Elsevier

Pediatric Neurology

Volume 44, Issue 1, January 2011, Pages 35-39
Pediatric Neurology

Original Article
Predictors of Meningitis in Children Presenting With First Febrile Seizures

https://doi.org/10.1016/j.pediatrneurol.2010.07.005Get rights and content

No data exist on the prevalence of meningitis in a first episode of seizures with fever in the Indian population. We investigated the prevalence of bacterial meningitis in children aged 6-18 months presenting with a first episode of seizures with fever, and we assessed clinical predictors of bacterial meningitis in these patients. We analyzed clinical and investigative profiles of 497 children, aged 6-18 months, admitted to pediatric casualty wards with a diagnosis of first febrile seizures. Lumbar puncture was performed in 199 (40.04%) infants. The prevalence of meningitis was 2.4% in children with first febrile seizures, 0.86% in simple febrile seizures, and 4.81% in complex febrile seizures. Duration of seizures more than 30 minutes, the presence of postictal drowsiness, and neurologic deficits were predictive of meningitis, with neurologic deficits as the most reliable. These predictors should be assessed in larger prospective studies.

Introduction

Fever is the most common presenting complaint among infants aged 90 days or younger at pediatric emergency departments [1]. By age 5 years, 2-5% of children experience one or more febrile seizures [2], [3], [4]. Most of these febrile seizures are benign and self-limiting. However, some may indicate an underlying pathology [5], [6], [7].

The National Institutes of Health (Bethesda, MD) defined the term “febrile seizure” as “an event in infancy or childhood, usually occurring between 3 months to 5 years of age, associated with fever but without the evidence of intracranial infection or defined cause. Seizures accompanied by fever in children who have suffered a previous nonfebrile seizure are excluded” [8]. Febrile seizures are further classified as simple or complex. Focal seizures, seizures lasting for ≥15 minutes, and the occurrence of more than one episode within 24 hours characterize complex febrile seizures.

Most febrile seizures are triggered by fevers from viral upper respiratory infections, ear infections, or roseola. Because the incidence of specific focal bacterial infections, including bacteremia, urinary tract infection, and meningitis, increases with increased temperature, seizures may be caused by these infections [9], [10]. The exact underlying pathophysiology is unknown, but genetic predisposition clearly contributes to the occurrence of this disorder. Meningitis as a cause of febrile seizures traces its origin to bacterial pathogens such as Haemophilus influenza type B, Neisseria meningitides, Streptococcus pneumonia, and Staphylococcus aureus, or viral pathogens such as Herpes simplex virus type 1. A lumbar puncture is usually recommended before the administration of empiric antibiotics [11], [12], because administering antibiotics without an evaluation of cerebrospinal fluid may lead to complications related to delayed diagnoses of bacterial meningitis or difficulties in interpreting cerebrospinal fluid pleocytosis [13].

The American Academy of Pediatrics in its consensus statement strongly recommends performing lumbar puncture in infants aged 6-12 months, and considering it in children aged 12-18 months, who manifest first simple febrile seizures, for the sake of diagnosing meningitis via cerebrospinal fluid analysis [14]. However, these guidelines are not strictly followed. Recent studies demonstrate a variable prevalence of meningitis in patients with first febrile seizures. However, few data exist regarding India. Thus, the primary objective of the present study was to determine the prevalence of bacterial meningitis in children aged 6-18 months presenting with first febrile seizures. Our secondary objective was to assess the clinical predictors of bacterial meningitis in such children.

Section snippets

Patients and Methods

This study involved a retrospective case review of patients with a first episode of seizures with fever, admitted to the pediatric casualty wards of the Guru Teg Bahadur Hospital (Delhi, India), a tertiary care center, from January 2003 to December 2008. The hospital serves both the urban and suburban populations residing mostly in slums, and belonging to the lower, upper lower, and lower middle socioeconomic strata, according to a modified Kuppaswami Scale [15]. The study population included

Results

From January 2003 to December 2008, 497 patients exhibiting a first episode of seizures with fever were admitted. A lumbar puncture was performed in 199 (40.04%) patients (Fig 1). The procedure could not be performed in 42 patients because consent was not received from the guardians. Lumbar puncture in the remaining 256 patients was excluded on clinical grounds by the attending physician. These patients were closely monitored and discharged after 24 hours, with uneventful recoveries.

Out of 199

Discussion

In our study, a lumbar puncture was performed in 40.04% of patients with a first episode of seizures with fever. Previous studies reported performing the procedure in 25-50% of patients [16], [17], [18]. Shaked et al. [14] performed a retrospective review of 50 patients with first simple febrile seizures, and analyzed the cerebrospinal fluid in 50% of these patients, none of whom manifested meningitis. Kimia et al. [18] performed a similar review of 704 patients with first simple febrile

Conclusions

The prevalence of meningitis in infants with a first febrile seizures is 2.4%, and is even lower for first simple febrile seizures (0.86%). Seizures of a duration >30 minutes, postictal drowsiness, and neurologic deficit are the signs that can predict meningitis in such patients, with neurologic deficit as the best predictor. These predictors need to be assessed in larger prospective studies.

References (24)

  • L.J. Baraff

    Management of fever without source in infants and children

    Ann Emerg Med

    (2000)
  • B.S. Krauss et al.

    The spectrum and frequency of illness presenting to paediatrics emergency department

    Pediatr Emerg Care

    (1991)
  • K.B. Nelson et al.

    Prognosis in children with febrile seizures

    Pediatrics

    (1978)
  • C.M. Verity et al.

    Febrile convulsion in a national cohort followed up from birth. I—Prevalence and recurrence in the first five year of life

    Br Med J [Clin Res]

    (1985)
  • Y.A. Al-Eissa et al.

    Antecedents and outcome of simple and complex febrile convulsions among Saudi children

    Dev Med Child Neurol

    (1992)
  • J.M. Freeman

    Febrile seizures: An end to confusion

    Pediatrics

    (1978)
  • R.J. Robinson

    Further assuring news about prognosis

    Br Med J [Clin Res]

    (1991)
  • A. Joffe et al.

    Which children with febrile seizures need lumbar puncture? Decision analysis approach

    Am J Dis Child

    (1983)
  • Consensus statement. Febrile seizures: Long-term management of children with fever associated seizures

    Pediatrics

    (1980)
  • A. Hoberman et al.

    Urinary tract infections in young febrile children

    Pediatr Infect Dis J

    (1997)
  • D.M. Jaffe et al.

    Temperature and total white blood cell count as indicators of bacteremia

    Pediatrics

    (1991)
  • J.A. Jaskiewicz et al.

    Febrile infants at low risk for serious bacterial infection—An appraisal of the Rochester criteria for management. Febrile Infant Collaborative Study Group

    Pediatrics

    (1994)
  • Cited by (28)

    • Clinical findings and management of patients with meningitis with an emphasis on Haemophilus influenzae meningitis in rural Tanzania

      2016, Journal of the Neurological Sciences
      Citation Excerpt :

      Although only a few patients had the classical meningitis triad of fever, neck stiffness and an altered mental state, van de Beek et al. state that at least two of those symptoms are warning signals in the diagnosis of meningitis, as well as an absence of all three symptoms can nearly exclude the diagnosis [29]. Another important factor in paediatric patients is the presentation of epileptic seizures associated with a fever (as opposed to febrile seizures), accompanied by impairment of consciousness or neurological deficits, as these symptoms may be indicators of bacterial meningitis [31,32]. Our study determined a higher occurrence of seizures in the patients with meningitis caused by H. influenza compared to all patients, a phenomenon which was already observed in earlier studies and may be used as an alert ‘red flag’ symptom for a H. influenzae infection [28,33].

    • Meningitis in children: Diagnosis and treatment for the emergency clinician

      2013, Clinical Pediatric Emergency Medicine
      Citation Excerpt :

      The classic signs of meningismus such as neck stiffness, headaches, photophobia, and Kernig or Brudzinski signs are not present either because of the immature nervous system in the newborn and infant or because the patient's not-yet developed speech makes it increasingly difficult to rely on the usual adult signs and symptoms.4,34,35 Instead, in the neonate and infant, one must rely on other nonspecific signs such as abrupt onset of fever, accompanied by decreased activity, decreased feeding, irritability, failure to thrive, and sleepiness, among others (Table 1).4-37 Neonates are at increased risk for severe systemic disease, particularly by HSV, with progression to encephalitis with seizures and/or focal neurologic findings.36

    View all citing articles on Scopus
    View full text