A 5-month-old Hispanic male presented to the emergency department (ED) at a children’s hospital in the Northeast United States directly from his daycare after caretakers witnessed 2 shaking, seizure-like episodes. The episodes lasted 1 to 2 minutes in the setting of a fever as palpated by the parents.
The patient’s past medical history was significant for spontaneous vaginal delivery at 32 weeks attributed to maternal incompetent cervix. The patient had no history of chronic illness, disease, or prior surgery and there was no recent travel or animal exposure. There was no history of a fall or injury. The patient lived with both parents and his 3 siblings, and there were multiple sick contacts at home.
The patient had been in his usual state of health until 10 days prior to presentation when he developed rhinorrhea, nasal congestion, and intermittent increased work of breathing. In that time frame, he was seen by multiple local ED providers and treated symptomatically for presumed bronchiolitis with improvement. At each visit, he was discharged home to continue supportive care.
According to the family, 1 day prior to admittance he intermittently started to feel warm to touch. At daycare, on the day of admission, the patient felt warm and had an episode of generalized shaking of his arms and legs with eye deviation, described as seizure-like, that lasted approximately 1 minute. The episode resolved without intervention. Emergency medical services were contacted and the child was brought directly to the local children’s hospital for further evaluation and treatment.
Evaluation and testing
On presentation to the ED, the patient was groggy and disoriented, but returned to baseline within 30 minutes after arrival. Both the family and daycare staff denied knowledge of any recent injury or trauma to the child.
While in the ED, the patient became febrile to 103.2°F and experienced a witnessed tonic-clonic seizure that resolved within 2 minutes. In light of the second seizure in less than 24 hours, laboratory studies were ordered and were significant for a cerebral spinal fluid study that was bloody in appearance with 130,000 RBC/µL; 3 WBC/µL; protein level of 161 mg/dL; and glucose of 67 mg/dL (serum glucose was 96 mg/dL). A complete blood count and comprehensive metabolic panel were normal, excepting a potassium level of 5.8 in a hemolyzed sample. An infectious workup, including urinalysis as well as influenza, respiratory syncytial virus (RSV), and herpes simplex virus (HSV) polymerase chain reaction (PCR) testing, were not suggestive of infection.
A computed tomography (CT) image of the head demonstrated an asymmetric linear lucency coursing obliquely across the right posterior parietal calvarium without overlying soft tissue swelling, concerning for nondisplaced right posterior parietal calvarial fracture (Figure 1). These findings raised the concern for nonaccidental trauma, given there was no history of reported fall or injury.
The patient was admitted to the hospital. As a result of the unexplained skull fracture in a child aged younger than 1 year, the Pediatric Trauma Team and the Child Protection Team were consulted to evaluate for further signs of trauma and concerns of possible abusive injury. A pediatric Neurology consult was requested for further management of the child’s atypical febrile seizure. Physical examination of the child suggested no signs of cranial deformities, step off, or overlying erythema or swelling. Additional laboratory studies were noncontributory in explaining either the seizure or fracture.