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:
His mother said: “no, never” But the kid said – “Oh, yeah, that has happened at school a few times – “my face winks”
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
Lung Ultrasound with Dr. Kylie Baker
A Tox Treat: Tox 101 with Drs Bryan Hayes and David McCoubrie
Mammography and pink cricket bats
About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
Q1: nocturnal seizures ?benign Rolandic epilepsy
Q2: daytime somnolence
Q3: polysomnography
Free beer?
1) Seizure: reflex anoxic secondary to nightmare/other fright
2) Does he remember having a nightmare? (possible cause)
3) Prolactin
I thought this could be Autosomal Dominant Nocturnal Frontal Lobe Epilepsy. Why? because I thought Casey might have given us a clue that there is something in the history that will tell us the answer.
There are other causes of nocturnal epilepsy in kids but few that are distinguishable on history alone (most need an EEG). So Casey – was there a family hx of nocturnal epilepsy?
Looks like I was wrong on this one, better luck next time 🙂
S
Simon, you could be right. This kid had no specific family history.
BECTS is autosomal dominant with variable penetrance – so not always there on the family history – and of course a mild case might be attributed to a stutter ot facial tic without a formal diagnosis.
Casey
Casey, can you get an EEG in Broome?
Or do they need to go to Perth?
Tim, no – need to fly south for an EEG 2000 km.
I think this is one of the situations where we need to bite the bullet and send em out
Casey
Despite my desire to minimize unnecessary scans etc, I think in the US, most people (myself included) would CT his head (or MRI if immediately available). Unwitnessed fall and he had a seizure, without prior history? I’m not saying it’s absolutely necessary or the right thing, but with the alignment of incentives in the US system, it’s probably well within normal practice.
Seth. Might have mislead you – no fall, just a GTC in bed. No trauma – would you still scan?
The story is pretty convincing for BECTS – so I would watch the I’d in ED or the ward overnight, get an opinion from a Neurologist in the AM
The “money” here is on the EEG – so I want to do it sooner rather than later, to make the diagnosis, allow the family a reassuring prognosis and avoid unnecessary medication or radiation.
EEG is harmless and will secure the diagnosis. We know the yield on CT in this scenario is super low.
Maybe I am a bit brave (or confident in my lawyers?) but I would not CT if it all seemed to fit BECTS.
C
Good points. I’m honestly not sure what I’d do. But I think a lot of EPs in the US would image for first seizure (even without trauma). I’m not sure if that’s correct or not but I would admit that I probably would CT.
So….would you still send them on a 2000km each way trip for an EEG? Just trying to play minimalist devil’s advocate here.
It can be tricky in rrual Oz – whereas some of our North American cousins suggest CT (or even MRI) ‘stat’, we may have to make decisions in rural Oz that are a pragmatic choice between safety and diagnositic yield
Me? I’d send ’em up to the big town for EEG and neuro opinion.
Tim, great points. In reality I think that the scenario described is: first seizure in a well child, no evidence of a malignant process that will lead to a problem in the short term.
This family certainly should have access to he same quality of care that the same child would in the city / tertiary centre.
This is what I love about my job – I can pick up the phone and talk to a seriously smart, practical and helpful Paediatric Neurologist on the day – get good info, a plan and reassure the family. I can skip the queue in the Public clinic system.
In some ways my remote patients get better service than people in the city.
This all relies on me (us) doing the basics well, giving the specialists accurate and complete information.
The kid needs a diagnosis – not a CT. So I would get advice on the phone early, then refer later for the EEG etc in the coming weeks.
That is how I would play this one.
Casey
Yep, me too. I love the new telehealth and the burgeoning use of email/twitter/skype etc to get the right specialist thinking about my patient…and help tee-up investigations
I think I’ve told you about the wonderful integrated Cardiac Care network we have in South Australia – truly visionary effort by Phil Tideman to bring specialist cardiology input to rural and remote patients via networks…they also help make all the downstream organisation of investigations happen
But you are spot on – diagnosis and management initially, confirmatory ‘special’ tests can wait..for now