Case: A 3 mo ex FT otherwise healthy boy presenting with first time seizure at home

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Discussion:

The classic newborn doing funny things. In this case, a 3 mo infant presents with reported seizure at home. With an otherwise benign history, normal vitals, and normal exam, the question becomes how much of a work up to undertake in the ED for a first-time seizure.

While most people agreed that everyone is “allowed” a first-time seizure. The age of this patient would push most to undergo at least a partial sepsis work up initially. When the initial labs (and EKG) are negative, and the patient continues to be well appearing, the next dilemma becomes additional work up and disposition.

Again, our suspicion of babies made most skeptical that this was “just” a seizure and additional work up and observation is indicated to evaluate for NAT, ICH, or meningoencephalitis. Dr. Chapman raised the point that while this child is well appearing with reassuring work up, infants can be deceiving; compared with a toddler running around the room, it is much harder to reassure oneself that this was “just” a seizure. As a result, many pursue admission +/- comply with neurology’s request for additional work up (HCT and LP)

For the subset who would prefer to admit and not subject the infant to the radiation of a HCT or trauma of an LP, a discussion was had about when to escalate conversation regarding the neurology fellow’s requests. Practically speaking, neither the neurology fellow or attending are going to come down and see the patient in the middle of the night. As a result, the consulting team will rely more conservative recommendations. Neurology was particularly concerned about HSV meningoencephalitis given mother’s history. This was a point of debate in the case as this infant was >6 weeks old and despite maternal history of HSV, this was not a primary infection, she had been on antivirals, had no prodrome and no lesions prior to/during/after delivery, and baby was delivered by C-section.

A review of available literature regarding workup for first time afebrile seizure was published by the American Academcy of Neurology in 2000 (https://www.ncbi.nlm.nih.gov/pubmed/10980722) . While routine EEG is recommended, additional lab work up and imaging is based on clinical features. Specifically looking at LP and head imaging, most of studies are in children greater than 6 months old and cannot be applied to this patient. Additionally, emergent head CT (as requested in this case), is only recommended if an MRI cannot be completed in the days following the seizure (if head imaging is indicated).

Denouement

A Head CT and LP (both negative) were performed in the ED prior to admission to the neurology service. The patient was empirically started on CTX and Acyclovir. He was admitted to Neurology and subsequently had a normal MRI and EEG. He had no further episodes concerning for seizure during admission.

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