Clinical Case 066: Things that go Bump in the Night

OK readers.  It has been a while since I gave you all the chance to cover yourselves in glory and show off your super-generalist diagnostic skills.  So todays case is a clinical quiz  – as always the prize is…. love and respect, and I will buy you a mango beer if you ever make it to Broome!  Onto the case.

You are doing the night shift and it has been QUIET.  Trying desperately to stay awake at 05:00 playing tetris on the computer when the door bell goes off – action stations.

The triage nurse escorts a frantic-looking mother into the Paeds bed.  She is talking a million-miles-an-hour, and her child, looks to be about 8 years old, is sleeping (appropriately for 5AM) in her arms.

After a cursory ABC exam, the monitors are all reassuring.  You slow down to take the story again.  Here is the history:

  • She awoke at ~ 04:40 to a loud banging sound that came from her son’s bedroom adjacent to her room.
  • She went in to inspect and he was convulsing “all over”, salivating heavily and had been incontinent.
  • The convulsing lasted about 2 or 3 minutes then he appeared to go back to sleep.
  • ON questioning – she thinks his speech was “a bit slurred” when he came around after the fit
  • He had been well, afebrile and has no recent illness or other ongoing medical problems
  • The nurse has done a BSL which was normal, he is afebrile, normal pulse, BP, RR and Spo2

OK.  That is it.  No more clues.  Over to you all.  Here are my questions:

Benign epilepsy of childhood with cortico-temporal spikes (BECTS) or BRE or what used to be called Rolandic epilepsy. This is a classic presentaion – early morning, nocturnal seizure in an otherwise healthy kid, post ictal phase may have some focal (Todd’s palsy – eg. dysarthria, unilateral face or arm weakness). BECTS is among the commonest form of seizure disorder in this age group – esp. in otherwise well kids
 

After this boy woke up and wondered what all the fuss was about we had the chance to ask him a few questions. Did he ever notice facial twitching, a “funny feeling tongue”, drooling, difficultly speaking clearly or other odd transient phenomena?

His mother said: “no, never”  But the kid said – “Oh, yeah, that has happened at school a few times – “my face winks”

OK, for me this is one where the EEG is diagnostic. By and large EEG is a somewhat imprecise test in sorting out seizures – however, there are a few syndromes where is is pathognomonic – and BECTS did not get its name for no good reason – they have a persistent spike pattern localised to the temporal areas.

PLease let me know if you have any other tests, or feel  there is another possible diagnosis.

Casey

 The result: Congrats to Damon Tedford @DamonTedford who was judged most accurate and correct with this twitter response:

Q1: Benign Ep. with centrotemporal spikes (BECTS)

Q2: aura or preceeded by facial twitch?

Q3: EEG – centrotemporal spikes

Damon is an  Resident in Saskatchewan, Canada – so I think the mango beer is safe for now?

See the above drop-downs for explanation and discussion

 

13 Comments

Add a Comment

Your email address will not be published.