Case Report

EPILEPSY IN CHILDHOODPresenter: Rizky Indah SorayaDay/Date:Supervisor in charge: dr. Hj. Tiangsa Br. Sembiring, M.Ked (Ped), Sp.A (K) INTRODUCTIONEpilepsy is one of most frequent of all neurologic disorder. Often it is only the manifestation of a disease state that is otherwise inapparent but persists for lifetime and requires regular medical care. In many other cases, seizure complete intercurrent medical and neurologic illnesses or brain injuries.1 As proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE) in 2005, epilepsy is defined as a brain disorder characterized by an enduring predisposition to generate epileptic seizures and by the neurobiologic, cognitive, psychological, and social consequences of this condition. 2, 3The incidence of epilepsy in children reported from various countries with a wide variation, about 4-6 per 1000 children, depending on the study design and population age group. In Indonesia, there are at least 70000-140000 case of epilepsy by increments of 70,000 new cases each year and an estimated 40% -50% occur in children. Most of idiopathic epilepsy, but often also accompanied by neurological disorders such as mental retardation, cerebral palsy, and so caused abnormalities in the central nervous system. In addition, also known as some epilepsy syndromes in children include Ohtahara syndrome, infantile spasms (West syndrome), Lenox-Gestaut syndrome, benign rolandic epilepsy, and juvenile myoclonic epilepsy.4The history can provide important information about the type of seizures. Children who have a propensity to develop epilepsy may experience the 1st convulsion in association with a viral illness or a low-grade fever. Seizures that occur during the early morning hours or with drowsiness, particularly during the initial phase of sleep, are common in childhood epilepsy.5A prolonged personality change or intellectual deterioration may suggest a degenerative disease of the CNS, whereas constitutional symptoms, including vomiting and failure to thrive, might indicate a primary metabolic disorder or a structural lesion. It is essential to obtain details of prior anticonvulsant medication and the child's response to the regimen and to determine whether drugs that may potentiate seizures, including chlorpromazine or methylphenidate, were prescribed. 5The description of the seizure along with the family history can provide clues to the presence of possible genetic epileptic syndromes. These include autosomal dominant nocturnal frontal lobe epilepsy, familial benign neonatal convulsions, familial benign infantile convulsions, autosomal dominant febrile seizures, partial epilepsy with auditory symptoms, autosomal dominant frontal lobe progressive epilepsy with mental retardation, absence epilepsy, and febrile seizures with later partial complex seizures.5Diagnosis of epilepsy is determined by examination consisting of anamnesis, physical examination and investigations. The usual investigations consisting of blood tests, urine, cerebrospinal fluid, electroencephalography and imaging. EEG examination is the best investigation to establish the diagnosis of epilepsy. The focal abnormalities on EEG showed the possibility of structural lesions in the brain, while their common abnormality on EEG showed the possibility of a genetic or metabolic abnormalities.6The ultimate goal of epilepsy treatment is to free patients from epileptic seizures, without interfering with the normal function of the CNS so that patients can perform their duties without interference.7 The type of anti-epileptic drugs is highly dependent on the nature of epileptic seizures. Most of epilepsy can be treated with phenobarbital, carbamazepine, primidone, phenytoin, ethosuximide, and valproic acid. 8Epilepsy prognosis depends on several things, including the type of epilepsy causes, when treatment is started , and adherence to medication. In general, the prognosis of epilepsy is quite encouraging. 9

The aim of this paper is to report a case about Epilepsy in a 2 years old girl.

CASEName: KAAge: 2 years 4 monthsSex: GirlDate of Admission: April, 12nd 2015

Chief Complaint: SeizureHistory: Seizures experienced by patient since this day with the frequency 2 times a day. Last seizures experienced one hour before admission to the hospital. Seizures occur all over the body with duration of 10 minutes and seizures stop with diazepam rectal administration in the clinic. Patient asleep after had the seizure. Patient experienced the seizures after preceded by the fever. Patient had a history of seizures since the age of 5 months with the frequency 5 times daily with generalized seizure. Seizures occur in the whole body with jerking movements of the arms and legs repeatedly and accompanied by stiffness in the whole body. Seizures are not preceded by the fever. Seizures occurred in duration of 5 minutes. History of fever was found since one week with a temperature of fluctuation. Fever is not accompanied by shiver. While in the room, patient is not in the fever state.History of cough was found since 2 week. No productive.History of trauma was not found.History of diarrhea was not found. The frequency of bowel movements in the last 2 days was as much as 4 times daily with the volume of cup aqua per times defecating. Consistency of stool is more watery. Blood was not found in stool.History of vomiting was found since 2 days ago, especially after the cough. The frequency of vomiting is 3 times a day with a volume of teaspoon per times vomiting. The vomits contents of regurgitated food and beverages consumed before.History of growth: to date patient can only lying to the side.History of Birth: Second child. Spontaneous birth, not cried immediately as soon as born. Enough months at birth. Birth weight was 2.4 kg. History of cyanosis was found.History of previous illness: Epilepsy in neurology unit of Adam Maliks General Hospital and regularly controls.History of previous medication: Valproic acid 2 x 1.6 cc (22 mg / kg / day) and paracetamol

Feeding HistoryFrom birth to 5 months: Breast Milk From 5 months until now (2 years 4 months): Formula milk + Rice Porridge

History of Growth and DevelopmentLying to the left/right : 8 monthsCrawling: Not yetSitting: Not yetStanding: Not yet Walking: Not yet

Physical ExaminationGeneralized statusBody weight: 7,4 kg, Body length: 72 cm, Head circumference: 40 cm, Arm circumference: 14,4 cmBW/BL : -2 SD < z-score < -1 SDBW/age: z-score< -3 SDBL/age : z-score < -3 SDHC/age : z-score < -2 SDAC/age: -1 SD < z-score< 0 SD

Presens statusSensorium : AlertBlood Pressure: 100/60 mmHgHeart Rate: 128 x/iRespiratory Rate: 40 x/iBody Temperature: 40,1oC.Anemic (-). Icteric (-). Cyanosis (-). Edema (-). Dyspnea (-).

Localized statusHead : Face: No edema.Eye:Light reflex (+/+), Isocoric pupil (+), no pale in inferior palpebra conjunctiva, no icteric sclera and no edema in inferior and superior palpebra.Ear / Nose / Mouth : within normal limit.Neck :No lymph node enlargement.Chest : Symmetrical fusiformis, no retraction and muscle wasting. HR: 128 bpm, regular, no murmur. RR: 40 tpm, reguler, coarse crackles (+/+). Abdomen :Soepel. Liver and spleen were not palpable. No shifting dullness. Bowel peristalsis was normal. Extremities : Pulse was 128 bpm, regular, adequate pressure and volume, warm, CRT < 3. BP: 100/60 mmHg.Urogenital : Female. Anus (+).

Neurological ExaminationSensorium :GCS 14 (E4 V4 M6) Nervus Olfactorius :NormosmiaNervus Opticus :Light reflexes (+/+), pupils isochoric 3mmNervus Oculomotorius, trochlear, abducens: Normal eye movementNervus trigeminus:Mastication as wellNervus Facialis:Symmetrical lip angleNervus Auditorius:NormalNervus Glossofaringeus, vagus:Uvula in medialNervus Accesoriu:NormalNervus hipoglossus:Tongue in medial

Motorical Examination : within normal limit

55555555555555555555Right/left muscle strength :

Physiological reflexes : Right LeftKPR/APR (+/+)(+/+)Biceps/Triceps (+/+)(+/+)Pathological reflexes : Babinsky ( - ) ( - )Chaddock ( - ) ( - )Gordon ( - ) ( - )Oppenheim ( - ) ( - )Meningeals sign :Nuchal rigidity (-), Kernigs sign (-), Brudzinski I/II (-). Laseque sign (-).

Electroencephalography Test Result: July 8th, 2013 in ST. Elisabeth Hospital Recording is done in a state of sleep with premedication chloralhydrate syrup. basic rhythm waves with a frequency of 6-7 cycles per second voltage being mixed with a frequency of 4-5 cycles per second. Does not seem significant asymmetry. There are high-amplitude and slow spike wave in the posterior right temporal and left frontal. Photic stimulation did not result in any significant change. Impression : EEG can be in accordance with the general convulsion disease with multifocal irritative focus.

Differential Diagnosis: Generalized symptomatic epilepsy + Bronchopneumonia + Global Development Delayed + Cerebral Palsy + Gastroenteritis without Dehydration Generalized idiopathic epilepsy + Bronchopneumonia + Global Development Delayed + Cerebral Palsy + Gastroenteritis without Dehydration

Working Diagnosis: Generalized symptomatic epilepsy + Bronchopneumonia + Global Development Delayed + Cerebral Palsy + Gastroenteritis without DehydrationManagement: O2 L/i nasal canule IVFD NaCl 0,9% 10 gtt/i micro Injection Paracetamol 100 mg / 8 hour / IV Injection Ceftriaxone 400 mg / 12 hour / IV Skin test Zinc 1 x 20 mg Valproic acid 2 x 1,8 cc (25 mg / kgBW / day) Diet : chicken porridge in diluted 740 kcal (100 kcal/ kgBW/ day) with 15 gram = 125 cc/NGT/6 hour

Diagnostic Planning: Complete Blood Count Arterial Blood Gas Analysis Serum Electrolytes Electroencephalography test Thoracic X-ray Consul to Neurology division Consul to Respirology division Consul to Growth and development division Consul to Gastroenterohepatology division

April 13rd-14th, 2015

SFever (-), Seizure (-)

OSens: GCS 15 (E4 V5 M6), Temp: 37oC. Anemic (-). Icteric (-). Edema (-). Cyanosis (-).Body weight: 7,4 kg, Body length: 72 cm. Urine colour : yellowish HeadLight reflex (+)/(+). Conjunctiva palpebra inferior anemic (-). Isochoric pupil.

NeckJugular vein pressure R-2 cmH2O. Lymph node enlargement (-).

ThoraxSymmetrical fusiformis, no retraction and muscle wasting. HR: 138 bpm, regular, no murmur. RR: 40 tpm, reguler, coarse crackles (+/+).

AbdomenSoepel. Liver and spleen were not palpable. No shifting dullness. Bowel peristalsis was normal.

ExtremitiesBaggy pants (-), thinning of subcutaneous fat (-), muscle hypotrophy (-). Crazy pavement dermatosis (-). Pulse 140 x/i, regular, adequate p/v, warm, CRT < 3. Pitting edema (-) pretibia. BP: 120/70 mmHg.

GenitalFemale, within normal limit

Laboratory Findings: April, 12nd 2015ParametersValueNormal Value

Complete Blood Count

Hemoglobin9,2 gr%11,3 14,1 gr%

Hematocrite29,2 %37 41%

Erithrocyte3,4 x 106 /mm34,40 4,48 x 106 /mm3

Leucocyte13,8 x 103 /mm34,5 13,5 /mm3

Trombosit263.000 /mm3150000 450000 /mm3

MCV85,90 fl81 95 fl

MCH27,10 pg25 29 pg

MCHC31,50 gr%29 31 gr%

RDW16,70 %11,6 14,8 %

Diftel0,3 / 0,4 / 72,2 / 19,4 / 7,7

Arterial Blood Gas Analysis

PH7,4367,35 7,45

pCO229,6 mmHg38 42

pO2188,4 mmHg85 100

Bikarbonat (HCO3)19,5 mmHg22 26

Total CO220,4 mmHg19 25

Base Excess (BE)-3,4 mmHg(-2) (+2)

Saturasi O299,7%95 100

Carbohydrate Metabolism

Blood Glucose ad random155 mg/Dl< 200

Electrolytes

Sodium (Na)133 mEq/L135 155

Pottassium (K)3,6 mEq/L3,6 5,5

Chloride (Cl)102 mEq/L96 106

Imunoserologi

Procalcitonin8,72 ng/mL