A 22-month-old girl with no significant co-morbidities presented to Paediatric
ER with a history of 36 hours of diarrhoea and vomiting associated with a 2 minute toniceclonic seizure with associated eye-rolling and post-ictal phase at home. On arrival to
ER she proceeded to have two further 2 minute toniceclonic seizures within 2 hours of the first. She had profuse diarrhoea and vomiting. She had been seen twice previously in hospital for Bronchiolitis and Viraleinduced wheeze. She had no known allergies, no recent travel abroad and was up to date with her immunisations. Her paternal aunt had febrile seizures as a child. There were no developmental concerns.
On examination she was afebrile throughout her time in A
þ E, well perfused with a CRT of less than 2 seconds, heart rate of 160 and respiratory rate of 40. Her general examination was normal however she had a GCS of 14 and was floppy in a post-ictal state.
She was admitted for a fluid challenge requiring continuous NG dioralyte and proceeded to have short generalised toniceclonic seizures about every 90 minutes on the ward. Bloods including glucose were normal. After the eighth seizure she had a CT head and LP which were normal. 48 hours into the illness she proceeded to have a generalised toniceclonic seizure lasting 7 minutes followed by increased tone on the right side in both upper and lower limbs. She was treated with buccal midazolam followed by IV Lorazepam 10 minutes later. After another 30 minutes with ongoing hypertonia on right side she was started on Phenytoin. She was started on IV Ceftriaxone and Aciclovir. After 2 hours the seizure ceased and she had no further seizures. She had been having seizures for a total of 24 hours.
Q1. What is the most likely cause for her seizures?
a) Febrile convulsions
b) Epilepsy
c) Meningitis
d) Rotavirus
e) Herpes Encephalitis
Q2. What type of seizures can occur in this condition?
a) Symmetrical seizures
b) Generalised seizures
c) Partial seizures
d) Partial seizures secondarily generalised
e) Absence seizures
Q3. Over what period of time do the seizures characteristically occur in this condition?
a) 12 hours
b) 24e48 hours
c) 3e5 days
d) 1 week
Answer
A1. Rotavirus
A2. aed
A3. 24e48 hours
A stool sample came back as positive for Rotavirus. Rota-virus is well documented to cause short seizures both generalised and focal, however case reports of status epi-lepticus are rare in afebrile children with rotavirus and is an important part of counselling parents whose children have gastroenteritis symptoms and present with seizures. Previous Asian studies have shown an incidence of afebrile seizures in children being 2.06% with the highest incidence being between 1 and 2 years (4.67%). These seizures most commonly happened on the third day of diarrhoea, typically
in a cluster lasting 24 hours with no status epilepticus reported. Seizures are usually symmetrical and generalised. However partial seizures and partial seizures secondarily generalised have also been described. Over the last 3 years non-Asian studies have been published showing similar results with a mean age of 17 months and maximum seizure duration lasting 10 minutes over 24-48 hours.
Children with rotavirus gastroenteritis are a frequent presentation to most paediatric units. Rarely they are noted to have short self-resolving seizures and parents can be counselled appropriately regarding this complication. It is very unexpected for a patient with no other co-morbidities who is afebrile to develop status epilepticus as a complication of rotavirus gastroenteritis and therefore patients are not usually counselled about this. Recognising this clinical picture and what it is helps to calm both the physician and the patient’s family, given the anxiety-provoking nature of clustered convulsions.
ER with a history of 36 hours of diarrhoea and vomiting associated with a 2 minute toniceclonic seizure with associated eye-rolling and post-ictal phase at home. On arrival to
ER she proceeded to have two further 2 minute toniceclonic seizures within 2 hours of the first. She had profuse diarrhoea and vomiting. She had been seen twice previously in hospital for Bronchiolitis and Viraleinduced wheeze. She had no known allergies, no recent travel abroad and was up to date with her immunisations. Her paternal aunt had febrile seizures as a child. There were no developmental concerns.
On examination she was afebrile throughout her time in A
þ E, well perfused with a CRT of less than 2 seconds, heart rate of 160 and respiratory rate of 40. Her general examination was normal however she had a GCS of 14 and was floppy in a post-ictal state.
She was admitted for a fluid challenge requiring continuous NG dioralyte and proceeded to have short generalised toniceclonic seizures about every 90 minutes on the ward. Bloods including glucose were normal. After the eighth seizure she had a CT head and LP which were normal. 48 hours into the illness she proceeded to have a generalised toniceclonic seizure lasting 7 minutes followed by increased tone on the right side in both upper and lower limbs. She was treated with buccal midazolam followed by IV Lorazepam 10 minutes later. After another 30 minutes with ongoing hypertonia on right side she was started on Phenytoin. She was started on IV Ceftriaxone and Aciclovir. After 2 hours the seizure ceased and she had no further seizures. She had been having seizures for a total of 24 hours.
Q1. What is the most likely cause for her seizures?
a) Febrile convulsions
b) Epilepsy
c) Meningitis
d) Rotavirus
e) Herpes Encephalitis
Q2. What type of seizures can occur in this condition?
a) Symmetrical seizures
b) Generalised seizures
c) Partial seizures
d) Partial seizures secondarily generalised
e) Absence seizures
Q3. Over what period of time do the seizures characteristically occur in this condition?
a) 12 hours
b) 24e48 hours
c) 3e5 days
d) 1 week
Answer
A1. Rotavirus
A2. aed
A3. 24e48 hours
A stool sample came back as positive for Rotavirus. Rota-virus is well documented to cause short seizures both generalised and focal, however case reports of status epi-lepticus are rare in afebrile children with rotavirus and is an important part of counselling parents whose children have gastroenteritis symptoms and present with seizures. Previous Asian studies have shown an incidence of afebrile seizures in children being 2.06% with the highest incidence being between 1 and 2 years (4.67%). These seizures most commonly happened on the third day of diarrhoea, typically
in a cluster lasting 24 hours with no status epilepticus reported. Seizures are usually symmetrical and generalised. However partial seizures and partial seizures secondarily generalised have also been described. Over the last 3 years non-Asian studies have been published showing similar results with a mean age of 17 months and maximum seizure duration lasting 10 minutes over 24-48 hours.
Children with rotavirus gastroenteritis are a frequent presentation to most paediatric units. Rarely they are noted to have short self-resolving seizures and parents can be counselled appropriately regarding this complication. It is very unexpected for a patient with no other co-morbidities who is afebrile to develop status epilepticus as a complication of rotavirus gastroenteritis and therefore patients are not usually counselled about this. Recognising this clinical picture and what it is helps to calm both the physician and the patient’s family, given the anxiety-provoking nature of clustered convulsions.
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