Case history
Case history #1
A previously healthy and developmentally normal 18-month-old boy presents to the emergency department by ambulance after his parents witnessed a seizure. The parents report the boy had a febrile illness with mild upper respiratory symptoms and they treated him with acetaminophen at home. The child then began to have frequent jerking movements of all limbs. The temperature was 103.1°F (39.5°C). The parents called 911, the child was taken to the emergency department. The jerking stopped after approximately 5 minutes. Afterward, the child was sleepy but responsive to verbal stimulation. Examination revealed a diffuse erythematous maculopapular rash and a normal mental and neurologic status.
Case history #2
A 10-month-old girl is brought to the emergency department with a history of recurrent right arm and leg jerking followed by prolonged sleepiness. The parents report a 2-day history of fever with chest congestion and irritability. The child is admitted to the hospital for neurologic evaluation.
Other presentations
Febrile seizures before 6 months of age in a child with a relatively low fever are atypical and require a full investigation to exclude acute bacterial meningitis or other CNS pathology. Another atypical presentation is a child with a prolonged focal (complex) febrile seizure who has Todd paralysis (transient hemiparesis) on recovery of consciousness. In one prospective series of 95 patients with febrile seizure, 2% had Todd paralysis.[7] Febrile status epilepticus is a prolonged or recurring seizure with fever and without recovery of consciousness between episodes. Classically, the duration is 30 minutes or more; some include seizures of shorter duration (10 minutes or more). Tonic-clonic generalized status is most common. In a large prospective, controlled study, patients with febrile seizure status were more likely to have neurologic abnormalities, a history of neonatal seizures, and a family history of epilepsy.[8] A prospective multicenter study of children with febrile status epilepticus (FEBSTAT study) found a median age of 1.3 years, and seizures that were most often focal, partial, and long, lasting a median of 68 minutes.[9] Febrile status epilepticus was frequently the first febrile seizure, and status was unrecognized in the emergency department.
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