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A six year old girl was brought to Saint Elsewhere Emergency room because of seizure for the first time. According to the ambulance emergency technician the child had been having tonic-clonic seizure for at least 20 minutes. She has a temperature of 96.3 F, pulse of 88/minute, breathing rate of 6/minute, and a blood pressure of 110/62 mm Hg. She breathing tube (intubation) was placed because her breathing is compromised. Her initial blood tests were normal including a blood sugar and acidity of the blood (pH and gasses). According to the mother, her daughter was doing her homework when she began drooling, her eyes turned to the left with some blinking. She related that her child had no recent illness or injury, headache, fever, or ingestion of any drug or chemical. The physical examination was normal. She was admitted to the Pediatric Intensive Care Unit (PICU). Other results of blood tests including serum and urine toxicology screens were normal. A CT of the head was normal too, no signs of bleeding or tumor. On arrival at the PICU, her breathing tube was removed. She was stable. The physical examination was still within normal. A neurologist was consulted. The MRI was reported as showing asymmetry involving the right medial temporal region with apparent volume loss in the right hippocampal area but no abnormal enhacement. The brain wave (EEG) showed right frontal-temporal slowing without waves that would suggest a focus for epilepsy. This EEG was interpreted a postictal slowing rather tan a true seizure. Because the EEG and the MRI were not alarming the girl was sent home. A week later she was back at the emergency room with prolonged seizure (status epilepticus). She was given intravenous medications to control the seizure and she was transferred to the PICU. The mother said that her daughter complained of intermittent headache with two days of fever of 102.7. That same morning she was seen by a pediatrician who diagnosed a viral infection to explain the fever and headache. A repeat MRI was done and it was unchanged from the first one. A spinal tap showed 300 white blood cells, with predominance of lymphocytes, 63 red blood cells, and normal sugar and protein. Culture of the spinal fluid and PCR (Polymerase Chain Reaction) for HVS were sent. The child was given intravenous antibiotic and acyclovir.
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