• 
• 

Three Part Question

In [children <5 years old presenting to the Emergency Department with a febrile convulsion] is [meningitis] a [common aetiology]?

Clinical Scenario

A 3-year-old boy has been brought to the Emergency Department after a convulsion at home, which has now resolved. His parents say he has been hot, sleepy and irritable that morning, and has been crying when his bedroom light was turned on. After investigation, meningitis is diagnosed and treated. You wonder how commonly meningitis is a cause of febrile convulsions.

Search Strategy

OVID Medline <1966 – June Week 3 2005>
EMBASE <1980 – 2005 Week 26>
CINAHL <1982 – June Week 3 2005>
The Cochrane Library 2005 Issue 2.
Medline
(exp Seizures, Febrile/ OR [seizure$.mp. AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR [convulsion$.mp. AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR [fit$.mp. AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] ) AND (exp MENINGITIS/ OR meningitis.mp. OR exp MENINGITIS, ASEPTIC/ OR exp MENINGITIS, BACTERIAL/ OR exp MENINGITIS CRYPTOCOCCAL/ OR exp MENINGITIS ESCHERICHIA COLI/ OR exp MENINGITIS, FUNGAL/ OR exp MENINGITIS, HAEMOPHILUS/ OR exp MENINGITIS, LISTERIA/ OR exp MENINGITIS, MENINGOCOCCAL/ OR exp MENINGITIS, PNEUMOCOCCAL/ OR exp MENINGITIS, VIRAL/) Limit to (humans and English language and ("infant (1 to 23 months)" or "preschool child (2 to 5 years)"))
EMBASE
(exp Febrile Convulsion/ OR [exp SEIZURE/ AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR [exp "SEIZURE, EPILEPSY AND CONVULSION"/ AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR [seizure$.mp. AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR [convulsion$.mp. AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR [exp CONVULSION/ AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR [fit$.mp. AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}]) AND (exp MENINGITIS/ OR meningitis.mp. OR exp ASEPTIC MENINGITS/ OR exp BACTERIAL MENINGITIS/ OR exp CARCINOMATOUS MENINGITIS/ OR exp EPIDEMIC MENINGITIS/ OR exp LEUKEMIC MENINGITIS/ OR exp MYCOTIC MENINGITIS/ OR exp TUBERCULOUS MENINGITIS/ OR exp VIRUS MENINGITIS/) Limit to (human and English language and (infant or preschool child <1 to 6 years>))
CINAHL
(exp Convulsions, Febrile/ OR [exp Seizures/ AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR [seizure$.mp. AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR [exp Convulsions/ AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR [convulsion$.mp. AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR [fit$ AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}]) AND (exp MENINGITIS/ OR meningitis.mp. OR exp MENINGITIS, BACTERIAL/ OR exp MENINGITIS, MENIGOCOCCAL OR exp MENINGITIS, VIRAL/) Limit to (English and (infant <1 to 23 months> or preschool child <2 to 5 years>))

Search Outcome

Medline: 233 papers found, 1 relevant.
Embase: 171 papers found, 6 relevant.
CINAHL: 22 papers found, 1 relevant new paper found.
Cochrane Library: no relevant papers found.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Rossi LN, Brunelli G, Duzioni N and Rossi G. 1986. Italy.	878 children aged between 1 month and 6 years presenting to an emergency department with their first episode of seizure and fever.	Retrospective cohort study.	Number of patients with lumbar puncture performed.	255/878 (29.0%)	Not all children were given a lumbar puncture and no details given about how it was decided which children were given a lumbar puncture.
			Number of positive cultures.	21/878 (2.4%)
			Types of meningitis detected.	7 bacterial, 14 viral.
			Number of patients without lumbar puncture.	623/878 (71.0%)
			Number of patients without lumbar puncture who developed meningitis.	0/623 (0%)
Akpede GO and Sykes RM. 1992. Nigeria.	522 children aged between 1 month and 6 years presenting to an emergency department with fever and convulsions during October 1988 and October 1989.	Retrospective cohort study.	Number of patients with lumbar puncture performed.	522/522 (100%)	No basic data given on the children.
			Number of positive cultures.	22/522 (4.2%)
			Number of patients with positive culture and no signs of meningitis.	6/22 (27.3%)
Offringa M, Beishuizen A, Derksen-Lubsen G and Lubsen J. 1992. The Netherlands.	309 children aged 3 months to 6 years old presenting to 2 emergency departments with their first episode of seizure associated with fever between March 1985 and March 1987.	Cohort study.	Number of patients with lumbar puncture performed.	171/309 (65%)	No basic data given on the children.
			Number of positive cultures.	23/309 (7%)
			Number of positive cultures in patients with no clinical signs.	2/23 (8.7%)
			Types of meningitis detected.	16 bacterial, 2 viral, 4 partially treated with antibiotics and 1 sterile culture.
			Number of patients without lumbar puncture.	138/309 (45%)
			Number of patients without lumbar puncture and meningitis.	0/138 (0%)
Al-Eissa YA. 1995. Saudi Arabia.	200 previously healthy children aged 3 months to five years brought consecutively to a paediatric emergency department with a seizure associated with fever.	Prospective cohort study.	Number of patients with lumbar puncture performed.	102/200 (51%)	Small sample size.
			Number of positive cultures.	7/200 (3.5%)
			Types of meningitis detected.	3 bacterial, 3 viral, 1 meningo-encephalitis and herpes simplex type1.
			Number of patients without lumbar puncture.	98/200 (49%)
			Number of patients without lumbar puncture and meningitis.	0/98 (0%)
Teach SJ and Geil PA. 1999. USA.	243 encounters of 218 patients presenting to an emergency department of a Children's hospital with febrile convulsion during the calendar year 1996.	Retrospective cohort study.	Number of patients with lumbar punctures performed.	66/243 (27.2%)	Not every child had a lumbar puncture performed. No details given about which children had lumbar puncture performed. No follow up done on the children.
			Number of positive cultures.	0/66 (0%, 95% CI 0.0%-4.5%)
Trainor JL, Hampers LC, Krug SE and Listernick R. 2001. USA.	455 children aged 6 to 60 months, presenting to 7 emergency departments with their first simple febrile convulsion between July 1995 and December 1997.	Retrospective cohort study.	Number of patients with lumbar punctures performed.	135/455 (29.6%)	Not all children had lumbar punctures performed. The 7 different hospitals may have different protocols for doing lumbar punctures. No data given on how many children received antibiotics before the lumbar puncture.
			Number of positive cultures.	0/135 (0%, 95% CI 0.0%-2.2%)
			Number of children with CSF pleocytosis.	0/135 (0%)
Al-Khathlan NA. 2005. Saudi Arabia.	69 consecutive children aged between 7-70 months presenting with febrile seizures to a hospital between 1st January 1997 and 1st January 2002.	Retrospective cohort study.	Number of patients with lumbar puncture performed.	52/69 (75%)	Data derived from abstract only. Small sample size.
			Number of positive cultures.	1/69 (1.4%)
Chin RFM, Neville BGR and Scott RC. 2005. UK.	24 children with convulsive status epilepticus and fever >38oC on presentation identified from first 6 months of a large study.	Retrospective cohort study.	Number of patients with CSF sampling performed.	9/24 (37.5%)	Small sample size. Not all children had CSF sample taken. No details given on how the children were chosen to have CSF sampled.
			Number of positive cultures.	4/24 (16.7%, 95% CI 15%-18%)
			Types of meningitis.	4 bacterial.
			Number of children with positive cultures and clinical signs of meningitis.	0/4 (0%)

Comment(s)

One paper could not be obtained in full and data was derived from the abstract. One weakness common to 7 of the 8 papers was that not all the children studied had their CSF sampled and cultured. Another weakness is that the papers did not state when the CSF samples were taken, as the timing may influence the result. The prevalence of meningitis stated varied and was reported to be higher in children who presented with febrile convulsive status epilepticus compared to children with simple febrile seizures.

Clinical Bottom Line

These studies suggest that meningitis is a possible cause of simple febrile convulsions and lumbar punctures should be performed if there is any suspicion of the disease clinically. Attention should be paid to suspicious histories, as meningitis may be present without clinical signs. If the lumbar puncture is negative, the child is unlikely to subsequently develop meningitis.

References

1. Rossi LN, Brunelli G, Duzioni N and Rossi G. Lumbar puncture and Febrile convulsions Helvetica Paediatrica Acta. 1986; 41(1-2):19-24.
2. Akpede GO and Sykes RM. Convulsions with fever as a presenting feature of bacterial meningitis among preschool children in developing countries. Developmental Medicine and Child Neurology. 1992; 34(6):524-529.
3. Offringa M, Beishuizen A, Derksen-Lubsen G and Lubsen J. Seizures anf fever - Can we rule out meningitis on clinical grounds alone? Clinical Pediatrics. 1992; 31(9):514-522.
4. Al-Eissa YA. Lumbar puncturs in the clinical evaluation of children with seizures associated with fever. Pediatric Emergency Care. 1995; 11(6):347-350.
5. Teach SJ and Geil PA. Incidence of bacteremia, urinary tract infections and unsuspected bacterial meningitis in children with febrile seizures. Pediatric Emergency Care. 1999; 15(1):9-12.
6. Trainor JL, Hampers LC, Krug SE and Listernick R. Children with first-time simple febrile seizures are at low risk of serious bacterial illness. Academic Emergency Medicine. 2001; 8(8):781-7.
7. Al-Khathlan NA. Clinical profile of admitted children with febrile seizures. Neurosciences. 2005; 10(1):30-33.
8. Chin RFM, Neville BGR and Scott RC. Meningitis is a common cause of convulsive status epilepticus with fever. Archives of Disease in Childhood. 2005; 90(1):66-9.