Case Presentation — Paediatrics Posting

📋 STRUCTURED CASE WRITE-UP

CASE SUMMARY (For Oral Presentation)

HISTORY OF PRESENTING ILLNESS

• Uprolling of eyes
• Tonic-clonic movements of all four limbs
• Frothing from mouth
• Clenching of teeth
• Sweating
• Each episode lasted approximately 5 minutes, occurring multiple times over 2 hours
• Consciousness was preserved during episodes (no loss of consciousness reported)

• No fever (rules out febrile seizures)
• No head trauma (rules out post-traumatic seizures)
• No vomiting or headache (rules out raised intracranial pressure)
• No ear discharge (rules out intracranial spread from otogenic source)
• No focal weakness (rules out focal/symptomatic epilepsy)
• No drug intake
• No developmental delay
• No birth asphyxia
• No history of tuberculosis
• No family history of seizures

BIRTH & DEVELOPMENTAL HISTORY

• Normal vaginal delivery, full-term, birth weight 2.9 kg
• Cried immediately after birth (no perinatal asphyxia)
• Developmental milestones achieved appropriately
• Immunized as per National Immunization Schedule

GENERAL PHYSICAL EXAMINATION

ANTHROPOMETRIC ASSESSMENT

PROVISIONAL DIAGNOSIS

1. Recurrent episodes (multiple in 2 hours) with prior similar history 4 years ago
2. Tonic-clonic semiology with autonomic features (sweating, frothing)
3. No fever, trauma, metabolic trigger identified on history
4. Preserved consciousness is unusual for GTCS (this needs further clarification — may suggest focal onset with bilateral propagation, or the grandmother may have misinterpreted preserved responsiveness)

1. Juvenile Myoclonic Epilepsy (JME) — though age is slightly young
2. Childhood epilepsy with generalized tonic-clonic seizures
3. Symptomatic epilepsy secondary to cortical dysplasia or prior CNS insult
4. Metabolic seizures (hypoglycemia, hyponatremia) — to be excluded
5. CNS infection (encephalitis/meningitis) — no fever but must consider

INVESTIGATIONS TO BE ORDERED

MANAGEMENT OUTLINE

• ABC, airway positioning, oxygen
• IV access → IV Lorazepam 0.1 mg/kg (or Diazepam 0.3 mg/kg rectal if no IV)
• If seizure persists → IV Phenytoin/Fosphenytoin or Levetiracetam
• If refractory → ICU, anaesthetic doses

• For GTCS in children: Sodium Valproate is first-line (broad-spectrum)
  • Dose: 15–40 mg/kg/day in 2–3 divided doses
• Alternatives: Levetiracetam, Lamotrigine (avoid in Dravet syndrome)
• Address drug compliance given prior hospitalization

• High-protein, calorie-dense diet
• Address PEM — possible referral to NRC (Nutritional Rehabilitation Centre) if MUAC < 11.5 cm (SAM criteria)
• Micronutrient supplementation (iron, zinc, vitamins)

• Seizure first aid education to caregivers
• Avoid triggers (sleep deprivation, stress)
• Do not stop medications abruptly
• School and activity safety

🎯 VIVA PREPARATION — EXPECTED QUESTIONS

Group 1: Basic Seizure Concepts

Per ILAE (2014): Epilepsy is defined by any one of the following:

1. ≥2 unprovoked (or reflex) seizures >24 hours apart
2. One unprovoked seizure + ≥60% probability of recurrence over next 10 years
3. Diagnosis of an epilepsy syndrome

Three onset types:

• Focal onset → aware / impaired awareness → motor/non-motor
• Generalized onset → motor (tonic-clonic, clonic, tonic, myoclonic, atonic) / non-motor (absence)
• Unknown onset

• Tonic phase (10–20 sec): sudden loss of consciousness, axial stiffening, uprolling of eyes, initial cry
• Clonic phase (1–2 min): rhythmic jerking of all limbs, frothing, tongue bite, cyanosis
• Postictal phase: confusion, drowsiness, Todd's paralysis possible

GTCS typically has loss of consciousness. Preserved consciousness with bilateral tonic-clonic movements may suggest:

• Focal onset bilateral tonic-clonic seizure (previously called secondarily generalized)
• The caregiver may have misinterpreted responsiveness
• This distinction is important as focal epilepsy has different workup and AED choices

Group 2: Diagnosis & Investigations

• EEG — to classify seizure type and identify epilepsy syndrome
• MRI brain — structural cause (preferred over CT; no radiation)
• Metabolic panel (glucose, electrolytes, calcium)

Generalized 3 Hz spike-and-wave or polyspike-wave discharges on a normal background (in idiopathic generalized epilepsy)

• Focal onset (or focal features)
• Abnormal neurological examination
• Developmental regression
• Refractory epilepsy
• Age < 2 years (first unprovoked seizure)

Chronic suppurative otitis media (CSOM) can cause intracranial complications: otogenic brain abscess, meningitis, lateral sinus thrombosis — all can present with seizures.

Group 3: Management

Sodium Valproate — first-line for idiopathic generalized epilepsy (broad-spectrum) Dose: 15–40 mg/kg/day in 2–3 divided doses Monitor: LFT (hepatotoxicity), CBC (thrombocytopenia), weight gain

Start after:

• Second unprovoked seizure, OR
• First seizure with high risk features (structural cause on MRI, focal deficits, abnormal EEG, family history)

Definition: Seizure lasting >5 minutes OR ≥2 seizures without return to baseline between them Management (stepwise):

1. 0–5 min: ABC, O₂, IV access
2. 5–20 min: Benzodiazepine — IV Lorazepam 0.1 mg/kg OR rectal Diazepam 0.5 mg/kg
3. 20–40 min: IV Phenytoin 20 mg/kg OR Levetiracetam 40–60 mg/kg OR Valproate 20–40 mg/kg

4. 40 min (Refractory SE): Midazolam/Thiopentone/Propofol infusion in ICU

• Previously diagnosed epilepsy — child may have had medication non-compliance or outgrown the dose (weight gain without dose adjustment)
• Need to check serum AED levels
• Re-evaluate for drug-resistant epilepsy if seizures continue despite adequate levels

Group 4: Anthropometry & Nutrition

Using WHO Z-scores or IAP classification:

• Height 116 cm vs expected 128 cm → Stunting (chronic malnutrition)
• Weight 18 kg vs expected 25 kg → Underweight
• MUAC 14 cm (normal ≥16 cm for age) → Wasting
• IAP Grade II–III PEM likely

Mid-Upper Arm Circumference:

• ≥12.5 cm: Normal (6 months–5 years)
• 11.5–12.4 cm: Moderate Acute Malnutrition (MAM)
• <11.5 cm: Severe Acute Malnutrition (SAM) For school-age children (>5 years): ≥14.5 cm is used as cutoff

Yes — indirectly:

• Hypoglycemia (energy deficit)
• Hypomagnesemia, hypocalcemia (low stores)
• Thiamine deficiency (Wernicke encephalopathy — rare in children)
• These should be excluded with serum electrolytes and glucose

Group 5: Differentials & Syndrome Identification

• Childhood epilepsy with GTCS alone — pure generalized seizures, normal EEG background, responds well to valproate
• Juvenile Myoclonic Epilepsy (JME) — morning myoclonus + GTCS, adolescent onset, 3–5 Hz polyspike-wave
• Lennox-Gastaut syndrome — multiple seizure types, intellectual disability, slow spike-wave <2.5 Hz
• BECTS (Benign Epilepsy with Centro-Temporal Spikes) — rolandic discharges, usually nocturnal focal but can secondarily generalize

Feature	Epileptic	PNES
Onset	Abrupt	Gradual
Duration	Usually <5 min	Often >5 min
Eye position	Uprolled/deviated	Closed, resist opening
Tongue bite	Lateral	Tip
Postictal	Confusion common	Rapid recovery
Video-EEG	Ictal changes	No EEG correlate

Group 6: Quick-Fire One-Liners

CLOSING STATEMENT (For Oral Presentation)

References: Kaplan & Sadock's Comprehensive Textbook of Psychiatry (ILAE seizure classification, epilepsy syndromes in children); clinical management based on standard IAP/NNF pediatric epilepsy guidelines.

CASE RECORD — PAEDIATRICS

PARTICULARS

CHIEF COMPLAINTS

HISTORY OF PRESENTING ILLNESS

• Onset: Sudden
• Duration: ~5 minutes per episode
• Frequency: Multiple episodes over a span of 2 hours
• Brought to hospital following the same

• Uprolling of eyes
• Tonic-clonic movements of all 4 limbs
• Frothing from mouth
• Clenching of teeth
• Sweating
• No loss of consciousness

NEGATIVE HISTORY

• Fever — to rule out febrile seizures
• Head trauma — to rule out post-traumatic seizures
• Vomiting / headache — to rule out raised intracranial pressure
• Ear discharge — to rule out intracranial spread from otogenic source
• Focal weakness
• Drug intake
• Developmental delay
• Birth asphyxia
• Tuberculosis
• Head injury
• Similar complaints in family members

PAST HISTORY

• Similar complaints present in the past
• Hospitalized 4 years ago for the same
• Received medications at that time

ANTENATAL HISTORY

• Mother had regular antenatal check-ups
• No history of maternal illness, drug intake, or infections during pregnancy

BIRTH HISTORY

• Normal vaginal delivery
• Full-term baby
• Birth weight: 2.9 kg
• Cried immediately after birth
• No NICU admission

POSTNATAL HISTORY

• No history of neonatal jaundice, neonatal seizures, or feeding difficulties

DEVELOPMENTAL HISTORY

IMMUNIZATION HISTORY

DIETARY HISTORY

FAMILY HISTORY

SOCIOECONOMIC HISTORY

PHYSICAL EXAMINATION

GENERAL PHYSICAL EXAMINATION

ANTHROPOMETRY

SYSTEMIC EXAMINATION

Central Nervous System

• Higher mental functions: Conscious, alert, oriented to time, place, and person
• Cranial nerves: Within normal limits
• Motor system: Tone normal, power 5/5 in all limbs, no focal weakness
• Sensory system: Intact
• Cerebellar signs: Absent
• Reflexes:
  • Deep tendon reflexes: 2+ bilaterally, equal
  • Plantar reflex: Flexor bilaterally
• Meningeal signs: Kernig's sign — Negative; Neck rigidity — Absent

Cardiovascular System

• S1, S2 heard; no murmurs

Respiratory System

• Bilateral equal air entry; no added sounds

Per Abdomen

• Soft, non-tender
• Liver and spleen not palpable
• No organomegaly

SUMMARY

PROVISIONAL DIAGNOSIS

DIFFERENTIAL DIAGNOSES

1. Focal onset bilateral tonic-clonic seizures (secondarily generalized)
2. Juvenile Myoclonic Epilepsy
3. Symptomatic epilepsy — cortical dysplasia / prior CNS insult
4. Metabolic seizures — hypoglycemia, hypocalcemia, hyponatremia
5. Meningoencephalitis (less likely — no fever)

INVESTIGATIONS

MANAGEMENT

A. Acute Management (During Active Seizure)

1. Position child in left lateral (recovery) position — prevent aspiration
2. Maintain airway, administer oxygen
3. Secure IV access; send blood for glucose and electrolytes
4. IV Lorazepam 0.1 mg/kg (or rectal Diazepam 0.5 mg/kg if no IV access)
5. If seizure continues >10 min → IV Phenytoin 20 mg/kg slow infusion OR IV Levetiracetam 40–60 mg/kg
6. If refractory (>30 min) → Midazolam infusion in ICU setting

B. Maintenance (Long-term AED)

• Sodium Valproate — first choice for idiopathic generalized epilepsy
  • Dose: 15–40 mg/kg/day in 2–3 divided doses
  • Monitor: LFT, CBC (hepatotoxicity, thrombocytopenia)
• Duration: Minimum 2 seizure-free years before considering taper
• Assess drug compliance (prior episode suggests possible non-compliance or dose not adjusted for weight gain)

C. Nutritional Rehabilitation

• Calorie-dense, high-protein diet
• Micronutrient supplementation — iron, zinc, Vitamin A, B-complex
• Regular anthropometric monitoring
• Referral to Nutritional Rehabilitation Centre (NRC) if SAM criteria met

D. Counselling

• Seizure first aid to caregivers:
  • Do not hold the child forcibly
  • Remove harmful objects from surroundings
  • Turn to lateral position
  • Time the seizure; call ambulance if >5 min
• Do not stop medications abruptly
• Avoid known triggers — sleep deprivation, missing meals, fever
• Inform school authorities
• No swimming or unsupervised height activities

PROGNOSIS

• Good if:
  • Idiopathic (no structural cause on MRI)
  • Normal development and examination
  • Good drug compliance
• ~60–70% of children with idiopathic GTCS achieve long-term remission with appropriate AED therapy