Case Illustration

Identity of Patient Name Gender Age Address Religion :F : Male : 4 years, 2 months, and 17 days : Duren Sawit : Moslem : 22nd of August 2010

Date of hospital admission

Identity of patients parents Father Age Occupation Education Mother: Age Occupation Education : 31 y.o : housewife : high school : 30 y.o : driver : high school

Anamnesis (Alloanamnesis with mother and medical record) Chief Complaint Seizure that was accompanied by high fever 5 hours PTHA (prior to hospital admission)

Present Disease History 5 hours PTHA, the patient got a high fever, then his mother brought him to Puskesmas. In the way to Puskesmas, the patient got seizure, his eyes opened and moved to the top, and his mouth was stiff.

There was no cough, cold, diarrhea, dyspnea, vomit, and bleeding. After arriving at the Puskesmas, he got anti seizure supposutoria (stesolid). The seizure was stopped afterwards. His seizure lasted for 20 minutes. Afterwards, the patient slept. He still got fever (temp 38.9o C). He was reffered to RSCM. When he arrived at RSCM, there was still fever. However, the seizure did not occur anymore. One day PTHA, he also got high fever, although his mother does not measure the temperature. He took paracetamol syrup, and the fever was relieved.

Past History of Disease He has ever got seizure 1 year PTHA, which was also accompanied by fever. History of urinary tract infection (+)

Family History of Disease Epilepsy (-) Seizure accompanied by fever (-) Allergic reaction to medication (-)

Social , and Growth and Development History Birth: he was born trough Caesarean section due to long labor. Birthweight: 3600grams, birthlength: 52 cm. He cried directly. He is the only child in the family. He has got complete immunisation. (BCG, campak, 4x polio, 4x HepB, 4x DPT) Growth and development: within normal limits o 1st tooth : 7 month old o Prone position : 4 month old o Sitting : 6 month old o Standing : 10 month old o Walking : 14 month old o Talking : within normal limit Nutrition: he ate 3-4 times a day. Good appetite. He got ASI until 2 years old. Additional food started at the 5th month.

Physical Examination (23rd of August 2010) General condition Consciousness Pulse Respiratory Temperature Blood pressure Body height Body weight Nutritional status :looked mildly ill : CM : 110x/minute, reguler, good filling : 25 x/minute, reguler, deep : 36,30C : 100/60 mmHg : 105 cm : 14 kg :

BW/age: 14/16 x 100% = 87.5% BH/age : 105/105 x 100% = 100% : 14 /17 x 100% = 82% wasted (gizi kurang)

BWact/BWheight

General Status Head Hair Eyes : no deformity, closed fontanel. Head circunference = 52cm : pull test (-), black hair : anemic conjunctiva -/-, icteric sclera -/-, round pupil, isochor 3mm Direct/indirect reflex +/+, hollow eyes -/Ears Nose Throat : secrete (-) : secrete (-), nose bridge (+), epistaxis (-) : tonsil T1/T1, hiperemic (-) : caries (+), ulcer/stomatitis (+)

Teeth and mouth Neck Lung

: lymph nodes enlargement (-) : symetrical static and dynamic vesiculer +/+, ronchi -/-, wheezing -/-

Heart

: 1st and 2nd HS normal, gallop (-), murmur (-)

Abdomen

: seemed flat, supple, liver and spleen not palpable, no pain on palpation, good turgor

Extremity

: within normal limit, multiple scar tissue on both legs with diameter 5mm each CRT <2seconds, warm acral

Neurological Status

a. Consciousness
Qualitative : Compos Mentis Quantitative : E4M6V5 (GCS 15) b. Pupil : Round, isochors, 3 mm/3mm, RCL +/+, RCTL +/+ c. Meningeal Sign: Stiff neck (-)

Brudzinsky I (-) Brudzinsky II (-) Lasegue >70/>70 Kernig >135/ >135

d. Cranial Nerve N. III, IV, VI Eye ball position Ptosis Strabismus Eksoftalmus : -/: -/: -/Eye ball movement Right Lateral Left Lateral Up Down Around N. V Motorik Jaw movement: symmetric Biting Sensorik V1-2-3 Light touch N. VII Mouth condition during resting Smiling with teeth showing N.VIII N. Koklearis Whispers Finger sound Rinne : good/good :good/good : was not done : closed : symmetric +/+ : no weaknes in masseter muscle and temporalis dextra sinistra : good : good : good : Good : Good

Weber Schwabach N. IX, X Pharyng Disfagi N. XI

: was not done : was not done

: symmetric :-

Cough

:-

Head movement (right left down) N. XII Tounge inside : middle Tounge outside: middle e. Motoric 5555 5555 f. Sensibility g. Reflex: Physiological reflex Tendon : touch normal

: good and symmetric

Tounge movement: symmetric and strong

5555 5555

Biseps Patella

Right normorefleks (+2) normorefleks (+2)

Left normorefleks (+2) normorefleks (+2)

Pathological Reflex Babinski

Right (-)

Left (-)

Supporting Examination Urinalysis (22nd of August 2010) Epitel + Leuko 2-3 RBC 0-2 Cylinder (-)

Crystal (-) Bacteria (-) Density (BJ) 1.030 pH 5.0 Protein (-)

Glucose (-) Keton (++) Bil (-) Urobilinogen (-) Leucocyte esterase (-)

Complete Blood Count (22nd of August 2010) Hb: 11.2 Ht: 35 Leucocyte: 12,100 Thrombocyte: 312,000 MCV: 71 MCH: 23 MCHC: 32 DiffCount: 0/0/4/84/10/2

List of Problems 1. Complex Febrile Seizure 2. Poor Nutritional Status

Management Diet: 1610 kcal/day Paracetamol 150-200mg/day (divided into 4-6 dosage) if he gets fever Diazepam 150mg when he gets fever >38OC Cefixime 2x100 p.o. Monitor general condition, vital sign, seizure.

Prognosis Prognosis ad vitam Prognosis ad functionam Prognosis ad sanactionam : bonam : dubia ad bonam : dubia

Literature Review
Febrile seizure
Definition
Seizure that is occured when body temperature (rectal) increases (38OC), which usually happened among babies and children between 6 month old and 5 years old, which is caused by an extracranium process, without any specific cause. It should be differed from epilepsy which have other seizure events without fever. Ferbrile seizure is divided into 2 types: 1. Simple febrile seizurelast less than 15 minutes, general, single 2. Complex febrile seizure last more than 15 minutes, or focal, or multiple (more than 1 seizure in 24 hours). It may indicate more serious diseases such as meningitis, abcess, or encephalitis.

Risk factors for developing febrile seizures

Family history of febrile seizures High temperature Neonatal discharge at an age greater than 28 days (perinatal illness that need hospitalization)

Children with delayed development Children under suspicion Low sodium level

If a child has 2 of these risk factors, then the probability of a first febrile seizure increases about 30%. Maternal alcohol intake and smoking during pregnancy increases the risk by 2-fold. Interestingly, there is not any data which show that a rapid increase in body temperature causes of febrile seizures.

Risk factors for recurrent febrile seizures include the following:

Age at time of first febrile seizure <12 months Relatively low fever at time of first seizure (below 38OC)

Family history of a febrile seizure in a first-degree relative Short duration between fever onset and initial seizure Multiple initial febrile seizures during same episode Family history of epilepsy

Patients who have 4 risk factors have >70% possibility of recurrence, while those with no risk factors have <20% chance of recurrence.

Risk factor for epilepsy (less than 5%)

Abnormal child development before the first febrile seizure Complex febrile seizure

Etiology
Febrile seizures happen among young children when they have lower threshold of seizure, when they are prone to infections such as upper respiratory infection, otitis media, viral syndrome, and they respond with comparably higher temperatures. Some studies on animals show a possible role of endogenous pyrogens, such as interleukin 1beta, in the increase of neuronal excitability, which may link fever and seizure activity. This statement is also supported by studies in children, although there is no specific pathological significance. Moreover, although there is not any exact molecular mechanisms of febrile seizures, underlying mutations have been found in genes encoding the sodium channel and the gamma amino-butyric acid A receptor.

Clinical Manifestation
Seizure usually occurs at the beginning of the fever. Tonic clonic seizure could be started by crying, then unconsciousness and muscle stiffness. It could be accompanied by apnea and incontinentia, then ended by lethargic seizure and sleep. Other manifestation of seizure could be seen in the movement of eyeballs to the top, accompanied by stiffness of weakness of muscles.

Other possible causes of seizure should be omitted, including possibility of encephalitis or meningitis (lumbal puncture might be indicated, especially for baby younger than 12 month old, since meningeal signs are difficult to be detected). Laboratory examinations are also indicated (those which are suitable to define the cause of seizure)

Management 1. Manage acute phase

Anti-pyretic : acetaminophen (10-15mg/kgBW/day, every 4-6 hours) Or ibuprofen 5-10mg/kgBW/day, every 4-6 hours) Anti convulsant: oral diazepam (0.3 mg/kg/day every 8 hours) Rectal diazepam (0.5mg/kg/time every 12 hours whenever fever >38OC)

2. Search and treat the causal 3. Prophylaxis treatment for reccurent seizure (intermitten and continuous). Continuos
prophylaxis is not recommended due to it good prognosis. Only in certain cases, phenobarbital 3-5mg/kgBW/day or valproic acid 15-40mg/kgBW/day are given for a year, then taping off in 1-2 years.

Continuous treatment are given to: a. Children with febrile seizure more than 15 minutes b. Prominent neurological deficit, before of after seizure (cerebral palsy or mental retardation) c. Focal febrile seizure d. History of epilepsy in the family e. First febrile seizure before 12 month old, or multiole seizures within 24 hours

Discussion
The diagnosis of febrile seizure was made based on anamnesis and physical examination. The child got seizure when his temperature reach 39.8OC, and the seizure was preceeded by the fever. Moreover, he has no history of seizure without fever. Based on the physical examination, it was found that there was no remaining symptoms from the seizure. The management for this patient were paracetamol 150-200 mg/day (divided into 4-6 dosage) in order to reduce the fever, oral diazepam 4mg/day (divided into 3 dosage, only when the fever reach >38OC) to prevent recurrent seizure, and cefixime 2 times 100mg per day in order to treat the possible cause of the fever. Monitoring of vital sign and seizure are necessary. Moreover, based on the nutritional status, he needs (his ideal bodyweight based on height) 17 x 90 kcal, which is 1610 kcal per day. Prognosis ad vitam of this patient is bonam, since his condition is stabile, and his disease does not endanger his life. Furthermore, his prognosis ad functionam is dubia ad bonam, since he does not show any abnormal post recovery symptoms, although precise effect of the seizure is unknown. However, his prognosis ad sanactionam is dubia, since he has a history of previous seizure. Therefore his possibility of getting another seizure attack is questioned.

References
1. Tumbelaka, Alan, Partini P.Trihono, Nia Kurniati, Dwi Putro Widodo. Penanganan Demam pada Anank Secara Profesional. 2005. Jakarta: Departemen Ilmu Kesehatan Anak FKUI. 2. Panduan Pelayanan Medis Departemen Ilmu Kesehatan Anak.2007. Jakarta: RSUP. Nasional DR. Cipto Mangunkusumo. 3. Tejani, Nooruddin R. Pediatrics, Febrile Seizure. Updated on the 25th of August 2010. Downloaded from: http://emedicine.medscape.com/article/801500-overview .