Viewpoint: Consider nonaccidental trauma, bleeds in differential diagnosis of seizures

I really enjoyed Drs Ewasiuk and Andrew's article, "When is a febrile seizure something else?" (Puzzler, November 2009). Haemophilus influenzae A and H influenzae B are diagnoses that young practitioners need to consider in their differentials, since many of us have not seen H influenzae illness firsthand.

I did, however, want to mention 2 important items on the differential diagnosis of first seizure. Bleeds (hemorrhagic or thombotic) must also be considered, and unfortunately, so should nonaccidental trauma. I have seen too many cases in my prior experience as medical director for a child abuse center in which a child presents to the emergency department with altered mental status or seizures and is later found to have suffered bleeds and/or neuronal injury as a result of nonaccidental trauma.

The presence or absence of fever with seizure should not stop the practitioner from considering nonaccidental trauma in the differential, as oftentimes there may be 2 underlying causes at play. Furthermore, we know that when children are ill, their caretakers can become very stressed, which then increases the risk of nonaccidental trauma.

Thanks again for another great Puzzler!

Maria Alcocer, MD
Chicago, Ill.