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Ruttkowski L, Wallot I, Korell M, Daur E, Seipelt P, Leonhardt A, Weber S, Mand N. Case report: Febrile infection-related epilepsy syndrome in a 14-year-old girl with multiple organ failure and lethal outcome. Front Neurosci 2024; 18:1255841. [PMID: 38505775 PMCID: PMC10948546 DOI: 10.3389/fnins.2024.1255841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 02/07/2024] [Indexed: 03/21/2024] Open
Abstract
We report a case of an otherwise healthy 14-year-old girl with febrile infection-related epilepsy syndrome (FIRES), multiple organ failure (MOF), and ultimately a lethal outcome. This is a rare case of FIRES with MOF and consecutive death. Only a few cases have been described in the literature. The adolescent girl was initially admitted to our pediatric emergency department with a first episode of generalized tonic-clonic seizures after a short history of fever a week before admission. Seizures progressed rapidly into refractory status epilepticus without any evidence of the underlying cause, and treatment subsequently had to be escalated to thiopental anesthesia. Since the initial diagnostics showed no promising leads, the rare syndrome of FIRES was suspected, representing a catastrophic epileptic encephalopathy linked to a prior benign febrile infection. Methylprednisolone, intravenous immunoglobulins, and a ketogenic diet were initiated. Respiratory, circulatory, kidney, and liver failure developed during treatment, requiring increasing intensive care. Multiple attempts to deescalate antiepileptic treatment resulted in recurrent status epilepticus. A cranial MRI on the 10th day of treatment revealed diffuse brain edema and no cerebral perfusion. The patient was declared dead on the 11th day of treatment. FIRES should be taken into account in previously healthy children with a new onset of difficult-to-treat seizures after a short febrile infection when no other cause is apparent. First-line treatment, besides seizure control, is the early initiation of immunomodulatory therapy and the start of a ketogenic diet. As treatment is difficult and MOF may develop, patients should be transferred to a specialized children's hospital providing full intensive care.
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Affiliation(s)
- Lars Ruttkowski
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Ines Wallot
- Pediatric Neurology, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Marie Korell
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Elke Daur
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Peter Seipelt
- Pediatric Neurology, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Andreas Leonhardt
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Stefanie Weber
- Pediatric Nephrology, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Nadine Mand
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
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Abstract
Context Refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE) are neurological emergencies with considerable mortality and morbidity. In this paper, we provide an overview of causes, evaluation, treatment, and consequences of RSE and SRSE, reflecting the lack of high-quality evidence to inform therapeutic approach. Sources This is a narrative review based on personal practice and experience. Nevertheless, we searched MEDLINE (using PubMed and OvidSP vendors) and Cochrane central register of controlled trials, using appropriate keywords to incorporate recent evidence. Results Refractory status epilepticus is commonly defined as an acute convulsive seizure that fails to respond to two or more anti-seizure medications including at least one nonbenzodiazepine drug. Super-refractory status epilepticus is a status epilepticus that continues for ≥24 hours despite anesthetic treatment, or recurs on an attempted wean of the anesthetic regimen. Both can occur in patients known to have epilepsy or de novo, with increasing recognition of autoimmune and genetic causes. Electroencephalography monitoring is essential to monitor treatment response in refractory/super-refractory status epilepticus, and to diagnose non-convulsive status epilepticus. The mainstay of treatment for these disorders includes anesthetic infusions, primarily midazolam, ketamine, and pentobarbital. Dietary, immunological, and surgical treatments are viable in selected patients. Management is challenging due to multiple acute complications and long-term adverse consequences. Conclusions We have provided a synopsis of best practices for diagnosis and management of refractory/superrefractory status epilepticus and highlighted the lack of sufficient high-quality evidence to drive decision making, ending with a brief foray into avenues for future research.
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Affiliation(s)
- Debopam Samanta
- Child Neurology Division, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Lisa Garrity
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ravindra Arya
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; USA. Correspondence to: Dr Ravindra Arya, Division of Neurology, Cincinnati Children's Hospital Medical Center, MLC 2015, 3333 Burnet Avenue, Cincinnati, Ohio, 45229 USA.
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Annecke T, Conzen P, Ney L. Propofol-related infusion syndrome induced by “moderate dosage” in a patient with severe head trauma. J Clin Anesth 2012; 24:51-4. [DOI: 10.1016/j.jclinane.2011.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2010] [Revised: 03/08/2011] [Accepted: 03/10/2011] [Indexed: 10/14/2022]
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Rossetti A, Santoli F. Traitement pharmacologique de l’état de mal réfractaire. Rev Neurol (Paris) 2009; 165:373-9. [DOI: 10.1016/j.neurol.2008.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Accepted: 12/05/2008] [Indexed: 10/21/2022]
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Update on the propofol infusion syndrome in ICU management of patients with head injury. Curr Opin Anaesthesiol 2009; 21:544-51. [PMID: 18784477 DOI: 10.1097/aco.0b013e32830f44fb] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The propofol infusion syndrome is a rare condition characterized by the occurrence of lactic acidosis, rhabdomyolysis and cardiovascular collapse following high-dose propofol infusion over prolonged periods of time. Patients with traumatic brain injury are particularly at risk of developing this complication because large doses of propofol are commonly used to control intracranial pressure, whereas vasopressors are administered to augment cerebral perfusion pressure. In this review, we provide an update on the literature with particular emphasis on patients with traumatic brain injury. RECENT FINDINGS Several new case reports and reviews, as well as a number of experiments, have contributed significantly to our increased understanding of the cause of the syndrome. At the basis of the syndrome lies an imbalance between energy utilization and demand resulting in cell dysfunction, and ultimately necrosis of cardiac and peripheral muscle cells. Uncertainty remains whether a genetic susceptibility exists. Nonetheless, the growing number of case reports has made it possible to identify several risk factors. SUMMARY Propofol infusion syndrome is a rare but frequently lethal complication of propofol use. In patients with risk factors, such as traumatic brain injury, it is suggested that an infusion rate of 4 mg/kg per hour should not be exceeded. Early warning signs include unexplained lactic acidosis, lipemia and Brugada-like ECG changes. When these occur, propofol infusion should be discontinued immediately.
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Cereda C, Berger MM, Rossetti AO. Bowel Ischemia: A Rare Complication of Thiopental Treatment for Status Epilepticus. Neurocrit Care 2008; 10:355-8. [DOI: 10.1007/s12028-008-9168-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2008] [Accepted: 10/29/2008] [Indexed: 10/21/2022]
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Abstract
Propofol (2, 6-diisopropylphenol) is a potent intravenous hypnotic agent that is widely used in adults and children for sedation and the induction and maintenance of anaesthesia. Propofol has gained popularity for its rapid onset and rapid recovery even after prolonged use, and for the neuroprotection conferred. However, a review of the literature reveals multiple instances in which prolonged propofol administration (>48 hours) at high doses (>4 mg/kg/h) may cause a rare, but frequently fatal complication known as propofol infusion syndrome (PRIS). PRIS is characterized by metabolic acidosis, rhabdomyolysis of both skeletal and cardiac muscle, arrhythmias (bradycardia, atrial fibrillation, ventricular and supraventricular tachycardia, bundle branch block and asystole), myocardial failure, renal failure, hepatomegaly and death. PRIS has been described as an 'all or none' syndrome with sudden onset and probable death. The literature does not provide evidence of degrees of symptoms, nor of mildness or severity of signs in the clinical course of the syndrome. Recently, a fatal case of PRIS at a low infusion rate (1.9-2.6 mg/kg/h) has been reported. Common laboratory and instrumental findings in PRIS are myoglobinuria, downsloping ST-segment elevation, an increase in plasma creatine kinase, troponin I, potassium, creatinine, azotaemia, malonylcarnitine and C5-acylcarnitine, whereas in the mitochondrial respiratory electron transport chain, the activity of complex IV and cytochrome oxidase ratio is reduced. Propofol should be used with caution for sedation in critically ill children and adults, as well as for long-term anesthesia in otherwise healthy patients, and doses exceeding 4-5 mg/kg/h for long periods (>48 h) should be avoided. If PRIS is suspected, propofol must be stopped immediately and cardiocirculatory stabilization and correction of metabolic acidosis initiated. So, PRIS must be kept in mind as a rare, but highly lethal, complication of propofol use, not necessarily confined to its prolonged use. Furthermore, the safe dosage of propofol may need re-evaluation, and new studies are needed.
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Affiliation(s)
- Vincenzo Fodale
- Department of Neurosciences, Psychiatric and Anaesthesiological Sciences, University of Messina, Messina, Italy.
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Abend NS, Dlugos DJ. Treatment of refractory status epilepticus: literature review and a proposed protocol. Pediatr Neurol 2008; 38:377-90. [PMID: 18486818 DOI: 10.1016/j.pediatrneurol.2008.01.001] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Revised: 09/06/2007] [Accepted: 01/14/2009] [Indexed: 11/18/2022]
Abstract
Refractory status epilepticus describes continuing seizures despite adequate initial pharmacologic treatment. This situation is common in children, but few data are available to guide management. We review the literature related to the pharmacologic treatment and overall management of refractory status epilepticus, including midazolam, pentobarbital, phenobarbital, propofol, inhaled anesthetics, ketamine, valproic acid, topiramate, levetiracetam, pyridoxine, corticosteroids, the ketogenic diet, and electroconvulsive therapy. Based on the available data, we present a sample treatment algorithm that emphasizes the need for rapid therapeutic intervention, employs consecutive medications with different mechanisms of action, and attempts to minimize the risk of hypotension. The initial steps suggest using benzodiazepines and phenytoin. Second steps suggest using levetiracetam or valproic acid, which exert few hemodynamic adverse effects and have multiple mechanisms of action. Additional management strategies that could be employed in tertiary-care settings, such as coma induction guided by continuous electroencephalogram monitoring and surgical options, are also discussed.
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Affiliation(s)
- Nicholas S Abend
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
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Bösebeck F, Möddel G, Anneken K, Fischera M, Evers S, Ringelstein EB, Kellinghaus C. [Refractory status epilepticus: diagnosis, therapy, course, and prognosis]. DER NERVENARZT 2006; 77:1159-60, 1162-4, 1166-75. [PMID: 16924462 DOI: 10.1007/s00115-006-2125-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Status epilepticus (SE) is a frequent neurological emergency with an annual incidence of 10-20/100,000 individuals. The overall mortality is about 10-20%. Patients present with long-lasting fits or series of epileptic seizures or extended stupor and coma. Furthermore, patients with SE can suffer from a number of systemic complications possibly also due to side effects of the medical treatment. In the beginning, standardized treatment algorithms can successfully stop most SE. A minority of SE cases prove however to be refractory against the initial treatment and require intensified pharmacologic intervention with nonsedating anticonvulsive drugs or anesthetics. In some partial SE, nonpharmacological approaches (e.g., epilepsy surgery) have been used successfully. This paper reviews scientific evidence of the diagnostic approach, therapeutic options, and course of refractory SE, including nonpharmacological treatment.
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Affiliation(s)
- F Bösebeck
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Strasse 33, 48129, Münster.
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