This document presents a case report of a 2 year old Malay girl admitted to the hospital due to fever and vomiting for 2 days prior to admission and 3 episodes of seizures on the day of admission. Upon examination and investigation, she was diagnosed with complex febrile seizures presumed to be caused by meningitis. She was treated with antibiotics and anticonvulsants and discharged after 5 days with no further seizures and good response to treatment.

1. CASE PRESENTATIONQhasmira Bt Abu Hazir 2008409674NurAmira Bt MohdAsri 2008409708Nurjuliana Bt Noordin 2008402524

2. PATIENT DEMOGRAPHICPATIENT NAME: FATIN AQILAH R/N: SB 00300220PATIENT’S INITIAL: FASEX: FEMALEAGE: 2YEARS AND 3 MONTHS ETHNIC GROUP: MALAYINFORMANT: MOTHER/FATHERRELIABILITY: FAIRWARD: 8CDATE OF ADMISSION: 24TH NOVEMBER 2010DATE OF CLERKING: 29TH NOVEMBER 2010DATE OF DISCHARGE: 1ST DECEMBER 2010

3. CHIEF COMPLAINTFA, a 2 years old Malay girl was admitted to the Sungai Buloh Hospital on 24th November 2010 due to fever and vomiting for 2 days prior to admission and 3 episodes of fits on the day of admission.

4. HOPI24TH NOVEMBER22ND NOVEMBER23RD NOVEMBERFEVER ( 1st day)Warm to touch

5. Intermittent in nature (on and off)

6. Temporarily relieved by syrup Paracetamol

7. Not ass. with rigorsVOMITINGnon-projectile

8. 4 episodes per day

9. Occur after taking food or fluid

10. Vomitus contained stomach content and no blood stained

11. Loss of appetite but not lethargic

12. Less activeFEVER (2ND day)Same presentation as before

13. Went to private clinic

14. Due to poor oral intake, she was given per rectal paracetamol

15. Temperature documented 38.5˚C- Temporarily relievedVOMITING- Same presentation as before3 EPISODES OF FITS

16. 1st episode of fitOccurred at home while she was playing (10am)

17. Witnessed by her grandfather. Her mother was away.

18. Was described as generalized stiffness

19. Lasted for 5 minutes

20. Her grandfather failed to explain more regarding on her granddaughter’s condition.

21. Mother was informed via phone and rushed to homePost-ictal (1st episode)Able to communicate with her parents

22. Appeared weak2nd episode of fitOccurred at private clinic while she was on her mother’s lap (15 minutes after 1st episode)

23. Was described as generalized stiffness of both 4 limbs followed by jerky movement.

24. Ass with up rolling of eyes, clenching of teeth and drooling of saliva

25. No bluish discoloration of lips, skin and nail bedLasted for 5 minutes spontaneouslyMother noticed that her daughter was feverish and warm to touchNo temperature was documentedNo medication given

26. Post-ictal (2nd episode)Regain consciousness and crying after the attack. Able to communicate with parents

27. Appeared weak

28. Not tolerate feeding and feel nauseated

29. No vomiting episodes

30. Was referred from private clinic to HSB for further management3rd episode of fit Occurred at ED of HSB (30 minutes after 2nd episode)

31. Witnessed by her father

32. fit was presented like before

33. Lasted less than 1 minute

34. Aborted by per rectal medication which her father did not knowPost-ictal (3rd episode)Appeared drowsy

35. Not able to communicate with her parents

36. Was admitted to ward 8C (3pm)SYSTEMIC REVIEW

38. PAST MEDICAL HXShe had no history of fit before. She also had never been hospitalized or undergone any surgery before. She had no long term illnesses.

39. DRUG HXShe had no known drug history

40. ALLERGY HISTORYNo allergy noted

41. BIRTH HXShe was born full term by spontaneous vertex delivery at SgBuloh Hospital. The birth weight was 3.15 kg. The delivery was uncomplicated and there was no resuscitation required. Antenatal, intrapartum and postnatal period were uneventful.

42. NEONATAL HXNeonatal period was uneventful

43. FEEDING HXShe was not breastfed since birth and she was given formula milk instead. She was first introduced to solid foods when she was 6 months old. At that time, she was given Nestum. She started to eat rice at the age of 1 year old. Currently, she is given porridge together with vegetables, fish and sometimes chicken. She is still given the formula milk (DUMEX 123). DUMEX 4 scoops in 4 oz (120ml), 2-3 hourly, prepared by the mother herself.

44. IMMUNIZATION HXHer immunization was completed up to her age. There was no complication developed after each injection. Her latest immunization was MMR which she took when she was one year old.

45. DEVELOPMENTAL HXAll of the developmental parameters were appropriate to her age.

46. FAMILY HXShe is the only child. There was no history of febrile fits running in both of her parents during their childhood lives. None of them was having fever before the patient even got one. Besides, both of her parents were completely healthy. No history of asthma, hypertension and diabetes mellitus running in her parents. There was also no epilepsy history in the family; including uncles and aunties from both maternal and paternal side. No consanguity noted.

47. SOCIAL HX AND ENVIRONMENTAL HXHer father and mother are working together in nasilemak’s stall owned by family. Both of them are working during the day. Thus, the patient is taken care by her mother’s father (grandfather). The total income of her family is about RM1000 per month. They live in an apartment at Sg Way with complete basic amenities. Her father is not a smoker as well as her mother.

48. HX OF CONTACTThere was no significant history contact

49. EFFECT OF THE ILLNESS She became less active ever since she got the fever. Both the parents were worried about her condition and whether these episodes of fits will recur. Her mother had to take leave from work while her father working to earn for the family.

50. Physical examination

51. Physical examinationGeneral examinationShe was sitting comfortably unsupported on her bed, holding marker pen and scribblingConscious, cooperative, alert to person and place.No respiratory distress, no dysmorphic feature, no abnormal movement and no muscle wasting.well hydrated and well nourished

52. Vital signPulse rate: 126 bpm, normal rhythms&vol.Respiratory rate: 36 bpmTemperature : 37 dcBlood pressure: 86/75 mmHgInterpretation:NADAnthropometryHeight: 86 cm (at 50thcentile)Weight: 13 kg (at 50thcentile )

53. CNS EXAMINATIONCentral nervous systemMental status: She was alert and conscious.Speech: Can speak clearly with no difficulty.Cranial nerves: There was no nystagmus. All her cranial nerves were intact.Muscle tone: There was no hypotoniaand hypertoniaMuscle power: all of her muscle power were 5/5

54. REFLEXES EXAMINATIONReflexes- all reflexes were normal

55. Cerebellar signs - she was able to walk steadily without support. Involuntary movement : no presence of any involuntary movementSigns of meningeal irritation : no neck stiffness, negative brudzinski’s and kernig’ssignSensory function: cannot be testedImpression: no abnormality detected.

56. CVS EXAMINATIONNO ABNORMALITY DETECTED

57. RESPIRATORY EXAMINATIONNO ABNORMALITY DETECTED

58. ABDOMINAL EXAMINATIONNO ABNORMALITY DETECTED

59. Systemic examinationCVS, Resp., abdominal, CNS :all NADSummaryFA, a 2 years old Malay girl was admitted to SgBuloh Hospital on 24th November 2010 due to 3 episodes of generalized tonic-clonic fits on the day of admission associated with fever for 2 days and vomiting for 2 days prior to admission with no LP done.

60. Provisional diagnosisComplex febrile fits-points to support:Fever Recurrent seizures in one febrile eventAge, febrile fits usually occur in 3 months to 6 years of age.

61. Differential diagnosis

62. Investigation FBCInterpretation: NAD

63. Electrolyte-: normal level of ca2+,Na2+ mg2+, PO42, random glucose indicate that there is no metabolic derangement in this patient hence - rules out fitting due to metabolic derangement

64. RENAL PROFILEnormal renal profile and this result exclude any dehydration as she had reduced in oral intake(fluids and solid food)

65. MICROBIOLOGICAL CULTUREthere is no presence of bacteremia, or bacteuria

66. LUMBAR PUNCTURELumbar puncture is performed to obtain cerebrospinal fluid (CSF) to rule out any CNS infection. However, parents of this patient refused lumbar puncture to be done to her daughter. Therefore, CNS infection was failed to be ruled out.

67. BRAIN IMAGING (CT SCAN)To detect any brain pathologyFindings:No intracranial bleedingNo focal brain parenchymal lesionNo hydrocephalus

68. CHEST X-RAY (not done)Chest x-ray was not indicated as there was no abnormality in the physical examination suggesting infection of lower respiratory tract. Altogether the history, physical examination and investigation had excluded a lower respiratory tract infection.

69. ELECTROENCEPHALOGRAPHY (EEG)to find out abnormal brain functionEEG is recommended to be performed on children who are neurologically abnormal or experience a complex seizure.

70. FINAL DIAGNOSISComplex febrile fits with presumed meningitis

71. DISCHARGED SUMMARYOn the day of admission, she had multiple seizures attack:1st episode occurred at home, lasted for 5 minutes and aborted spontaneously2nd episode occurred at private clinic, lasted for 5 minutes and aborted spontaneously3rd episode occurred at Emergency Department of HSB, lasted for 1 minute aborted by suppository Valium (diazepam) 5 mg4th episode occurred in ward 8c around 3.30pm lasted for 1 minute and aborted by suppository Valium 5mg5th episode occurred at 6pm in ward 8c, lasted for less than 1 minute and loaded with IV Phenytoin and started maintenance There was total of 5 episodes of fits and patient was febrile at that timeNo more episode since then.She had good response towards antibiotic given to her.

72. ManagementControl feverTake off clothing & tepid spongingAnti pyretic eg; syrup/rectal Paracetamol 15mg/kg 6hrlyAntipyretic is indicated for patients comfort, but there is no evidence that by using it, it can reduce recurrence rate /risk of febrile convulsion.As for this patient, she was given syrup Paracetamol (200 mg) 6 hourly

73. Vital sign monitoring4 hourly vital signs monitoringFit charts

74. Control fits/recurrent fitsRectal Diazepam (valium) 5 mgIV Phenytoin

75. Parents should be advisedon first aid measures during a convulsion;Not to panic, remain calm. Note time of onset of fitLoosen child’s clothing especially around neckPlace child in left lateral position with head lower than the bodyDo not insert any object into mouth even if the teeth are clenchedWipe any vomitus of secretion from the mouth.Do not give any fluids/ drug orallyStay near the child until convulsion is over and comfort the child as she is recoveringThis is a very important point, as febrile fits can recur. Therefore his parents should be counsel about this upon discharged

76. Patient was treated as presumed meningitis.IV Ceftriaxone for 1/52(complete 7 days) she had good response toward antibiotic givenAcyclovir

77. DISCUSSION

78. FEBRILE CONVULSIONConvulsion occurring in association with fever in children between 3 months and 6 years of age, in whom there is no evidence of intracranial pathology or any metabolic derangement.

81. Causes of febrile fitOtitismedia (middle ear infection)Respiratory tract infectionUrinary tract infection (infection of bladder,urethra/kidneys)GastroenteritisViral infection- such as chicken pox or influenza

82. PathophysiologyunclearIt is generally believed that a febrile seizure is an age-dependent response of an immature brain to fever. This was postulated due to (80-85%) febrile seizure occurs between 3 months to 6 years of age ,with a peak at 18 months.It is well known that febrile seizure tend to occur in families because of it is an autosomal dominant inheritance.

83. Prognosis in Febrile Seizureit is a benign events with excellent prognosis30% recurrence after 1st attack48% after 2nd attack2-7% develop subsequent afebrile seizure or epilepsyNo evidence of permanent neurological deficits following febrile convulsions or even febrile status epilepticusNo deaths were reported from simple febrile convulsion

84. Risk factors for subsequent epilepsyNeurodevelopmentalabnormalityComplex febrile fitsFamily history of epilepsyBrief duration between onset of fever and initial convulsions

85. Lumbar PunctureIt is also called a spinal tapis a common medical test that involves taking a small sample of CSF for examination. In a lumbar puncture, a needle is carefully inserted into the lower spine to collect the CSF sample.

86. IndicationsSuspected meningitis, encephalitisIntrathecal chemotherapy for oncology patientIn selected patient being investigated for neurometabolic disorder

87. ContraindicationsIncreased intracranial pressure due to space occupying lesions (from signs, symptoms, raised blood pressure, fundoscopic sign)Bleeding tendency (platelet <50, 000/mm3) or prolonged PT/APTTskin infection over site of lumbar puncture

89. Thank you…