A Child with Fever & Seizure

State the clinical features of encephalitis.

1. Acute infectious encephalitis is preceded by non specific symptoms such as sore throat, fever, headache. 2. Followed by characteristic symptoms of: progressive lethargy, behavioral changes, neurological deficits.

Describe briefly pathophysiology of bacterial meningitis.

1. Bacterial colonization of nasopharynx. 2. Invasion into bloodstream through mucosa (bacteremia). 3. Breach into BBB (meningeal invasion). 4. Bacteria gain entry to CSF through choroid plexus. 5. Bacteria multiply rapidly in SA space. 6. Presence of bacterial virulence component trigger host reaction. 7. Release of inflammatory cytokines. 8. Stimulates inflammatory host response (neutrophilic infiltration). 9. Increased vascular permeability, alterations of BBB, vascular thrombosis.

State 3 clinical features of encephalitis in infants & young children.

1. Bulging of fontanelle. 2. Nausea & vomiting. 3. Poor feeding. 4. Irritability.

Name two antibiotic therapy in treatment of bacterial meningitis.

1. C Penicillin. 2. Cefotaxime.

Parents should be counselled on the benign nature of febrile seizure. State three management that can be done by the parents.

1. Control fever - avoid excessive clothing, antipyretic (PCM), First Aid Measure during a seizure. 2. Children with high risk of recurrent febrile seizure - parents supplied with rectal Diazepam (0.5 mg/kg), administer for seizure > 5mins.

State three differences between: 1. Simple febrile seizure. 2. Complex febrile seizure.

1. Duration. 2. Type of seizure. 3. Number of seizure during febrile episode.

Encephalitis is an inflammatory response of brain parenchyma leading to cerebral dysfunction. Most common causes are viruses. Name 3 etiologies causing encephalitis.

1. Enteroviruses - poliovirus, enterovirus. 2. HSV. 3. VZV. 4. EBV. 5. Mumps virus.

Describe briefly three differential diagnosis in child with fever & seizure.

1. FEBRILE SEIZURES: Fever, age 3months-6 years old, seizure develop within 24 hours of fever, absence of CNS infection or metabolic imbalance, absence of prior afebrile seizure history, benign & self limiting. 2. BACTERIAL MENINGITIS: Fever, Sepsis: tachycardia, tachypnea, prolonged CRT. Non-specific symptoms: lethargy, poor feeding, vomiting, irritability. Non-blanching petechial, purpura rash, bacterial causes. 3. ENCEPHALITIS: High fever, seizures, headache, vomiting, neurological deficits, bulging fontanelle, poor feeding, viral causes.

Enumerate 4 clinical features of bacterial meningitis in neonates.

1. Fever. 2. Poor feeding. 3. Lethargy. 4. Vomiting. 5. Shrill cry. 6. Irritability. 7. Seizures. 8. Bulging anterior fontanelle.

Enumerate 4 clinical features of bacterial meningitis in infants.

1. Fever. 2. Tachycardia. 3. Bulging fontanelle. 4. Photophobia. 5. Poor feeding. 6. Irritability. 7. Vomiting.

State 3 contraindications of lumbar puncture.

1. Haemodynamic instability. 2. Signs of increased ICP - focal neurological deficit, depressed level of consciousness. 3. Thrombocytopenia. 4. Local infection at site of LP.

Enumerate 4 clinical features of bacterial meningitis in older children.

1. Headache. 2. Neck stiffness. 3. Kernig & Brudzinski sign. 4. Photophobia. 5. Fever. 6. Vomiting. 7. Back pain. 8. Convulsions. 9. Petechial rash.

Name 3 etiologies of febrile seizure.

1. Infection - Roseola infantum, Influenza A. 2. Vaccines - MMR, DTaP. 3. Risk factor - Family hx of febrile seizure.

Name two positioning of lumbar puncture.

1. Lateral recumbent. 2. Sitting.

Prognosis of bacterial meningitis is worse in younger children. State 3 complications of bacterial meningitis.

1. Subdural effusion - bulging fontanelle, rapid increase HC, increased ICP, emesis, seizures. 2. Cerebral edema. 3. Prolonged fever (>10 days).

State 3 indications of lumbar puncture.

1. To investigate or exclude meningitis. 2. To exclude SA hemorrhage in acute severe headache. 3. Investigate neurological disorders - MS, GBS. 4. To administer therapeutic or diagnostic agents - spinal anesthesia, antibiotics.

Explain briefly pathophysiology of febrile seizure.

1. When seizure threshold is low in young children at time of development, they are susceptible to frequent childhood infections such as URTI, otitis media, viral syndrome which respond with FEVER. 2. Increased cytokines response such as IL-1B which increased neuronal excitability by excite the NMDA receptor. 3. Increased action potential thus lead to seizure.

What is lumbar puncture?

A procedure of spinal needle is put into lower part of spinal column (L4 level or below) to collect CSF or to give drugs. + Should be performed only after a neurologic examination. + But should never delay potentially life-saving interventions such as antibiotic administration and steroids in patients with suspected meningitis.

CSF analysis: 1. Opalescent to purulent appearance. 2. 100 - 50,000 leukocytes. 3. 1-5 g/L protein. 4. Low glucose. State the probable diagnosis.

Acute bacterial meningitis.

What is Kernig's sign?

After flexing the hip and knee at 90 degree angles, pain and resistance are noted.

CSF analysis: 1. Variable, often clear appearance. 2. 50 - 500 leukocytes. 3. 0.5 - 2 g/L protein. 4. Normal or low glucose. State the probable diagnosis.

Fungal meningitis.

Meningitis occurs when there is inflammation of the meninges covering the brain. Classify the etiology of bacterial meningitis according to age: 1. Neonatal to 3 months: 2. 1 month to 6 years: 3. > 6 years:

Neonatal to 3 months: Group B Streptococcus, E. coli, Listeria monocytogenes. 1 month to 6 years: N. meningitides, Strep. pneumonia, H. influenzae. >6 years: N. meningitides, Step. pneumoniae.

Define febrile seizure.

Seizure that occur in association with FEVER (>38C) with NO EVIDENCE OF INTRACRANIAL PATHOLOGY or METABOLIC DERANGEMENT in children between 3 months & 6 years old.

What is Brudzinski's sign?

Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed.

CSF analysis: 1. Opalescent appearance. 2. 10 - 500 leukocytes. 3. 1-5 g/L protein. 4. Low glucose. State the probable diagnosis.

TB meningitis.

CSF analysis: 1. Clear appearance (unless cell count >300 mm3). 2. 10 - 1000 leukocytes. 3. Normal protein. 4. Normal glucose (60% of blood glucose). State the probable diagnosis.

Aseptic meningoencephalitis (Viral meningitis, encephalitis).