“No, never,” she answered.
I saw something worrisome: The child’s eyes were staring not straight ahead but to the right.
“When did she start getting sick?”
“She started running a fever this morn
ing. That’s why I made the appointment.”
“Did she have any other symptoms? Vomiting, rash, any sign of pain?”
“No,” the mother replied.
The nurse interrupted: “Her temperature is 103.1.” That was high, but not excessive for a 1-year-old. Again, young children often run very high fevers with minor viral illnesses. I looked at the child once more. In these situations, continued reevaluation is critical.
To my relief, in just minutes the seizure stopped. The little girl was lying quietly on the table, still pink, still breathing. I checked the oxygen monitor: 97 percent. Good. Now I could relax a bit, but I had to keep probing. What had caused this little girl’s seizure? Was it an indication of something that we needed to treat right away? Was she likely to start seizing again very soon? While many conditions can cause a seizure in a child, they fall into only a few common categories. I mulled them over as I began to examine her again, and I ticked off the possibilities.
Highest on the list of causes is infection. Fevers that trigger seizures are most often due to flu, cold, or ear infection, but they can also be due to meningitis. Thanks to modern immunizations, this dreaded infection of the fluid and membranes that surround the brain and spinal cord is nowhere near as common as it once was. I began to make a mental list of tests I would need for this child, and the first one was a lumbar puncture, or spinal tap, to sample her cerebrospinal fluid and rule out meningitis.
Another possible cause of a seizure is a mass inside the brain, such as a brain tumor. I recalled that the child’s eyes had been gazing to one side during her seizure, and now I noticed that, even though the seizure had stopped, she was holding her left arm and leg in an oddly stiff posture. The subtle asymmetry of her eyes and extremities suggested to me that this child’s seizure was focal. Focal seizures may be triggered by something going wrong in a specific location in the brain. The problem can sometimes turn out to be, among other things, a tumor. An MRI scan went on the to-do list. I was not going to send this child home tonight.
Some children’s brains are simply prone to having seizures. We say that such a child has a seizure disorder, which is also known as epilepsy. We think there is some area of scar tissue or other irregularity in the brain’s cortex that acts as an “irritable focus”; it can suddenly trigger a seizure, frequently with no provocation at all. This irritable focus often shows up on an electroencephalogram (EEG), a recording of the brain’s spontaneous electrical activity. Fortunately, some medications can decrease the frequency of seizures in people with epilepsy. The drugs have some side effects, but most patients can live healthy and active lives. However, the focal nature of the seizure I had just witnessed had me very worried that this little girl might have something worse inside her brain.
I telephoned a pediatric colleague and arranged for the child to be transported to the hospital. I checked the reports in the computer as they came in over the next couple of days. I was pleasantly surprised to find that her spinal fluid was normal, her MRI did not show a tumor or any other abnormality, and her EEG showed perfectly normal brain activity with no sign of a seizure focus. The pediatric neurologist decided that she did not have epilepsy and did not need to be treated with anticonvulsant medication.
She is home now, and doing wonderfully. With any luck she’ll never have another episode like this one. So why did she have a seizure? We can’t explain it, other than to chalk it up to the mystery of a child’s brain. In this case, I was delighted to have been wrong.
Mark Cohen is a pediatrician with Kaiser Permanente in Santa Clara, California. The cases described in Vital Signs are real, but names and other details have been changed.
