Risk of bacterial or herpes simplex virus meningitis/encephalitis in children with complex febrile seizures

Simple and complex febrile seizures: is there such a difference? Management and complications in an emergency department

OBJECTIVE

We aimed to analyse the prevalence, characteristics, and management of simple and complex febrile seizures. The secondary objective was to compare the risk of underlying organic lesion and epilepsy in both types of seizures, with a particular focus on the different subtypes defining a complex febrile seizure.

MATERIAL AND METHODS

We performed a retrospective cohort study including patients aged 0-16 years who were treated for febrile seizures in the paediatric emergency department of a tertiary hospital over a period of 5 years. Epidemiological and clinical variables were collected. Patients were followed up for at least 2 years to confirm the final diagnosis.

RESULTS

We identified 654 patients with febrile seizures, with a prevalence of 0.20% (95% CI, 0.18-0.22); 537 (82%) had simple febrile seizures and 117 (18%) had complex febrile seizures. The clinical and epidemiological characteristics of both types were similar. Significantly more complementary tests were requested for complex febrile seizures: blood tests (71.8% vs 24.2% for simple febrile seizures), urine analysis (10.3% vs 2.4%), lumbar puncture (14.5% vs 1.5%), and CT (7.7% vs 0%). Similarly, admission was indicated more frequently (41.0% vs 6.1%). Underlying organic lesions (central nervous system infection, metabolic disease, tumour/intracranial space-occupying lesion, intoxication) were diagnosed in only 11 patients, 5 of whom had complex forms (4.3%; 95% CI, 0.6-7.9). Risk factors for developing epilepsy, identified in the multivariate analysis, were complex forms with recurrent seizures in a single attack (odds ratio [OR]: 4.94; 95% CI, 1.29-18.95), history of seizures (OR: 17.97; 95% CI, 2.26-143.10), and seizures presenting at atypical ages (OR: 11.69; 95% CI, 1.99-68.61).

CONCLUSIONS

The systematic indication of complementary tests or hospital admission of patients with complex febrile seizures is unnecessary. The risk of epilepsy in patients with complex forms gives rise to the need for follow-up in paediatric neurology departments.

Crises fébriles chez l’enfant : à propos d’une histoire familiale

Les crises fébriles (CF) sont les crises convulsives les plus fréquentes prises en charge dans les services d’urgence dans la population des moins de cinq ans. Elles sont une crise accompagnée de fièvre, sans infection du système nerveux central, se produisant chez les enfants entre six mois et cinq ans. Les critères utilisés et enseignés pour classer les crises en simples ou complexes n’ont pas la même signification en pratique clinique pour prendre la décision d’effectuer une ponction lombaire et/ou une imagerie cérébrale, et pour l’indication de la prescription d’un antiépileptique de recours ou de fond. Certains facteurs sont prédictifs de la récurrence fébrile, tandis que d’autres sont prédictifs d’une épilepsie. À partir de deux cas cliniques de CF complexes, nous proposons une démarche de prise en charge et de faire une revue des syndromes épileptiques survenant au décours des CF chez le jeune nourrisson.

Febrile Seizure Team-based Learning

Audience

This modified team-based learning (mTBL) is designed for junior and senior emergency medicine and pediatric residents.

Introduction/Background

Febrile seizures are the most common cause of seizures in children under 5 years old and are frequently evaluated in the emergency department.1,2 Febrile seizures can be frightening for parents to witness and often necessitate extensive parental reassurance and education by the emergency medicine (EM) provider. Most febrile seizures are brief, do not require a broad workup, and have a benign prognosis. With introduction of conjugate vaccines for Haemophilus influenzae type B (Hib) and Streptococcus pneumoniae in the United States in 1987 and 2000 respectively, the incidence of bacterial meningitis is low, but still present.3-7 The most recent American Academy of Pediatrics practice guidelines no longer recommend routine lumbar puncture on children presenting with simple febrile seizures.2 A review of the current literature shows that bacterial meningitis in children after a complex febrile seizure is unexpected when the clinical examination is not suggestive of meningitis or encephalitis.5-8 The goal of this mTBL is for residents to feel comfortable counseling parents about their child currently in the emergency department and the future risk of recurrence. The second goal is for residents to identify which patients presenting with fever and a seizure do require workup beyond simply identifying the source of the fever.

Educational Objectives

By the end of this educational session, the learner will:List the characteristics of a simple febrile seizure.Discuss the management of a child with a simple vs. complex febrile seizure.Discuss the risk factors that correlate with an increased risk of a subsequent febrile seizure.Determine when a lumbar puncture should be considered in a febrile child with a seizure.Identify when to give anti-epileptics and construct an algorithm for their use.Discuss with parents, provide education and return precautions.

Educational Methods

This didactic session is a mTBL. The classic learner responsible content (LRC) has been omitted and a short PowerPoint presentation is given to start the session before the individual and group readiness assessment tests.

Research Methods

A post-TBL survey was given to each participant. A Likert scale was used to assess each participant's assessment for the learning session in the following categories: overall, context, quality, and speaker feedback. They were also given fields to enter ways in which they would improve their practice after this learning exercise and suggestions they had for improving the current educational opportunity.

Results

In the pilot session of this mTBL, 4 out of 11 participants (EM residents and pediatric emergency medicine [PEM] fellows) completed the post-TBL survey. Overall, this session was rated as "outstanding" (Likert 5/5) by 1 and "excellent" (Likert 4/5) by 3 for a weighted average of 4.25. All participants completing the survey found the activity "highly relevant," "very engaging," and wanted to repeat the activity in the future. Negative feedback consisted of wanting a video of a child having a seizure to be played and having a more interactive PowerPoint portion of the session like the interaction in the readiness assessment tests and group application exercise.

Discussion

Overall the content was effective as evidenced by the list of ways residents said they would improve their practice on the post-TBL survey. In the future, I would extend the session from 60 minutes to 90 minutes to allow for more time for the group application exercise and discussion of answers. I found this to be an enjoyable, highly interactive experience with high engagement of the residents during the session.

Topics

Simple febrile seizures, complex febrile seizures, seizure with fever, meningitis, lumbar puncture, status epilepticus.

Crises fébriles chez l’enfant : à propos d’une histoire familiale

Les crises fébriles (CF) sont les crises convulsives les plus fréquentes prises en charge dans les services d’urgence dans la population des moins de cinq ans. Elles sont une crise accompagnée de fièvre, sans infection du système nerveux central, se produisant chez les enfants entre six mois et cinq ans. Les critères utilisés et enseignés pour classer les crises en simples ou complexes n’ont pas la même signification en pratique clinique pour prendre la décision d’effectuer une ponction lombaire et/ou une imagerie cérébrale, et pour l’indication de la prescription d’un antiépileptique de recours ou de fond. Certains facteurs sont prédictifs de la récurrence fébrile, tandis que d’autres sont prédictifs d’une épilepsie. À partir de deux cas cliniques de CF complexes, nous proposons une démarche de prise en charge et de faire une revue des syndromes épileptiques survenant au décours des CF chez le jeune nourrisson.

Complex Febrile Seizures, Lumbar Puncture, and Central Nervous System Infections: A National Perspective

OBJECTIVES

The objective was to determine the national lumbar puncture (LP) practice patterns relative to the incidence of central nervous system (CNS) infections among children presenting to the emergency department (ED) with complex febrile seizures (CFS).

METHODS

This was a retrospective study of ED visits for CFS from 2007 to 2014 in patients aged 0 to 5 years using a national sample. Primary outcomes include the frequency of LP, incidence of CNS infections, and ED disposition.

RESULTS

Of 28,810 ED visits for CFS (44.4% female; mean age = 1.39 years), LP was performed in 7,445 (25.8%, 95% confidence interval [CI] 23.5%-28.2%). There was no significant difference in the proportion due to hospital teaching status or geographical region. The proportion decreased from 31.4% to 17.8% over the study period (Rao-Scott statistic = 5.85, p < 0.001). CNS infection was diagnosed in 80 (0.3%) encounters (95% CI = 41-112). The most commonly associated infections were otitis media (16.8%), upper respiratory infections (15.8%), and other viral infections (14.6%). A total of 14,696 encounters (51.0%, 95% CI = 47.9%-54.1%) resulted in a hospital admission.

CONCLUSIONS

Although rates have been declining, LP was performed in one-fourth of ED encounters for CFS over the 8-year study period. The incidence of CNS infections was very low, however, suggesting that this procedure could be avoided in many patients.

An Introduction to Natural Language Processing: How You Can Get More From Those Electronic Notes You Are Generating

Electronically stored clinical documents may contain both structured data and unstructured data. The use of structured clinical data varies by facility, but clinicians are familiar with coded data such as International Classification of Diseases, Ninth Revision, Systematized Nomenclature of Medicine-Clinical Terms codes, and commonly other data including patient chief complaints or laboratory results. Most electronic health records have much more clinical information stored as unstructured data, for example, clinical narrative such as history of present illness, procedure notes, and clinical decision making are stored as unstructured data. Despite the importance of this information, electronic capture or retrieval of unstructured clinical data has been challenging. The field of natural language processing (NLP) is undergoing rapid development, and existing tools can be successfully used for quality improvement, research, healthcare coding, and even billing compliance. In this brief review, we provide examples of successful uses of NLP using emergency medicine physician visit notes for various projects and the challenges of retrieving specific data and finally present practical methods that can run on a standard personal computer as well as high-end state-of-the-art funded processes run by leading NLP informatics researchers.

Febrile seizures: emergency medicine perspective

PURPOSE OF REVIEW

The review describes current evidence on the evaluation of febrile seizures in the acute setting, the need for further outpatient assessment, and predictors regarding long-term outcomes of these patients.

RECENT FINDINGS

New evidence has been added in support of limited assessment and intervention: evidence on low utility of lumbar puncture, emergent neuroimaging, and follow-up electroencephalography, as well as low yield for antipyretic prophylaxis and intermittent use of antiepileptic drugs. Finally, there is growing evidence regarding the genetic basis of both febrile seizures and vaccine-related seizures/febrile seizures.

SUMMARY

Routine diagnostic testing for simple febrile seizures is being discouraged, and clear evidence-based guidelines regarding complex febrile seizures are lacking. Thus, clinical acumen remains the most important tool for identifying children with seizures who are candidates for a more elaborate diagnostic evaluation. Similarly, evidence and guidelines regarding candidates for an emergent out-of-hospital diazepam treatment are lacking.

[Complex febrile seizures: study of the associated pathology and practical use of complementary tests]

INTRODUCTION

Although one third of febrile seizures are complex, a consensus has still not been reached on how to manage them, as is the case with simple febrile seizures. The objective of this study is to estimate the usefulness of complementary examinations and the risk of associated serious intracranial pathology.

PATIENTS AND METHODS

A retrospective review was conducted from 2003 until 2011 on patients from 6 months to 6 years presenting with a complex febrile seizure admitted to a tertiary care hospital, excluding the cases with previous neurological disease. Epidemiological and clinic variables were collected, as well as complementary tests and complications.

RESULTS

We found 65 patients (31 females and 34 males), of whom 44 had repeated seizures in the first 24 hours, with 15 having focal seizures. The vast majority (90%) of the recurrences occurred before 15 hours. The mean age was 20.7 months and temperature was 39.1 ± 0.12°C. None of the patients had severe intracranial pathology. The electroencephalogram gave no helpful information for the diagnosis. Neuroimaging was normal in all studied cases.

CONCLUSIONS

The incidence of complications in complex febrile seizure in our series did not justify the systematic admission or the systematic study with complementary tests when the neurological examination was normal. The routine electroencephalogram does not appear to be justified.

Necessity of lumbar puncture in patients presenting with new onset complex febrile seizures

Introduction: This study aims to characterize the population of patients presenting to a pediatric emergency department (ED) for a first complex febrile seizure, and subsequently assess the rate of acute bacterial meningitis (ABM) occurrence in this population. Furthermore, this study seeks to identify whether a specific subset of patients may be at lesser risk for ABM or other serious neurological disease.

Methods: This retrospective cohort study reviewed the charts of patients between the ages of 6 months to 5 years of age admitted to an ED between 2005 and 2010 for a first complex febrile seizure (CFS). The health information department generated a patient list based on admission and discharge diagnoses, which was screened for patient eligibility. Exclusion criteria included history of a complex febrile seizure, history of an afebrile seizure, trauma, or severe underlying neurological disorder. Data extracted included age, gender, relevant medical history, descriptions of seizure, treatment received, and follow-up data. Patients presenting with two short febrile seizures within 24 hours were then analyzed separately to assess health outcomes in this population.

Results: There were 193 patients were eligible. Lumbar puncture was performed on 136 subjects; it was significantly more likely to be performed on patients that presented with seizure focality, status epilepticus, or a need for intubation. Fourteen patients were found to have pleocytosis following white blood cell count correction, and 1 was diagnosed with ABM (0.5% [95% confidence interval: 0.0–1.5, n=193]). Forty-three patients had 2 brief febrile seizures within 24 hours. Of the 43, 17 received lumbar puncture while in the ED. None of these patients were found to have ABM or other serious neurological disease.

Conclusion: ABM is rare in patients presenting with a first complex febrile seizure. Patients presenting only with 2 short febrile seizures within 24 hours may be less likely to have ABM, and may not require lumbar puncture without other clinical symptoms of neurological disease.

Clinical factors associated with invasive testing and imaging in patients with complex febrile seizures

BACKGROUND

Complex febrile seizures (CFSs) are a common diagnosis in the pediatric emergency department (PED). Although multiple studies have shown a low likelihood of intracranial infections and abnormal neuroimaging findings among those who present with CFS, the absence of a consensus recommendation and the diversity of CFS presentations (ie, multiple seizures, prolonged seizure, focal seizure) often drive physicians to do a more extensive workup than needed. Few studies examine the factors that influence providers to pursue invasive testing and emergent neuroimaging.

OBJECTIVE

The objective of this study was to determine the clinical factors associated with a more extensive workup in a cohort of patients who present to the PED with CFSs.

METHODS

Patient visits to a tertiary care PED with an International Classification of Diseases, Ninth Revision, diagnosis of CFS were reviewed from April 2009 to November 2011. Patients included were 6 months to 6 years of age. Complex febrile seizures were defined as febrile seizures lasting 15 minutes or longer, more than 1 seizure in 24 hours, and/or a focal seizure. Charts were reviewed for demographics, clinical parameters (duration of fever, history of febrile seizure, focality of seizure, antibiotic use before PED, and immunization status), PED management (antiepileptic drugs given in the PED or by Emergency Medical Services, empiric antibiotics given in the PED, laboratory testing, lumbar puncture, or computed tomography [CT] scan), and results (cultures, laboratories, or imaging). A logistic regression model was created to determine which clinical parameters were associated with diagnostic testing.

RESULTS

One hundred ninety patients were diagnosed with CFS and met study criteria. Clinical management in the PED included a lumbar puncture in 37%, blood cultures in 88%, urine cultures in 47%, and a head CT scan in 28%. There were no positive cerebral spinal fluid or blood cultures in this cohort. Of the 90 patients, 4 (4.4%) with urine cultures had a urinary tract infection. Of the 53 patients who had head CT imaging, there were no significant findings that guided therapy. The only factor associated with having a lumbar puncture performed was whether empiric antibiotics were used (odds ratio [OR], 2.96; 95% confidence interval [CI], 1.28-6.8). History of a febrile seizure was associated with lower odds of a lumbar puncture (OR, 0.29; 95% CI, 0.12-0.69). In addition, higher age category was also associated with lower odds of a lumbar puncture (OR, 0.53; 95% CI, 0.31-0.91). Those who received an antiepileptic drug had a higher odds of getting a head CT (OR, 3.5; 95% CI, 1.5-8.6). Furthermore, patients presenting with a focal seizure also had higher odds of getting a head CT (OR, 4.89; 95% CI, 1.41-16.9).

CONCLUSIONS

Despite the low utility of associated findings, there are important clinical parameters that are associated with obtaining a lumbar puncture or a head CT as part of the diagnostic workup. National practice parameters to guide evaluation for CFSs in the acute setting are warranted to reduce the amount of invasive testing and imaging.

Risk of bacterial meningitis in young children with a first seizure in the context of fever: a systematic review and meta-analysis

Background

Of major concern in any febrile child presenting with a seizure is the possibility of bacterial meningitis (BM). We did a systematic review to estimate the risk of BM among various subgroups of young children with a first seizure in the context of fever, and to assess the utility of routine lumbar puncture (LP) in children with an apparent first FS.

Methods/Principal Findings

MEDLINE, INIST, and the COCHRANE Library databases were searched from inception to December 2011 for published studies, supplemented by manual searches of bibliographies of potentially relevant articles and review articles. Studies reporting the prevalence of BM in young children presenting to emergency care with a first: i) “seizure and fever”, ii) apparent simple FS, and iii) apparent complex FS were included. Fourteen studies met the inclusion criteria. In children with a first “seizure and fever”, the pooled prevalence of BM was 2.6% (95% CI 0.9–5.1); the diagnosis of BM might be suspected from clinical examination in 95% of children >6 months. In children with an apparent simple FS, the average prevalence of BM was 0.2% (range 0 to 1%). The pooled prevalence of BM among children with an apparent complex FS was 0.6% (95% CI 0.2–1.4). The utility of routine LP for diagnosis of CNS infections requiring immediate treatment in children with an apparent first FS was low: the number of patients needed to test to identify one case of such infections was 1109 in children with an apparent first simple FS, and 180 in those with an apparent first complex FS.

Conclusion

The values provided from this study provide a basis for an evidence-based approach to the management of different subgroups of children presenting to emergency care with a first seizure in the context of fever.

Febrile and other occasional seizures

Seizures with fever that result from encephalitis or meningitis usually occur late in the course of febrile illness, and are focal and prolonged. Febrile seizures are by far the most common affecting 5% of the population, followed by posttraumatic seizures and those observed in the setting of a toxic, infectious, or metabolic encephalopathy. This chapter reviews the clinical presentation of the three most common forms, due to fever, trauma, and intoxication. Febrile seizures carry no cognitive or mortality risk. Recurrence risk is increased by young age, namely before 1 year of age. Febrile seizures that persist after the age of 6 years are usually part of the syndrome of Generalized epilepsy febrile seizures plus. These febrile seizures have a strong link with epilepsy since non-febrile seizures may occur later in the same patient and in other members of the same family with an autosomal dominant transmission. Complex febrile seizures, i.e., with focal or prolonged manifestations or followed by focal defect, are related to later mesial temporal epilepsy with hippocampal sclerosis; risk factors are seizure duration and brain malformation. Prophylactic treatment is usually not required in febrile seizures. Early onset of complex seizures is the main indication for AED prophylaxis. Early posttraumatic seizures, i.e., within the first week, are often focal and indicate brain trauma: contusion, hematoma, 24 hours amnesia, and depressed skull fracture are major factors of posttraumatic epilepsy. Prophylaxis with antiepileptic drugs is not effective. Various psychotropic drugs, including antiepileptics, may cause seizures.

Yield of diagnostic studies in children presenting with complex febrile seizures

OBJECTIVE

The objective of this study was to determine the yield of diagnostic workup in children presenting with complex febrile seizures.

METHODS

We performed a retrospective review of charts of patients who presented to our pediatric emergency department with complex febrile seizures (focal, prolonged, or recurrent). Patients with known seizure disorder, congenital central nervous system malformations, or hydrocephalus were excluded. The charts were reviewed for diagnostic workup.

RESULTS

There were 71 eligible encounters (mean age, 1.5 years); 59.2% were males. None of the 71 patients had positive blood or urine cultures; none had abnormal blood count or serum chemistries. Only 1 patient who had a very abnormal presentation in febrile status epilepticus had positive cerebrospinal fluid culture and abnormal brain computed tomography scan and magnetic resonance imaging.

CONCLUSIONS

Most patients with complex febrile seizures do not require extensive diagnostic workup.

Yield of lumbar puncture among children who present with their first complex febrile seizure

OBJECTIVE

To assess the rate of acute bacterial meningitis (ABM) among children who present with their first complex febrile seizure (CFS).

DESIGN AND METHODS

This study was a retrospective, cohort review of patients aged 6 to 60 months who were evaluated in a pediatric emergency department (ED) between 1995 and 2008 for their first CFS. Cases were identified by using a computerized text search followed by a manual chart review. Exclusion criteria included prior history of nonfebrile seizures, an immunocompromised state, an underlying illness associated with seizures or altered mental status, or trauma. Data extracted included age, gender, seizure features, the number of previous simple febrile seizures, temperature, a family history of seizures, findings on physical examination, laboratory and imaging study results, and ED diagnosis and disposition.

RESULTS

We identified 526 patients. The median age was 17 months (interquartile range: 13-24), and 44% were female. Ninety patients (17%) had a previous history of simple febrile seizures. Of the patients, 340 (64%) had a lumbar puncture (LP). The patients' median white blood cell count during a CFS was 1 cell per microL (interquartile range: 1-2), and 14 patients had CSF pleocytosis (2.7% [95% confidence interval [CI]: 1.5-4.5]). Three patients had ABM (0.9% [95% CI: 0.2-2.8]). Two had Streptococcus pneumoniae in a culture of their cerebrospinal fluid. Among these 2 patients, 1 was nonresponsive during presentation, and the other had a bulging fontanel and apnea. The third child appeared well; however, her blood culture grew S pneumoniae and failed the LP test. None of the patients for whom an LP was not attempted subsequently returned to the hospital with a diagnosis of ABM (0% [95% CI: 0, 0.9]).

CONCLUSION

Few patients who experienced a CFS had ABM in the absence of other signs or symptoms.