How to identify and manage partial seizures in a pediatric patient with suspected meningitis and a history of seizures?

Identifying and Managing Partial Seizures in Pediatric Meningitis

Recognition of Seizures in Suspected Meningitis

Seizures occur in 10-56% of children with bacterial meningitis at hospital admission, and their presence—whether generalized or partial—should never delay immediate empiric antibiotic therapy and diagnostic workup. 1

Key Clinical Context

• Seizures are a common presenting feature of bacterial meningitis in children, occurring in 9-34% of neonates (more common with Group B Streptococcal infection) and 10-56% of children beyond neonatal age 1
• In children with meningitis, seizures may be the presenting sign in up to 1 in 6 cases, and critically, meningeal signs may be absent in one-third of these patients 2
• Partial (focal) seizures in the context of suspected meningitis are particularly concerning as they may indicate focal neurologic involvement, cerebral vasculitis, or localized brain injury 3

Immediate Management Algorithm

Step 1: Do Not Delay Antibiotics for Imaging or Seizure Workup

• Administer empiric antibiotics immediately after blood cultures are obtained, even before lumbar puncture if there are contraindications to LP 1
• For pediatric bacterial meningitis, initiate ceftriaxone or cefotaxime plus vancomycin without delay 1
• Do not wait for CT results or seizure control before starting antimicrobial therapy 1

Step 2: Identify Seizure Type and Treat Promptly

Partial seizures in meningitis context include: 3

• Focal motor seizures (oral, finger, or eyelid twitching)
• Seizures with focal onset that may or may not secondarily generalize
• Seizures occurring outside typical febrile convulsion age range (6 months to 5 years)

Treatment approach: 1

• Treat suspected or proven seizures early with anticonvulsant therapy
• Do not delay treatment waiting for EEG confirmation
• Consider levetiracetam as first-line agent (20 mg/kg loading dose in children, titrated to 60 mg/kg/day in divided doses) 4
• Monitor for status epilepticus, including non-convulsive status, particularly in patients with fluctuating consciousness 1

Step 3: Determine Need for Lumbar Puncture

Perform LP immediately unless contraindications exist: 1

Contraindications requiring CT first (in adults; less stringent in children): 1

• Immunocompromised state
• History of CNS disease
• Papilledema
• Altered consciousness with focal neurologic deficits
• Note: In children, seizures alone (even prolonged) are NOT a contraindication to LP, as seizures occur in up to 30% of pediatric bacterial meningitis cases before admission 1

Critical indicators mandating LP or presumptive treatment: 3

• Bulging fontanel (in infants)
• Neck stiffness
• Impaired consciousness
• Partial seizures
• Seizures outside febrile convulsion age range
• Cyanosis

Specific Considerations for Partial Seizures

Why Partial Seizures Matter in Meningitis

Partial seizures indicate focal cerebral involvement and predict worse outcomes: 5, 3

• Focal seizures suggest localized brain injury, vasculitis, or abscess formation
• Children with persistent neurologic deficits after meningitis (which partial seizures may indicate) are at significantly higher risk for late epilepsy (P<0.001) 5
• Partial seizures are an independent indicator of bacterial meningitis presence (sensitivity 79%, specificity 80% when combined with other indicators) 3

Distinguishing from Simple Febrile Seizures

Partial seizures are NOT simple febrile seizures and require full meningitis workup: 2, 6

• Simple febrile seizures are generalized, brief (<15 minutes), and occur once in 24 hours
• Any focal features, prolonged duration, or recurrence within 24 hours mandates LP to exclude meningitis 2
• Meningitis presents with seizures in 23% of cases, and bacterial meningitis carries 14.4% fatality rate 6

Diagnostic Workup

Essential Studies

Immediate: 1

• Blood cultures before antibiotics
• CSF examination (opening pressure, cell count with differential, protein, glucose, Gram stain, culture)
• Serum glucose (for CSF:serum glucose ratio; <0.4 suggests bacterial meningitis in children >12 months, <0.6 in neonates) 1

Consider based on clinical presentation: 3

• Neuroimaging (CT or preferably MRI) if focal deficits persist, consciousness doesn't improve, or partial seizures continue
• EEG if status epilepticus suspected (fluctuating GCS, subtle movements) 1

CSF Findings in Bacterial Meningitis

Typical profile: 1

• WBC count: 1000-5000 cells/mm³ (range 100-110,000)
• Neutrophil predominance: 80-95% (though 10% present with lymphocyte predominance)
• Protein: elevated
• Glucose: <40 mg/dL in 50-60% of cases

Critical Pitfalls to Avoid

Common Errors

1. Delaying antibiotics for any reason in suspected bacterial meningitis with seizures 1, 7

   • Mortality remains high in untreated bacterial meningitis
   • Never delay while awaiting diagnostic confirmation

2. Assuming absence of meningeal signs excludes meningitis 1, 7

   • Classic triad (fever, neck stiffness, altered mental status) present in only 41-51% of cases
   • Neck stiffness sensitivity is only 31% in adults, even lower in young children
   • Younger children have more subtle, atypical presentations

3. Failing to recognize that partial seizures indicate higher-risk meningitis 5, 3

   • Focal seizures suggest cerebral injury and predict long-term neurologic sequelae
   • These patients require aggressive management and close monitoring

4. Withholding LP in children with seizures 1

   • Unlike adults, pediatric seizures are NOT a contraindication to LP
   • Up to 30% of children with bacterial meningitis present with seizures

Age-Specific Considerations

Neonates: 1

• Present with nonspecific symptoms (irritability, poor feeding, respiratory distress)
• Fever present in only 6-39% of cases
• Maintain extremely low threshold for LP—clinical exam cannot rule out meningitis

Infants and young children: 1

• Classical signs less frequent than in older children
• Headache reported in only 2-9% under 1 year (vs. 75% over 5 years)
• Fever most common symptom (92-93%)
• Vomiting in 55-67%

Seizure Management Specifics

Anticonvulsant Selection

Levetiracetam is preferred in acute meningitis setting: 4

• Pediatric dosing: Start 20 mg/kg/day divided BID, titrate by 20 mg/kg/day increments every 2 weeks to target 60 mg/kg/day
• Effective for partial onset seizures (26.8% reduction over placebo in pediatric trials)
• Common adverse effects: somnolence (22.8%), behavioral changes (37.6%), hostility (11.9%)
• Monitor for behavioral symptoms requiring dose reduction (10.9% of patients)

Monitoring for Status Epilepticus

Maintain high suspicion for non-convulsive status: 1

• Patients with fluctuating consciousness off sedation
• Subtle abnormal movements
• Failure to return to baseline mental status
• Requires EEG monitoring for definitive diagnosis and management

Prognosis and Follow-up

Long-term seizure risk: 5

• 7% of children develop late afebrile seizures after bacterial meningitis
• Only children with persistent neurologic deficits are at high risk for epilepsy
• Those with normal examinations after acute illness have excellent prognosis
• Presence of permanent neurologic deficits is the only independent predictor of late epilepsy (P<0.001)