Case Report

First Simple Febrile Seizures caused by Pharyngitis

Supervisor : dr. Ismet, Sp.A

Firdaus Riza, S.Ked

Novella Treskasyma, S.Ked
Nurcahaya Antika, S.Ked
Pramita Rukmana, S.Ked

CLINICAL CLERKSHIP OF PEDIATRIC DEPARTMENT

MEDICAL FACULTY OF RIAU UNIVERSITY
ARIFIN ACHMAD GENERAL HOSPITAL
PEKANBARU
2020
 INTRODUCTION
Febrile Seizure Neurological disorders

< 5 years old

Fever : > 38 oC

• Recurrence: 30-40%
• United States and Europe: children aged 6 months - 5 years (12-18 months)
• Indonesia (2008): 2-4%, 80% caused by respiratory infections
 INTRODUCTION

Seizure Apnea hypoxia

 
Increases the risk of Brain neuron cell capillary permeability
developmental delay, damage and brain edema
mental reterdation,
paralysis and
progression to
epilepsy
 INTRODUCTION

Upper respiratory tract infection

Main Symptom (30%) :

sore throat
often occurs in children

Febrile Seizure
 Pyrexia
Altering upward of the
thermoregulatory set point

Normal :
Axila : 36,4 (34,7 – 37,3)°C
Oral : 36,6 (35,5 – 37,5)°C
Rectal : 37,0 (36,6 – 37,9C
Tympanic : 36,6 (35,7 – 37,5)°C
 Febrile Seizure Genetic
Risk Factor
• 2-4% : 6 months – 5 years old Body Temprature
• The U.S National Collaborative Perinatal
Project (NCCP)
Viral Infection
Caucasian 3,5 %
African 4,2 %
Japanese 9-10 %
Simple Febrile Seizures
• Neurological Consensus of Indonesian Classification
Pediatrician
Complex Febrile Seizures
Etiology Abnormal body temprature
Febrile Seizure
Diazepam iv 0,2-0,5 mg/kg
Clinical Manifestations speed : 2 mg/min
Max dose : 10 mg

•- Lumbal Puncture Diazepam rectal 0,5-0,75 mg/kg

•- EEG
•- Head CT-Scan < 12 kg : 5 mg
•- Head MRI > 12 kg : 10 mg

Diagnosis Treatment
Febrile Seizure
- Central Nervous System Infection
- Epilepsy
- delirium
- tremor,
- Syncope
- anoxic seizure
Risk of reccurent seizure :
- Family history of febrile seizures or epilepsy
- < 12 years old
- > 39°C during seizure
- Short time intervals between onset of fever with seizure
- First seizure is complex feb rile seizure

Differential
Prognosis
Diagnosis
 Tonsillitis

Sore throat
Tonsillopharyngitis

Nasopharyngitis
Pharyngitis
Steptococcus β hemolyticus group A

Penisilin
 Case Report
Identity
– Name : AN. MAA
– No MR : 01032951
– Age : 1 year 1 month old
– Address : Kelapa Sawit street, Bukit Raya, Pekanbaru
– Date of admission : 6th January 2020
– Date of discharge : 8th January 2020
– Patient status : Alive

Chief Complaint:

Seizures since 1 hour before admitted to the hospital

 History of Present Illness

1 hour 1 day
Seizure
- Once, 2 minutes Fever
- Eyes glance up and jerking of limbs -Gradually
- Lose consciousness during seizure -Increase at night
- Conscious after seizure - decrease with paracetamol
- get anti-convulsants

Fever (40oC )
Anamnesi
s • Meal history
• Past medical history : • Breast milk : 0-6 months
• Companion breast milk: 6 months – now
-
• Immunization history
• Family’s medical history
• Hepatitits B : 1x
• Family’s member never
• Polio : 1x
complained about the same
• Measles: Notyet (caused fever)
complains.
• DPT : Notyet (caused fever)
• Parent’s history :
• History of growth and development
• Father : driver • Birth weight : 2400 gram, Birth length : ? cm
• Mother : housewife • Weight now : 8,5 kg, Length now : 78 cm
• Pregnancy history : • Gross motor: stand without holding
• The 3rd child • Fine motor: bring 2 small xqcubes together
• Spontaneously in hospital • Speak: 2 syllables, ma-ma, pa-pa
• Never complained • Socialization: differentiate strangers
Physical Examination
General appearance : Moderate Illness
Awareness : Composmentis

Vital signs:
- Blood pressure : 100/60 mmHg
- Pulse : 130x/min, regularly
- Respiratory rate : 24x/min
-Temperature : 39,7 ºC
- Height : 75 cm
- Weight : 8,5 kg
- Arm Circumference : 14 cm
- Head circumference : 45 cm
Physical Examination
Normocephal, ear and
nose within normal limit. Pale conjunctiva (-/-), yellow sclera (-/-),

Mouth: dirty tongue (-),

pharyngeal hyperemi (+)
tonsil T1-T1, hyperemia (-)
detritus (-)
Inspection: symmetrical chest wall
movement left and right, retraction (-)
Palpation: symmetrical vocal fremitus left
and right lung
Percussion: resonant in both lungs
Auscultation: Vesicular (+ / +), ronchi
Neck stiffness (-) (-/-), wheezing (-/-)
Neck and axilla lymph
nodes enlargement (-)

Inspection : Ictus cordis was invisible

Palpation : palpable in the left midclavicle line, ICS
IV
Percussion : no cardiomegaly
Auscultation: HR : 130x/min,S1 S2 regular (+),
murmur (-), gallop (-)
Physical Examination

Male, normal form,

congenital anomalies (-),
phimosis (-)
Inspection : Flat, symmetrical, distention
(-)
Auscultation : bowel sound (+) 10 times a
minute
Palpation : pain tenderness (-),
hepatomegaly (-)
Percussion: Timpani (+)

Warm, CRT <2 seconds,

edema(- /-),
cyanosis (- / -), muscle tone
(5)
Neurological Examination • Cranial nerves:
- Nervus II / III. : round pupil,
isochorism, pupil diameter 3mm,
• Physiological reflexes : light reflex (+/- +)
Achilles pess reflex and knee pess - Nervus III / IV / VI: Eyeball
reflex do not increase movement in either direction,
nystagmus (-)
• Pathological reflexes : - Nervus VII : face parese (-)
Babinski (+) Chaddock (-) - Other cranial nerves are difficult
to assess
• Meningeal stimulation :
Stiff neck (-), brudzinski I (-), • Motor : No impression parese
brudzinski II (-), brudzinski III (-)
• Tonus : not increased
Laboratorium finding

January 6th 2019

Hemoglobin : 11,1 g/dl Basofil : 0,3 % Simple Blood Sugar Test : 67 mg/dL
Leukocyte : 21.660/µL Eosinofil : 0 %
Trombocyte : 423 10’3/µL Neutrofil : 81,1 % Na+ : 140 mmol/L
Hematocryte : 34,6% Limfosit : 12,2 % K+ : 4,3 mmol/L
Eritrocyte : 4,39 10’6/µL Monosit : 6,4 % Cl : 106 mmol/L
Working Diagnosis

First Simple Febrile Seizures caused by Pharyngitis

Nutrition Diagnosis

Normal

Differential Diagnosis

1. Meningitis
2. Encephalitis
Therapy
Medicamentosa :

• IVFD KAEN 1B 10 gtt/minutes

• Inj. Ceftriaxone 300 mg/12 hours/i.v
• Inf. Paracetamol 100 mg/6 hours/i.v
• Stesolid syr 3 cth I (once)
• Liquid food 6 x 100 cc
Follow Up (Saturday, 7-1-2020)

Subjectif • Fever (-)

• Seizure (-)
Objectif • Awarness : Composmentis
• General Appearance : Moderate illness
• Pharyngeal : hyperemi ( )

Assasment First Simple Febrile Seizure caused ny

Pharyngitis
Therapy • IVFD KAEN 1B 10 gtt/minutes
• Inj. Ceftriaxone 300 mg/12 hours/i.v
• Diet : nasi tim 3x/day
 Discussion
Boy ( 1 year 1 month old)
Simple Febrile Seizure

Seizure (IDAI)
• 6 months – 5 year
• Fever (> 38oC )
DISCUSSION Anamnesis

- Fever since 1 day

- Gradually Remittent Fever
- Increase at night = often occurs in children
- decrease with
paracetamol

Seizure
- Once, 2 minutes Simple Febrile Seizure
- Eyes glance up and jerking of limbs - < 15 minutes
- Lose consciousness during seizure - Generalized seizures
- Conscious after seizure - do not repeat within 24 hours
 DISCUSSION Physical examination

Axilla temperature 39,7°C  seizure fever (>38,4°C)

Pharyngeal hiperemi + sore throat and fever  Pharyngitis

 DISCUSSION Laboratory finding

Leukocytes 21.660 gr/dl  Infection

Hb : 11,1 gr/dl  Mentzer score : iron deficiency anemia

Lumbal puncture, EEG, CT Scan and MRI not done

DISCUSSION Therapy

• Oral or rectal diazepam can reduce febrile seizures and as an

intermittent prophylaxis  Rosman et al

• Antibiotics  bacterial pharyngitis infection (centor score: 28-

35% cause pharyngitis is group A Streptococcus hemolyticus)
 Education
Convince parent that simple febrile seizure have a good prognosis

How to handle seizure

Recurrent seizure

Oral diazepam prophylaxis

THANK YOU
 Pertanyaan
• 1. bagaimana penanganan awal jika kita menumukan pasien
yang sedang mengalami kejang? Yang dapat kita lakukkan pada
pasien yaitu pertama tengkan orang tua pasien, kemudian
membuka atau melonggarkan pakaian pasien, memiringkan
pasien kekiri dan tidak memasukkan suatu benda kedalam
mulut pasien
• 2. bagaimana jika kita mendapatkan pasien dengan kejang,
kemudian kita telah melaukkan tatalaksana awal deangan
memasukan diazepam rektal namun kejang tidak berhenti?
Hafal algoritma kejang, kita bisa memberikan diazepam rektal
itu sesuai dengan brat badan 5/10 mg, dapat diulang selam 2
kali dalam selang 5 menit, kalau tidak juga berkurang pakai
diazepam iv dan selanjutnya, hafal aja algoritma tatalaksana
kejang.
• 3. kapan kita melaukkan pemeriksaan penunjang seprti EEG<
CT SCAN dan MRI? Sebenarnya sih ini udah ada jawabannya
pada penjelasan tapi gpp, jawab aja lagi,