Hot Seat Case # 112 Denouement: 12 mo male with seizure-like activity

Posted on: May 7, 2018, by :

Lauren Kinneman, DO Inova Children’s Hospital

Case: 12 month old full term male brought in by EMS for concern of a seizure and rash. Had two episodes < 1 minute, one with the parents at home and another with EMS upon transport. On exam appeared not to be encephalitic and noted to have a rash consistent with erythema multiforme.

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Discussion:

The illness script for many providers was spot on! Complex febrile seizures. The entire group present for discussion stated that if no rash was present this would be diagnosed as complex febrile seizure and no workup would be needed. Interestingly enough, 4/12 poll responders stated that the presence of the rash would affect their management. 6 people responded No and 2 were left unsure.

Given the appearance of the rash, Dr. Cahill and Ward’s minds quickly made the association of erythema multiforme (EM) and HSV/Mycoplasma. Thus, the group felt that serum labs would not be helpful for medical decision making and rather the one test that would be helpful would be CSF studies. To tap or not to tap, that is the question (isn’t that always the question!). In an otherwise well appearing infant/child the LP was deferred.

Disposition was touched on briefly, but as Dr. Prieto pointed out, the disposition for this diagnosis is institutional specific.

Denouement:

The patient appeared to be at baseline on arrival, and with fever reduction appeared more comfortable. However, with the rash, labs were drawn and normal (CBC, CMP, CRP).The leading diagnosis was complex febrile seizures with urticarial multiforme. The patient was ultimately discharged with close primary care provider follow up.

https://www.ncbi.nlm.nih.gov/books/NBK470259/

  • Herpes infection, mainly with HSV-1, is most frequently in the cause. This is most often a minor EM. Herpes lesions precede EM for a few days (7 to 10 days). In contrast, all herpes outbreaks are not accompanied by EM and some outbreaks of EM can be caused by asymptomatic herpes recurrences. Viral research is often negative at the moment of the diagnosis. In the case of a recurrence of EM, a herpes origin must be suspected. It is observed in 70% of cases of recurrent EM.
  • Mycoplasma pneumoniae should be systematically sought for treatment in children. EM complicates 2% to 10% of infections with Mycoplasma pneumoniae in children and most often has a mucosal involvement. It is responsible for about two-thirds of EM with mucosal involvement. It is advisable to systematically perform a chest x-ray in addition to bacteriological research, if possible by gene amplification (PCR).
  • Epstein Barr, hepatitis virus, Coxsackie, parvovirus B19, human immunodeficiency virus) and bacterial (tuberculosis, streptococci) infections were incriminated.

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