Faculty of Medicine and Health Sciences

Pediatrics
(MDP 50108)

Case Write-Up 2

Year 5
Session 2018/2019

Name : Zul Hisyam Fikri Bin Ismail

Matrix no. : 46095
Supervisor : Dr Wai Wai Shien
 PATIENT DATA

Name : Mohd Omar Faiq

Gender : Male
Age : 5 months old
Race : Malay
Date of Admission : 28th /12/2018
Date of Clerking : 31st /12/2018
Informer : Mother

CHIEF COMPLAIN

Fever for one day and recurrent afebrile fit 4 days prior to admission

HISTORY OF PRESENTING ILLNESS (HOPI)

He was well previously until last 5 days he was presented with low grade fever, intermittent
in nature, there was no chills and rigor, no rash, not associated with fit. There also no sick
contact in family members, no symptoms of URTI such as cough, running nose and rapid
breathing, no symptoms of UTI such as dysuria, hematuria and increase frequency and urgency.
No documented temperature, and fever resolve without administered any PCM syrup.

For the next day, he was developed fitting during morning, around 9 am, witness by the
mother. Child was lying just besides the mother and his mother watching TV. She described
there was jerking movement of bilateral upper limbs, eyes stare at one sides, associated with
drooling of saliva, perioral cyanosis, and unsure urinary or bowel incontinence. At that time,
mother try to awake the child by calling his names, but he was unresponsive, but she not put
anything in the child’s mouth. The duration was 1-2 minutes and seizure abort spontaneously.
Post ictal shows he was drowsiness and sleep, when mother call his name, he response a while,
and back to sleep again. He awake 30 minutes after that for feeds. There was no Todd’s
paralysis present. There was no known precipitating factors, no complication like head trauma,
oral or buccal trauma. Last meal was around 8 am prior to seizure. At 4 pm, the seizure was
recur again, same semiology.

On Day 2 of illness, 2 episodes of seizures, same semiology.

On Day 3 of illness, 2 episodes of fitting with same semiology. At that time, then her
mother bring the child to KK Muara Tuang. Previously, she was unaware that her child was
fitting until her aunty told her that the child actually fitting and need to seek medical attention.
At KK Muara Tuang, he was under monitored. 1 episode of seizure occurs at KK, same
semiology and abort spontaneously. PR diazepam was given, and he was rush to hospital and
sent via ambulance.

On ETD, the seizures recurs again, same semiology and abort spontaneously. He was given
IV phenytoin, once he was stable, he was admitted to peadiatric ward.

Investigation was done such as blood investigation, CT brain and lumbar puncture. The
results shows no significant findings. He was given IV phenytoin, and syrup sodium valproate.

On Day 4 and Day 5 of illness, he was well, afebrile, active, no more fitting, able to tolerate
orally. On day 6, he was allowed to discharge with plan; TCA peads clinic in one month’s later
for repeated lumbar puncture, set appointment for EEG and taper down phenytoin medication.

SYSTEMIC REVIEW

Other systems was unremarkable.

PAST MEDICAL AND SURGICAL HISTORY

Insignificant

MEDICATION AND ALLERGY HISTORY

She was no taking any long term medication, no history of over counter drugs and she was
not practicing any traditional medicine. No allergy was documented. She was prescribed
syrup phenytoin and syrup sodium valproate.

PRENATAL/NATAL/POSTNATAL HISTORY

Pre-natal: Uneventful.
Natal : the bay was delivered via spontaneous vaginal delivery (SVD) at 38 weeks, baby
weight was 2.9 kg. at the time of birth,. Apgar score was unknown, but mother
noted baby was pink, crying, move all four limbs and not required any
breathing/ventilation support.
Post-natal: noted minimal neonatal jaundice, but mother unaware the level of bilirubin. Child
was no required any hospitalization, only follow up at clinic.

FEEDING HISTORY

Type of feeding: mixed: formula milk with semi-solid food.

Breast Feeding
Supplementary breast feeding in 4 months duration. The child demand 2 hour , and spent time
around half an hour. It was good latch and suck, and proper position during breastfeeding.
Satiation after feed was achieved, after breast feed he was asleep. Napkin changing was 5-6
times per day with fully soaked and passing stools 1-2 times per day. No problem associated
with breastfeeding.

Formula feeding history:

He consumed Pediasure milk 5-6 oz, 3 times per day. His mother keeps practicing bottle
hygiene. Mother wash and brush the bottles with soap. She sterile the bottles by soak into the
boiling water. She also kept the milk in the container.

The child was not started any weaning yet.

IMMUNIZATION HISTORY

Immunization up to date
Received DTaP, IPV and HiB.

DEVELOPMENTAL HISTORY

Alisha’s development was correspond to the age.

Gross motor: She can sit steady without support. She able to lean forward and recover balance.
She also can stand with support. She can roll herself from supine to prone since
3 months. She also can gets into sitting position from supine position.

Visual and
Fine motor : she able to grasp object, and transfer object from hand to hand, and feed anything
from what he grasp and bangs objects together. She also achieve index approach.

Hearing, speech
and language : she able to turn into sound, and able to babbling in single syllabus sound. She
able to talk ‘mama’ ‘papa’. Eye-to-eye contact was intact. He also able to put
food into mouth.

Social, emotional
and behavioral : he developed his stranger anxiety, waves bye bye.

FAMILY HISTORY
 24 26

4 year 5 mo

There was no consanguinity in family, there was no history of epilepsy, no family history of
developmental delay or intellectual disability, no inherited genetic disorder or metabolic
disorder in the family, no family history of malignancy.

SOCIAL HISTORY

Parent live at Tabuan Jaya, together with other family members. Mother was housewife,
father was contract worker al welding factory. They have their own transport. Home was fill
with basic amities and adequate water and electrical supply. There was family members who
smoking in the house, but not consumed alcoholic, no drug abuse. No major event occurs in
family like divorce or death of family members. He has good family support, and adequate
financial income.

PHYSICAL EXAMINATION

General examination:
A 5 month old boy with normal body size, lying comfortably on the bed .He was alert and
awake. He appeared pink and not cyanosis.

Vital signs:
Pulse rate : 100 bpm; regular and adequate volume
Respiratory rate : 16 breathe per minute
Temperature : 37 º C

Anthropometric measurement
Height : 62 (50th centile)
Weight : 6.6 kg (50th centile)
Head circumference : 41 cm (between 50th and 75th centile)

Hands : There was no cyanosis, pallor or clubbing noted.

Legs : There was no ankle edema, cyanosis, pallor or clubbing.
Face : From the eyes, , no pallor and no jaundice noted. The oral
hygiene was good with no cyanosis noted from the mouth.
Neck : No lymph gland enlargement noted.
Ear Nose and Throat: No ear discharge was seen. There was no nasal polyp seen. Throat was
not injected.

Central nervous system examination

Inspection : examination was covered both upper limb and lower limb. Both upper and lower
limbs appear to be symmetrical, no scars and muscle wasting present. No
deformities, no neurocutaneous stigmata such as café au lait , neurofibroma,
tuberous sclerosis.
Palpation : no muscle bulk or muscle atrophy. No fasciculation.
Examine of :
1) Tone : tone was normal , no spasticity
2) Power : all power was full both upper and lower limb
3) Clonus : absent
4) Reflex : normal both upper and lower limb
5) Sensory : cannot appreciate with 5 months old boy
6) Kernig and Brudzinski test : negative (to rule out meningitis)

Respiratory examination:
Inspection: Chest movement was symmetrical, present of suprasternal and subcostal
recession, no Harrison’s sulci , no surgical scars seen.
Palpation: The apex beat was palpable at the left 4th intercostal space in mid clavicular line
with normal character.
Percussion: Percussion note was resonant on both sides of the anterior chest wall with
normal liver and cardiac dullness.
Auscultation: occasional ronchi bilateral more on lower lungs.

Cardiovascular examination and abdominal examination reveals no significant findings

 SUMMARY

Omar Faiq, 5 months boy presented with fever for one day and recurrent afebrile fever for 4
days. Seizure was came with same semiology, abort spontaneously without medication and no
focal neurological deficit post-ictally. Otherwise, no family history of febrile fit, epilepsy or
intellectual disability. Examination shows normal vital sign, afebrile, neurological exam shows
normal without any neurocutaneous stigmata present. At hospital, septic and CSF workout was
done, but no significant result. He was under anti-epileptic medication and allow to discharge
of Day 3 hospitalization. Appointment for EEG was set in outpatient.

PROVISIONAL DIAGNOSIS

Epilepsy of West Syndrome (Infantile Spasm)

Points for
 Age (between 2 to 12 months)
 Male affected commonly

Differential diagnosis

1. Febrile seizure
Points for diagnosis Points against this diagnosis
 He was afebrile when seizure occurs
 History of fever

2. Meningitis

Points for Points against

 History of fever  No photophobia, neck stiffness
 Kernig and Brudzinski sign negative
INVESTIGATIONS

1. Full blood count with differential cell count

Test Results Normal Range

WBC (103/ µ L) 9.96 4.0-9.0

RBC (106/ µ L) 4.23 3.9-5.6

Haemoglobin ( g/dL) 9.6 11.5-16.0

Haematocrit (%) 29.9 36.0-56.0

MCV (fL) 70.7 80-100

MCH ( pg) 22.7 27.0-32.0

MCHC (g/dL) 32.5 32.0-36.0

Platelet (103/ µ L) 504 150-400

Differemtial count
Lymphocyte – 5.85 (H) Eosinophil – 0.5
Neurophil – 3.13 basophil – 0.01
Monophil – 0.46

Reason: For general assessment of patient’s condition and to detect presence of infection.

Results: slight reduce hematocrit, MCV and MCH level. Increase platelet and lymphocyte
shows evidence of virus infection

2. Blood urea serum electrolyte

Aims to access renal function and to rule out electrolyte imbalance that could be leading
cause of seizures.
Result : Normal Range

3. Liver function test

Aims to check level of magnesium or calcium that could be a leading cause of seizure.
Results : Normal Range

3. Cerebrospinal fluid (CSF) workout

 Protein – 0.382
 Pandy test – negative
 Chloride – 125
  Latex agglutination – negative
 Cell counts
 Appearance : clear
 Direct smear : no organism
 Cytology :
 Total cell : 1/cmm
 RBC : Nil

 Glucose : 3.9
 Culture and sensitivity : normal

Results: all readings was normal. The reasons to perform CSF workout mainly to exclude
meningitis which can manifest with atypical finding. CSF glucose also indicate if
patient seizure secondary to hypoglacemia.

Random blood glucose: 5.8 ( 3.5 -7.8)

Results – normal. To exclude hypoglycemia

DISCUSSION

West Syndrome (or infantile spasm) starts between age of 2 and 12 months , male affected
more commonly, and consists a triad of infantile epileptic spasms that usually occur in clusters
such as drowsiness upon arousal, developmental regression, and typical EEG pictures called
hypsarrhythmia (Kliegman et al, 2016). Omar previously was no history of developmental
delay, and no strong family history of epilepsy. Kliegman et al (2016) mentioned that patient
with cryptogenic West syndrome have normal developmental before onset, while patients with
symptomatic West syndrome have preceding developmental delay owing to perinatal
encephalopathies, malformation, underlying metabolic disorder or other etiologies. Patients
with West syndrome consist of flexor or “jack-knife” seizure or “salam spasm” with the sudden
drawing up of the legs on the abdomen and hunching forward of the neck and shoulder (David,
Isaac and John, 2005). Management of this patient includes multi-disciplinary approach. Anti-
convulsion that prescribed by this patient was phenytoin, sodium valproate and sodium chloral
hydrate. Careful monitoring of developmental milestones is essential since patient with West
syndrome has high risk of developmental regression, therefore, speech therapy or counseling
play an important role. EEG should be done to this patient to confirm diagnosis.
 Hypsarrythmia with an irregular multifocal high-voltage spike and wave
activity with chaotic high-voltage slow background.

Reference.

Kliegman, R, M., Stanton, B. F., St Geme, J, W. & Schor, N,F. (2016). Nelson Textbook of
Pediatrics. California: Elsevier

David, J. F., David, I. & John, S. (2005). Tutorial in Pediatric Differential Diagnosis. UK:
Elsevier