 Which one to choose?
 MRI --- better anatomical delineation
 Grey-white distinction
 Myelination status
 Vascular anomailes better identified
 Midline, posterior fossa lesions better appreciated
 Special sequences like. DWI, MRA,MR Spectroscopy
 NO RISK OF RADIATION
 BUT REQUIRES SEDATION SOMETIMES GEN ANAESTHESIA

26.  MRI brain shows dilated supraventricular
system suggestive of non communicating
hydrocephalus
 Multiple ring enhancing lesions of sub
centromere size b/l supratentorial cerebral
parenchyma suggestive of multiple
granulomas

30.  MRI showing hydrocephalus and multiple ring
enhancing lesions
 What is its relevance in the present case?
 WHAT ARE WE DEALING WITH?

31.  Tubrculoma
 Neurocysticercosis
 CNS Neoplasms – Glioma,CNS Lymphoma
 Metastsis to CNS
 Post radiation changes
 Toxoplamosis involving CNS
 cryptococcosis

34.  CSF- clear – proteins -459mg%
Sugar – 45mg% (blood sugar 64mg%)
Total cells – 20 (LYMPHOCYTES)
 CSF ADA – 17 mg% (increased)

37.  CSF- clear – proteins -459mg%
Sugar – 45mg% (blood sugar 64mg%)
Total cells – 20 (LYMPHOCYTES)
 CSF ADA – 17 mg% (increased)

38.  PROTEINS – increased
 SUGAR - normal
 Cells – 20 – LYMPHOCYTES
 CNS TB
 INTRAUTERINE INFECTIONS
 VIRAL

40.  ARE WE DEALING WITH CNS
TUBERCULOSIS?

43.  Sleep EEG showed interictal spike and wave
discharges localised to left frontocentral
region

45.  It distinguishes seizure from nonseizure
states
 Helps in diagnosis of epilepsy and epilepsy
syndromes

46.  2% normal population have abnormal EEG
 EEG is normal in interictal period in patients
with actual epilepsy

47.  42 day old male infant
 Fever with seizures
 Macrocephaly
 CSF protein-rasied;20 lymphocytes
 CSF ADA – raised
 MRI BRAIN –non communicating
hydrocephalus with multiple ring enhancing
lesions both cerebral parenchyma

48.  Congenital toxoplasmosis
 CNS – TB

49.  Further child had generised tonic clonic
seizures requiring phenytoin loading dose
followed by maintenance AED
 Child remained afebrile
 However drowsiness was present through out
 No other symptoms noticed

50.  Airway – position,clear secretions
 Oxygen
 Iv access – iv midazolam,lorazepam(0.1mg/kg)
 Iv access difficulty – midazolam (0.3 mg/kg) –
IM,Buccal,nasal
 Rectal Diazepam – 0.5mg/kg
 No control in 5 minutes---PHENYTOIN LOADING –
20mg/kg in NORMAL SALINE
 Slow iv infusion – 1 mg/kg/min
 Check sugar,electrolytes
 Control temperature
 Shift to ICU
 PRACTICALLY ANY SEIZURE > 5 MINUTES IS STATUS
EPILEPTICUS
 Seizure must be controlled to protect BRAIN DAMAGE

53.  Started on ATT
 Empirical antibiotics also started
 Due to rarity of CNS TB at this age further
evaluation continued

54.  TB PCR of CSF ---negative
 Retrospectively, no contact h/o TB
 TB Screening of family members negative
 Mantoux test - negative

55.  In view of fever, seizure , congenital
hydrocephalus----- possibility of congenital
toxoplasmosis considered
 TORCH titer sent

56.  Toxoplasma antibody panel IgM
18.7(increased)
 Toxoplasma IgG 86.7(increased)
 CT brain intracerebral calcification which
revealed generalized cerebral atrophy with
periventricular, basal ganglia and sub cortical
calcifications

58.  In view periventricular calcification,
 CMV PCR --- not detected
 Diagnosed CONGENITAL TOXOPLASMOSIS
 Started on pyrimethamine @1mg/kg/day
 Sulfadiazine @ 100mg/kg/day
 Folinic acid @ 1 mg/kg /day

59.  AED ---phenytoin continued
 ATT stopped
 Ophthalmology evaluation --- Normal

60.  Delayed milestones
 No social smile
 Head lag
 Not reaching for objects at 4 months

61.  Detailed ophthalmologic evaluation revealed
moderate to severe visual impairment
 Opinion of pediatric ophthalmologist taken
 Advised conservative management

62.  Child developed abnormal body movements
in the form of spasms
 In clusters – 15 to 20 per day

65.  Sleep EEG showed interictal spike and wave
discharges on chaotic/asymmetrical
background, representing hypsarrythmia
 INFANTILE SPASMS
 Started on ACTH 40 IU/day

66.  42 day old male infant
 Fever with seizures
 Macrocephaly
 CSF protein-rasied;20 lymphocytes
 CSF ADA – raised
 MRI BRAIN –non communicating hydrocephalus
with multiple ring enhancing lesions both
cerebral parenchyma
 CT BRAIN – Perivetricular calcifications
 Positive toxoplasma serology
 Infantile spasms
 Blindness

67.  CONGENITAL TOXOPLASMOSIS WITH
INFANTILE SPASMS

68.  Toxoplasma gondii
 Protozoa,intracellular
 Transmitted by cat,oocysts
 Congenital inf ---through placenta
 Incidence---20/10,000 to 1 /10,000

69.  Involve multiple organs including brain
 Risk of transmission highest if inf in third
trimester
 Severity highest if infected in first trimester
 Mainly involves CNS and EYE

70.  Clinical features---
chorioretinitis,seizures,CNS
calcifications,hydrocephalus,microcephaly,he
patosplenomegaly,jaundice,skin
rash,anemia,deafness,visual impairment
 Varies from mild to severe
 Wide variety of severity
 May present later in infancy also

71.  Diagnose with neonatal IgM antibodies
against toxoplasma
 CSF findings
 Neuroimaging
 Ophthalmology evaluation

72.  Treatment
 Sulphadiazine- --50 mg/kg---daily—BD
12months
 Pyrimethamine---1mg/kg---daily BD---6
Months----thrice weekly---next six months
 Folinic acid

73. THANK YOU