Hot Seat #177: Denouement

Posted on: October 9, 2021, by :

The Cases: A baby with apnea and for a toddler with a complex febrile seizure.

Here’s how you answered:

This week we discuss two kids with the same dilemma: Do they need an emergent lumbar puncture?

In the first case, we have a baby presenting with concern for an apnea episode at home. Initially, both junior and senior respondents favored basic lab work or urine studies, and only 1 respondent in each group immediately felt inclined to obtain a lumbar puncture. Our discussion focused on the significance of the child’s apnea alarm sounding at home, and most felt it was an unlikely indicator of sepsis in an otherwise healthy child. Most agreed that this not-yet-corrected-to-term patient warrants admission for observation, but not necessarily lumbar puncture. Furthermore, there was concern that a young patient with potential apnea may have respiratory difficulty or more apnea when being positioned for the LP. Ultimately, the parents of this patient refused to have a lumbar puncture performed, so he was admitted to the NICU on antibiotics and 2L oxygen, weaned quickly, and was discharged home without complications. The source of his apnea was ultimately believed to be from RSV infection.

Our second case featured a 15-month-old boy transferred to our hospital following a generalized tonic clonic seizure for 20 minutes at home in the absence of fever. By the time of his arrival, he was well appearing and back to his neurological baseline. While our junior respondents chose a range of initial testing strategies, our senior respondents 100% chose not to perform any workup in the emergency department. Our neurology team recommended CSF studies given the complex nature of the seizure. During our discussion, we talked about the differentiation of “complex” and “simple” febrile seizures. The majority agreed that this differentiation is outdated, especially in a patient who has returned to their neurological baseline without any deficits, and this history is unlikely to represent meningitis. Similarly, HSV meningoencephalitis would be unlikely to present with an isolated seizure and rapid return to baseline. This patient underwent LP in the emergency department: 0 WBCs, normal protein and glucose, negative meningitis/encephalitis PCR panel including HSV. The patient was admitted to the neurology service on antibiotics, he underwent EEG that was ultimately negative, and was discharged home with diagnosis of enterovirus infection and complex febrile seizure.

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Walter Palmer