The role op lumbar puncture in young infants with seizures and fever in a resource-constrained setting

Coetzee, Ashton (2016-12)

Thesis (MMed)--Stellenbosch University, 2016.

Thesis

ENGLISH SUMMARY: Background Differentiating febrile seizures from serious infections like bacterial meningitis is essential but remains a clinical dilemma for many clinicians. This has lead to local guidelines advocating routine lumbar puncture (LP) in all infants less than 18 months of age presenting with fever-associated seizures irrespective of clinical findings. Recently revised American Academy of Pediatrics (AAP) guidelines for simple febrile seizures (SFS) recommends a LP only if there are ‘clinical signs or symptoms of concern’. This guidance can however not necessarily be extrapolated to resource-constrained settings as studies chosen to inform these guidelines have deliberately excluded studies from developing countries. This study aim to evaluate the utility and outcome of LP, as a special investigation, in infants between the ages of 6 months and 18 months, presenting with seizures and associated fever, in a setting with uncertain immunization coverage and high burden of malnutrition, HIV and TB. Methodology A retrospective cohort review was conducted of infants aged 6 to 18 months admitted with fever and seizures to the Paediatric Emergency & Ambulatory unit at Tygerberg Children’s Hospital over a 12 month period. Patients were identified using the admission records, patient admission notes and laboratory CSF results. Descriptive statistics was performed on demographic outcome variables. Univariate analysis for continuous variables were performed to determine adjusted associations between historical and/or clinical findings and CSF results. Results Fever and associated seizures were the presenting feature in 25% of infants between the ages of 6 to 18 month in our study. Infants included in our study were mostly well, with normal growth and development, none were HIV-infected and only 10% exposed to a known TB case. Immunizations were complete for age in 79% of infants. 62/84 (74%) of the infants eligible for the study underwent a lumbar puncture. The majority of infants were diagnosed as Febrile Seizures (75/84, 89%). Viral upper respiratory infection was the most common cause for fever (63%) in these infants. A clear source of fever was found to be statistically significant in differenciating between patients with normal and abnormal CSF results (p< 0.001). Meningitis was diagnosed in 6/84 (7%) of infants; of whom 3 had abnormal neurological findings suggestive of meningitis at presentation. Based on CSF results, 3/62 (5%) were diagnosed as viral meningitis, 1/62 (2%) as tuberculous meningitis and 2/62 (3%) as presumed bacterial meningitis. No cases of meningitis were diagnosed in infants fulfilling the case definition of Simple Febrile Seizures in this study. Three children (3%) presenting with Complex Febrile Seizures and normal neurological findings were diagnosed and treated as meningitis (1 viral, 2 bacterial) following a LP. Conclusion Fever with associated seizures in infants between the ages of 6 to 18 month presented a significant burden of disease in our emergency unit; and underlines the need for evidence-based management guidelines. If American Academy of Pediatrics (AAP) guidelines for SFS had been applied to our study population, all cases of serious illness would have been investigated and identified. AAP guidelines could thus be applied to well infants between the ages of 6 and 18 months in resource-constrained settings; decreasing the use of LP with associated cost savings. Larger studies are required to identify clinical variables to guide best practice, especially in infants presenting with complex febrile seizures.

AFRIKAANSE OPSOMMING: Agtergrond Om koorsstuipe van ernstige infeksies soos bakteriële meningitis te differensieer is noodsaaklik, maar bly 'n kliniese dilemma vir baie dokters. Dit het gelei tot die plaaslike riglyne wat roetine lumbaalpunksie (LP) aanbeveel in alle babas minder as 18 maande wat met koors en konvulsies presenteer, ongeag die kliniese bevindinge. Onlangse hersiene ‘American Academy of Pediatrics’ (AAP) riglyne vir eenvoudige koorsstuipe (SFS) beveel 'n LP slegs aan indien daar kliniese tekens of simptome van kommer is. Hierdie aanbeveling kan egter nie noodwendig geëkstrapoleer word tot instellings met beperkte hulpbronne nie aangesien studies wat die riglyne toegelig het, doelbewus studies uitgesluit het van ontwikkelende lande. Hierdie studie het ten doel om die nut en uitkoms van LP, as 'n spesiale ondersoek, te evalueer in babas tussen die ouderdomme van 6 maande en 18 maande, wat presenteer met konvulsies en verwante koors in 'n omgewing met onseker immunisering dekking en 'n hoë las van wanvoeding, MIV en TB. Metodiek 'n Retrospektiewe groep hersiening is gedoen van babas tussen die ouderdomme 6-18 maande wat toegelaat is met koors en konvulsies in die Pediatriese Nood & Ambulatoriese eenheid by Tygerberg Kinderhospitaal oor 'n tydperk van 12 maande. Pasiënte is geïdentifiseer mbv die toelatingsrekords, pasiënt toelatingsnotas en laboratorium SSV resultate. Beskrywende statistiek is uitgevoer op demografiese veranderlikes. Eenveranderlike analise vir kontinue veranderlikes is uitgevoer is om aangepaste assosiasies tussen historiese en / of kliniese bevindinge en SSV resultate te bepaal. Resultate Koors en verwante konvulsies was die presenterende klagte in 25% van babas tussen die ouderdomme van 6 tot 18 maande in ons studie. Babas in ons studie was meestal gesond, met 'n normale groei en ontwikkeling, niemand was MIV-geinfekteerd, en slegs 10% was blootgestel aan 'n bekende TB geval. Inentings was op datum vir ouderdom in 79% van gevalle. 62/84 (74%) van die babas wat gekwalifiseer het vir die studie het 'n lumbaalpunksie ondergaan. Die meerderheid van die babas is met ontslag gediagnoseer as koorsstuipe (75/84, 89%). Virale boonste respiratoriese infeksie was die mees algemene oorsaak vir koors (63%) in hierdie babas. 'n Duidelike bron van koors is gevind om statisties beduidend te wees in die onderskeiding van pasiënte met normale en abnormale SSV resultate (p <0.001). Meningitis is gediagnoseer in 6/84 (7%) van babas; waarvan 3 met abnormale neurologiese bevindings suggestief van meningitis presenteer het by aanbieding. Op grond van SSV resultate, is 3/62 (5%) gediagnoseer as virale meningitis, 1/62 (2%) as tuberkuleuse meningitis en 2/62 (3%) as vermoedelike bakteriële meningitis. Geen gevalle van meningitis is gediagnoseer in babas wat aan die gevalsdefinisie van eenvoudige koorsstuipe voldoen het in hierdie studie nie. Drie kinders (3%) wat met kompleks koorsstuipe en normale neurologiese bevindings presenteer het, is gediagnoseer en behandel as meningitis (1 virale, 2 bakteriële) nav die LP ondersoek. Gevolgtrekking Koors met gepaardgaande konvulsies in babas tussen die ouderdomme van 6 tot 18 maande maak 'n beduidende deel uit van siektetoestande in ons noodeenheid; en beklemtoon die noodsaaklikheid vir bewysgebaseerde behandelingsriglyne. As die ‘American Academy of Pediatrics’ (AAP) riglyne vir SFS toegepas was op ons studie populasie, sou alle gevalle van ernstige siekte korrek ondersoek en geïdentifiseer wees. AAP riglyne kan dus toegepas word in gesonde babas tussen die ouderdomme van 6 en 18 maande in beperkte hulpbron instellings; met gevolglike vermindering van die gebruik van LPs en gepaardgaande kostebesparings. Groter studies is nodig om die kliniese veranderlikes te identifiseer wat tot beste praktyk kan lei, veral in babas wat presenteer met komplekse koorsstuipe.

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