Original ArticlePredictors of Meningitis in Children Presenting With First Febrile Seizures
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.
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