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What caused a tonic-clonic seizure?
Aninda Das, Md, Peter Liu, Md, and Janet Ching, Md
Dr. Das is in practice in the department of pediatrics at Healthcare Partners Medical Group, Mission Hills, Calif.
Dr. Liu is a pediatric hospitalist at Valley Presbyterian Hospital, Van Nuys, Calif.
Dr. Siberry is an assistant professor of pediatrics in the divisions of general pediatric and adolescent medicine and pediatric infectious diseases at Johns Hopkins Hospital, Baltimore.
The authors and section editor have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.
The EMT squad has just left your office, headed for the local community hospital with one of your patients in an ambulance. A short time ago, the 4-year and 11-month-old boy experienced a left-sided focal seizure in an examining room of the practice that progressed to a generalized tonic-clonic seizure. You were able to control the seizure with intravenous lorazepam, 0.1 mg/kg of body weight, while awaiting EMS. Now, you pause in the middle of an otherwise routine day of appointments to ask: What chain of events led to these tense moments?
Just over three weeks ago, this Caucasian boy, who has a notable history of cognitive developmental delay and reported penicillin allergy, was seen by one of your partners for right-sided acute otitis media (AOM). Despite the boy's speech delay, he is known in the practice to be able to communicate appropriately with his mother, and had complained of right-ear pain. Your partner, his regular pediatrician, started the patient on cefdinir (Omnicef).
An uneventful three weeks passed. Then, today, the boy was brought in by his mother with a four-day history of fever (maximum recorded axillary temperature, 102°F) and discharge from the right ear, along with an upper respiratory tract infection. In your partner's absence, you saw the patient. He wasn't in discomfort and hadn't complained of earache at home. Other than the discharge, fever, and respiratory complaint, your exam was unremarkable. You prescribed ofloxacin otic drops (Floxin Otic) for possible perforated AOM and advised his mother to bring the boy back in 72 hours for a recheck.
But the patient's mother returned just 10 minutes later, her son in her arms, agitated because he "wasn't making eye contact and was stiff with his jaws locked up". As she explains this, the seizure begins; you and your staff take action, and EMS is called.
Deterioration on admission
The story picks up on the pediatric ward of the community hospital, where the boy has been admitted. Blood, cerebrospinal fluid (CSF), and urine specimens are immediately sent for culture. The patient undergoes noncontrast cranial computed tomography; the radiologist interprets the scan as right-sided mastoiditis-"opacity of the right mastoid without gross evidence of bone destruction."
Spinal tap reveals the following CSF values: cell count, 7/mm3 (with a differential count of 92% neutrophils and 8% lymphocytes); glucose, 65 mg/dL; and protein, 83 mg/dL.
Complete blood count reveals a white blood cell count of 5.6 X 103 /μL (with a differential count of 23% segmented neutrophils, 47% band forms, 14% lymphocytes, and 16% monocytes); hemoglobin, 11.4 g/dL; and a platelet count of 214 X 103 /μL. Urinalysis parameters are within normal ranges.