ABSTRACT
Case Presentation ................................................................................................... 141 Differential Diagnosis/Diagnostic Approach ........................................................ 141 Treatment ............................................................................................................... 142 Outcome ................................................................................................................. 143 Clinical Pearls ........................................................................................................ 144 Suggested Reading ................................................................................................. 144
This case involves refractory status epilepticus (RSE), which occurs when seizure activity persists despite adequate therapy. In children, cases of RSE not responding to rst-line therapy usually occur secondary to an acute symptomatic SE or related to an underlying progressive neurological disorder. Psychogenic seizures (or nonepileptic seizures) must also be considered when seizures persist despite treatment, but are very unusual in the younger child. Unusual motor movements, an “on/off”
A 10-year-old boy with a several-day history of fever, malaise, diarrhea, and emesis developed convulsive status epilepticus (CSE) requiring diazepam, phenobarbital, and phenytoin. Cranial computed tomography (CT) was unremarkable, and cerebrospinal uid (CSF) contained six white blood cells/mm3 (95% lymphocytes, 5% monocytes), with normal sugar and protein. Electroencephalogram (EEG) revealed diffuse slowing with occasional temporal spikes. He continued to have frequent seizures described as sudden staring episodes with head and eye deviation to the left, associated with cyanosis. He was intubated and transferred to the ICU where he was treated with a pentobarbital infusion. Pentobarbital was weaned 2 days later, but he then had a recurrence of his seizure. Sodium thiopental was given, followed by midazolam. When the seizures persisted, high-dose phenobarbital was used.
