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Case 13
A 20 month-old boy is brought to the ED by his parents after a seizure. He awoke with a runny nose, and
had been pulling at his right ear in the afternoon. The mother had planned to bring her child to the
pediatrician the next morning. When she put the child down to sleep, he squealed, extended both arms
and legs, then shook for several minutes, during which his eyes rolled up. Immediately afterwards,
unable to awaken him, his parents brought him to the ED. En route, he began to awaken. In the ED, he
had a temperature of 38 C and a red, swollen right tympanic membrane. He cries vigorously while being
examined. His settles down quickly when held by his mother, reaching for a toy presented from either
side. His reflexes are normal.

1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies, consultations) would you
obtain? What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? How would you
monitor his condition and its treatment? What is the prognosis?A 20 month-old boy after a seizure.

Case 13
A 20 month-old boy is brought to the ED by his parents after a seizure. He awoke with a runny nose, and
had been pulling at his right ear in the afternoon. The mother had planned to bring her child to the
pediatrician the next morning. When she put the child down to sleep, he squealed, extended both arms
and legs, then shook for several minutes, during which his eyes rolled up. Immediately afterwards,
unable to awaken him, his parents brought him to the ED. En route, he began to awaken. In the ED, he
had a temperature of 38 C and a red, swollen right tympanic membrane. He cries vigorously while being
examined. His settles down quickly when held by his mother, reaching for a toy presented from either
side. His reflexes are normal.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies, consultations) would you
obtain? What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? How would you
monitor his condition and its treatment? What is the prognosis?

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