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EXPERIENCE & REASON |
Division of General Pediatrics, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
ABSTRACT
A 12-month-old girl with occult bacterial meningitis presented with a simple febrile seizure. On examination, the patient was alert, interactive, and smiling responsively without meningeal signs, focal neurologic findings, or signs of extreme illness. Her parents were reluctant to allow a lumbar puncture, and the patient was admitted for observation without lumbar puncture. Her fever resolved, and she was playful, had good oral intake, and was discharged 24 hours after admission. Her initial blood-culture result remained negative. Within 24 hours of discharge, the patient had a focal febrile seizure, came back to the hospital, and was found to have meningitis with a penicillin-susceptible, nonvaccine Streptococcus pneumoniae strain 12F.
Key Words: febrile seizures • pneumococcal meningitis
Abbreviations: WBC, white blood cell • CSF, cerebrospinal fluid • AAP, American Academy of Pediatrics
Recent retrospective studies have found that children with bacterial meningitis who present with febrile seizures almost always demonstrate additional signs including meningeal signs (such as photophobia, stiff neck, Kernig or Brudzinski sign), focal neurologic findings, complex febrile seizures, or signs of extreme illness (altered sensorium, hypotension, grunting, cyanosis, petechial rash, etc).1–5 In 2002, Caroll and Brookfield6 analyzed 15 retrospective-review studies and found that, of 4102 children with febrile seizures, 33 had bacterial meningitis. Of the 30 children with bacterial meningitis and documented presentations, 4 presented without additional signs of meningitis beyond the febrile seizure. In 3 cases, the presence or absence of additional signs was not recorded. Of the 4 cases of children who presented without confirmed additional signs of meningitis and the 3 without documented presentations, 2 had no documented age, 4 were older than 1 year, and one was in the 6-months to 1-year age range. Caroll and Brookfield and many authors of studies in their review concluded that, when there are no supplementary signs of meningitis independent of the seizure, lumbar puncture is not indicated for a child with a simple febrile seizure.5–7 Caroll and Brookfield suggest patient observation as a reasonable option.6
CASE REPORT
A 1-year-old girl presented with fever and a febrile seizure. The child's parents picked her up from day care and were told that she had a fever. At home, the child's temperature was 103°F, and her parents administered acetaminophen. They gave her a cool bath, and she ate some pasta. Soon after, the parents described an event during which the patient had symmetric stiffening of her upper and lower extremities, abnormal eye movements described as "rolling back," perioral cyanosis, and unresponsiveness. The event reportedly lasted for 1 minute, and she appeared "dazed" for the next 10 minutes. The parents called the paramedics, who arrived after the episode had resolved, noted the patient's temperature to be 105°F, and brought her to the emergency department. At the emergency department, the patient's temperature was 105°F; she had a heart rate of 187 beats per minute, a respiratory rate of 42 breaths per minute, and oxygen saturation of 98%. On examination by the emergency department physician, no meningeal or focal neurologic abnormalities were noted. She was given ibuprofen and improved clinically. The pediatric hospitalist physician was called to evaluate the patient.
Patient History
A review of systems was negative except for the fever noted above. She had received immunizations consistent with the recommended childhood immunization schedule through her 6-month immunizations (she had received the 7-valent pneumococcal conjugate vaccine (Prevnar) at 2, 4, and 6 months).
Physical Examination
On evaluation by the pediatric hospitalist 
1 hour after arrival, the patient had drunk 6 oz of milk and was playful, turned her head to facilitate the otoscopy evaluation, and smiled responsively. Her temperature was 99.6°F, her heart rate was 120 beats per minute, her respiratory rate was 30 breaths per minute, and her oxygen saturation was 98% in room air. Her physical examination was unremarkable. Her oropharynx was clear, her nares had mild, clear rhinorrhea, and her tympanic membranes were without opacity, bulging, or erythema. Her heart was without murmur, she had good perfusion, and her femoral pulses were 2+ bilaterally. She displayed no respiratory distress, and her lungs were clear to auscultation. Her skin was warm and dry without rashes or lesions. There was no swelling, erythema, or pain with movement of her joints. She was alert and interactive, following objects and moving her neck horizontally and vertically 180° without signs of pain or irritation. Her anterior fontanel was open and flat, her extraocular movements were intact, her pupils were round and reactive to light, and cranial nerves II–XII were grossly intact. Her strength was 5/5, and she had good tone and normal bulk in her upper and lower extremities. Her deep-tendon reflexes were 2+ and symmetric in her lower extremities, and her Babinski reflex was equivocal. Kernig and Brudzinski signs were negative. She displayed withdrawal and localization to touch. She reached for objects with a pincer grasp, was able to sit alone, and was able to take a few steps.
Laboratory Data
Her white blood cell (WBC) count was elevated at 23.5 cells per mm3, with a differential of 67% neutrophils, 19% lymphocytes, 5% monocytes, and 9% bands. Her C-reactive protein level was elevated at 1.7 mg/dL. Results of tests for serum electrolytes, hemoglobin, hematocrit, platelet concentrations, and urinalysis were normal.
Hospital Course
The patient's initial diagnosis was simple febrile seizure. Although this patient's seizure was described as primarily tonic, as opposed to more common tonic-clonic movements, it qualified as a simple febrile seizure lasting <15 minutes without focal signs. The patient had leukocytosis. Despite discussing the risks and benefits of lumbar puncture with the parents, they remained opposed to the procedure. The child showed no signs of respiratory distress, and a chest radiograph was not performed. At 2 AM, the patient was admitted to the pediatric floor for observation.
At 4 AM, the patient again had an elevated temperature of 104°F, which slowly decreased with administration of antipyretics until it reached 99.1°F at 8 AM. Between 8 AM and 4 PM, her temperature remained between 99.1 and 101.5°F. On serial evaluations that day, she was eating well and was playful and did not demonstrate any signs of meningitis including nuchal rigidity. During the day, she began to demonstrate mild nasal discharge. She was discharged that night with a diagnosis of simple febrile seizure and fever, likely of viral source.
The night after discharge, the patient had a focal seizure involving the right upper extremity and lasting 1 to 2 minutes; she was readmitted to the hospital. On this admission, her WBC count had decreased to 11.3 cells per mm3 with 46% neutrophils, 14% lymphocytes, 4% monocytes, and an increase of 36% bands. Her C-reactive protein level had increased to 7.8 mg/dL. After some discussion, the parents agreed to a lumbar puncture, which revealed a WBC count of 2215 cells per mm3 with a differential of 94% neutrophils, 1% lymphocytes, and 5% monocytes. Her cerebrospinal fluid (CSF) red blood cell count was 35 cells per mm3, her protein level was 103 mg/dL, and her glucose level was 57 mg/dL. Results of an initial head computed tomography scan were negative, and the child was treated prophylactically for bacterial and herpes simplex virus meningitis with ceftriaxone, vancomycin, and acyclovir. The CSF culture grew Streptococcus pneumoniae serotype 12F.
The patient's diagnosis on her second admission was bacterial meningitis. The bacteria were sensitive to penicillin. The vancomycin was discontinued, and the patient received 2 weeks of parenteral penicillin treatment. She had 1 additional seizure the night of this admission and had no additional seizures. She was quite irritable for the first 2 days of the admission, with fevers up to 104°F, but remained afebrile after 2 days of antibiotic treatment. The herpes polymerase chain reaction was negative on day 2, and acyclovir was discontinued. Her neurologic evaluation and an electroencephalogram remained normal throughout her hospitalization. At 1 month after discharge, a follow-up examination by the pediatric neurologist revealed no neurologic sequelae, and her brainstem auditory evoked potential responses were unremarkable. She will follow-up with the neurologist as needed. In follow-up with her pediatrician 6 months after discharge, she did not display signs of neurologic deficits including hearing impairment. Her pediatrician plans to recheck her hearing at her 3-year well-child check. Of note, the S pneumoniae serotype 12F is not covered by the pneumococcal 7-valent conjugate vaccine (Prevnar). In addition, the patient's blood and urine cultures from the first admission remained negative.
DISCUSSION
The incidence of bacterial meningitis as a cause of febrile seizures has decreased over the past 20 years6 and is now between 0.23% and 2%.6, 8 The incidence of serious bacterial infection in children with simple febrile seizures is the same as for febrile children without seizures.7 The bacterial causes of meningitis have evolved over the past 20 years. Haemophilus influenzae type b meningitis in children has dramatically decreased since the introduction of the H influenzae type b conjugate vaccine.6 Since the introduction of the pneumococcal conjugate vaccine in 2000, the overall incidence of invasive pneumococcal disease in infants and children has decreased significantly.9–13 Some epidemiologic studies have reported concurrent increases in nonvaccine serotypes, particularly serogroups 15 and 33,9, 10, 14 but this remains controversial. The 7-valent pneumococcal conjugate vaccine is a first-generation vaccine. In the future, 9- or 11-valent pneumococcal vaccines may be necessary to cover expanding serotypes in the United States. The epidemiologic changes of bacterial meningitis over the past 20 years may have played a role in the apparent decreased incidence of occult meningitis.6
The 1996 American Academy of Pediatrics (AAP) Subcommittee on Febrile Seizures recommended that, after a simple febrile seizure, lumbar puncture should be strongly considered for infants 
12 months of age and considered for children aged 12 to 18 months, because meningeal signs in these age groups may be minimal, subtle, or absent.15 The AAP practice parameter has been criticized as being too conservative and not representative of recent literature.16 The AAP recommendations were based on 1977 studies in which 30% to 35% of the children with febrile seizures who presented without additional meningeal signs nevertheless had bacterial meningitis (these children were primarily <18 months of age).15, 17, 18 The AAP maintained that the recommendation is conservative because it is intended for practitioners with a wide range of experience.15
This rare case of a child with occult bacterial meningitis who initially presented with simple febrile seizure and no additional signs of meningitis provides evidence for conservative management when considering lumbar puncture for children with simple febrile seizures. Although Caroll and Brookfield's review concluded that independent risk factors are necessary to warrant lumbar puncture in children with simple febrile seizures,5–7 the 4 cases of children with bacterial meningitis who presented without any additional signs beyond a febrile seizure in their review may, themselves, support a more conservative evaluation of children with simple febrile seizures. Our case reinforces the utility of lumbar puncture in the evaluation of children <18 months old with simple febrile seizures. In addition, the attempt to observe the patient in lieu of lumbar puncture proved unsuccessful in detecting her occult meningitis. The patient's high temperature of 105°F was considered in the presentation, but this temperature did not fall under the recommendations and risk factors for hyperpyrexia (typically described as a temperature of >106°F).19 Although the second-admission blood culture grew S pneumoniae, this child's initial blood-culture results remained negative. It is possible that her meningitis was not present on initial evaluation but manifested shortly thereafter. The bacteremia may have been intermittently cleared by the liver and spleen while already "seeding" the meninges. It is also possible that handling or volume blood culture was not optimal. In previous studies, 80% to 88% of children with nonpretreated CSF-positive S pneumoniae meningitis had positive blood-culture results.20, 21 Although obtaining a complete blood count and C-reactive protein level are not necessary as discharge criteria, the complete blood count may be monitored twice weekly for any bone marrow suppression during administration of ß-lactam antibiotics.22 The child's complete blood count was checked once weekly and did not reveal any bone marrow suppression.
CONCLUSIONS
It is important that pediatricians be cautious when evaluating children with simple febrile seizures, even children 12 months and older. Although cases of occult bacterial meningitis are rare, this case highlights the continued utility of the 1996 AAP Subcommittee on Febrile Seizures recommendations.
ACKNOWLEDGMENTS
This work was conducted with grant support from the US Department of Health and Human Services, Health Resources and Services Administration, Physician Faculty Development, Primary Care General Pediatrics.
I appreciate the assistance of my pediatric hospitalist co-workers at Mercy Hospital (Coon Rapids, MN).
FOOTNOTES
Accepted Jan 26, 2007.
Address correspondence to Allison Golnik, MD, Division of General Pediatrics, McNamara Alumni Building, University of Minnesota, 200 Oak St SE, Suite 260, Minneapolis, MN 55455. E-mail: allison.golnik{at}gmail.com
The author has indicated she has no financial relationships relevant to this article to disclose.
REFERENCES
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