Pediatrics/original research
Do All Children Who Present With a Complex Febrile Seizure Need a Lumbar Puncture?

https://doi.org/10.1016/j.annemergmed.2016.11.024Get rights and content

Study objective

We assess the prevalences of bacterial meningitis and herpes simplex virus meningoencephalitis (HSV-ME) in children with a complex febrile seizure and determine these prevalences in the subgroup of children with a clinical examination result not suggestive of meningitis or encephalitis.

Methods

This multicenter retrospective study was conducted in 7 pediatric emergency departments (EDs) in the region of Paris, France. Visits of patients aged 6 months to 5 years for a complex febrile seizure from January 2007 to December 2011 were analyzed. We defined a subgroup of patients whose clinical examination result was not suggestive of meningitis or encephalitis. Bacterial meningitis and HSV-ME were sequentially sought for by analyzing bacteriologic and viral data at the visit, looking for data from a second visit to the hospital after the index visit, and telephoning the child’s parents.

Results

From a total of 1,183,487 visits in the 7 pediatric EDs, 839 patients presented for a complex febrile seizure, of whom 260 (31.0%) had a lumbar puncture. The outcomes bacterial meningitis and HSV-ME were ascertainable for 715 (85%) and 657 (78.3%) visits, respectively, and we found 5 cases of bacterial meningitis (0.7% [95% confidence interval [CI] 0.2% to 1.6%]) and no HSV-ME (0% [95% CI 0% to 0.6%]). Among the 630 visits of children with a clinical examination result not suggesting meningitis or encephalitis, we found no bacterial meningitis (0% [95% CI 0% to 0.7%]) and no HSV-ME (0% [95% CI 0% to 0.8%]).

Conclusion

In children with a complex febrile seizure, bacterial meningitis and HSV-ME are unexpected events when the clinical examination after complex febrile seizure is not suggestive of meningitis or encephalitis.

Introduction

Febrile seizures are defined as seizures occurring in children aged 6 months to 5 years, in a context of fever, without a history of an unprovoked seizure or concurrent central nervous system infection.1, 2 They affect 2% to 5% of children in Europe and North America.3, 4 They are categorized as complex if at least one of the following features is present: focal seizure, prolonged seizure (>15 minutes), or multiple seizures (>1/24 hours). Because a seizure in the context of fever may be associated with bacterial meningitis5 or herpes simplex virus meningoencephalitis (HSV-ME),6 deciding whether a lumbar puncture should be performed to rule out these central nervous system infections in children presenting with a complex febrile seizure may be a challenge.

Editor’s Capsule Summary

What is already known on this topic

Complex febrile seizure in children is an uncommon (<1%) presenting symptom of bacterial meningitis or herpes meningoencephalitis. Many debate the need for emergency lumbar puncture in these children.

What question this study addressed

What is the current prevalence of bacterial meningitis and herpes meningoencephalitis in children with complex febrile seizure who have no other clinical findings suggestive of these conditions?

What this study adds to our knowledge

In a multicenter retrospective study conducted in Paris, France, among 839 children aged 6 months to 5 years with complex febrile seizure, 0.7% had bacterial meningitis and none had herpes meningoencephalitis. Among children free of other suggestive clinical findings of either, none had these diseases.

How this is relevant to clinical practice

These data support the development of guidelines limiting lumbar puncture for complex febrile seizure in the absence of other concerning signs in urban vaccinated populations.

Before the availability of immunization against Haemophilus influenzae type b and Streptococcus pneumoniae (prepneumococcal conjugate vaccine era), the global prevalence of bacterial meningitis in children with “seizure and fever” was found to be 0.8%7 and was approximately 5 times higher after a complex than a simple febrile seizure.8 However, a recent meta-analysis including 2 postvaccine-era studies found a pooled prevalence of bacterial meningitis in children with a complex febrile seizure of 0.6%.9 Currently, the scarce guidelines on the performance of a lumbar puncture in children with complex febrile seizure are heterogeneous,10, 11, 12, 13 and thus clinical practices are also.14 In the context of a complex febrile seizure, potential contributing reasons for this heterogeneity are a low risk of bacterial meningitis, an unknown risk of HSV-ME, an unknown risk of bacterial meningitis or HSV-ME in the subgroup of patients for whom the clinical examination does not suggest these infections, and the fact that complex febrile seizure include some very different clinical situations such as brief generalized multiple seizures and status epilepticus.15

We hypothesized that among children with complex febrile seizure, the subpopulation presenting with a clinical examination result not suggestive of meningitis or encephalitis had prevalence for these infections of close to zero. The objective of this study was to calculate the proportion of bacterial meningitis and HSV-ME in children with a complex febrile seizure, and to determine these proportions according to the feature of the seizure and in the subgroup of children with a clinical examination result not suggestive of meningitis or encephalitis.

Section snippets

Study Design

We retrospectively reviewed the records of all visits of patients aged 6 months to 5 years in 7 pediatric emergency departments (EDs) in the Paris region in France between January 2007 and December 2011 for a complex febrile seizure and determined the proportion of bacterial meningitis and HSV-ME in this population. In France, conjugate immunizations against H influenzae type b or S pneumoniae were introduced in 1992 and 2003, respectively, and the respective national immunization coverage was

Results

From 2007 to 2011, there were 1,183,487 visits in the 7 participating ED, including 654,459 visits for children aged 6 months to 5 years. The search informatics tool identified at the first step 16,902 visits of children for a potential seizure (Figure 1). Then the manual review yielded 2,103 visits for a potential complex febrile seizure. After a standardized analysis of these visits, we found 839 visits for a complex febrile seizure (ie, 15.3% of the 5,463 visits for febrile seizure). The

Limitations

This study has some limitations. First, because of a retrospective design, all children with a complex febrile seizure and presenting to the ED might not have been included. This bias was reduced by a customized computerized identification of potential eligible patients. Although our list of words was comprehensive, it may have missed some unusual descriptions. Thus, we cannot be confident of the complete exhaustiveness of all the cases.

Second, we were not able to directly determine the outcome

Discussion

To our knowledge, this is the first multicenter European study dealing specifically with the assessment of the prevalence of bacterial meningitis and HSV-ME in children presenting a complex febrile seizure. We found no HSV-ME (0%; 95% CI 0% to 0.6%) and a very low risk of bacterial meningitis (0.7%; 95% CI 0.2% to 1.6%). Moreover, we found neither bacterial meningitis nor HSV-ME in the subgroup of children with a clinical examination result nonsuggestive of meningitis or encephalitis.

For

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  • Cited by (0)

    Please see page 53 for the Editor’s Capsule Summary of this article.

    Supervising editor: David M. Jaffe, MD

    Author contributions: RG, HC, and RC designed the study and obtained research funding. RG and RC supervised the conduct of the study and data collection. RG, LT, LDP, SB, GN-O, BP, OC, FA, JD, CL, R. Cohen, SL, PLL, and R. Carbajal helped in the implementation of the study in their emergency departments, took part in the patients’ selection, and collected the data. RG and RC analyzed the data. RG drafted the article, and all authors contributed substantially to its revision. R. Carbajal takes responsibility for the paper as a whole.

    All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    Guigoz did not participate in any of the following: design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the article.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. Dr. Guedj received a grant from Guigoz for this study.

    Trial registration number: NCT01694524

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