Review Question - QID 217254

This patient currently has symptoms of an upper respiratory viral illness (e.g., clear rhinorrhea, non-productive cough, and sore throat). Since the patient likely had a simple febrile seizure (generalized and lasting less than 15 minutes), only supportive treatment is currently warranted.

Febrile seizures are characterized by fever temperatures higher than 38°C and the lack of other underlying provoking etiology. They occur in the pediatric population. While the pathophysiology is not clear, febrile seizures have a known genetic disposition with first-degree relatives who also had febrile seizures. They fall into 2 categories: simple and complex. The former are generalized seizures that do not last longer than 15 minutes and do not recur in 24 hours. The latter are focal, last longer than 15 minutes, and/or have a recurrence within 24 hours. While complex seizures will require further workup, simple febrile seizures can be treated conservatively as long as the patient returns to baseline with a normal neurological exam. The fever itself can be managed with intermittent antipyretic use (e.g., ibuprofen and acetaminophen).

Hirtz et al. reviewed the literature on febrile seizures and report on guidelines for their treatment. The vast majority of patients do not have any recurrence. Treatment with anti-epileptic drugs also does not effectively improve the prognosis for seizure remission. Given the potential adverse cognitive and behavioral side effects of these medications, they are not indicated for the prevention of epilepsy.

Incorrect Answers:
Answer 1: Ceftriaxone and vancomycin are used for empiric antimicrobial therapy for acute bacterial meningitis, specifically against N. meningitidis and S. pneumoniae. Patients usually present with neurological symptoms (e.g., headache, confusion, and photophobia), fever, and nuchal rigidity. Despite having a fever and having a single seizure, this patient lacked these findings and is at baseline.

Answer 2: Dexamethasone is used to reduce intracranial pressure secondary to vasogenic edema caused by intracranial malignancies. Metastatic sources include sarcomas and germ cell tumors while primary tumors include polycystic astrocytomas and medulloblastomas. Although seizures can arise, this patient did not have any other related neurological symptoms (e.g., headache, nausea, or vomiting).

Answer 3: Ethosuximide is the first-line treatment for absence seizures. These seizures are characterized by multiple, brief episodes of unresponsiveness that appear to observers as blank stares. There is no postictal confusion or deficit. The patient’s seizure did not have these features.

Answer 5: Valproic acid is a broad-spectrum anti-epileptic drug. It can be used for generalized tonic-clonic, myoclonic, as well as absence seizures in pediatric patients. Per American Academy of Pediatrics guidelines, simple febrile seizures do not require any anti-epileptic treatment.

Bullet Summary:
Patients with febrile seizures who have returned to their neurological baseline should only receive supportive treatment.