Child Suffers Seizures After Physicians Fail To Diagnose Encephalitis

This case involves a 9-year-old male patient who presented to the emergency room with reports of ongoing fever. His temperature on admission was 103 degrees. An acetaminophen protocol was administered several hours after admission, at which point the child’s oral temperature had reached 105 degrees. The patient was given a chest X-ray and urine screening, both of which were normal. The patient was then discharged with a diagnosis of febrile illness. The child’s parents were given instructions to administer additional acetaminophen and to follow up with the child’s pediatrician if his condition did not improve. The patient returned to the hospital 3 days later with a temperature of 104 degrees. An ibuprofen protocol was administered and the patient was discharged with a prescription for antibiotics. Several days later, the patient suffered a seizure at home, was taken to the hospital and was administered Ativan. The pediatric emergency medicine staff were unable to diagnose the origin of the fever before the patient suffered an additional seizure in the hospital. The patient remained in the PICU for over a month and required in-patient rehabilitation. He remained with cognitive impairment secondary to the seizure. The patient was eventually diagnosed with encephalitis, but the cause of his seizures was never determined.

Question(s) For Expert Witness

1. Please describe your experience in treating pediatric patients like the one described above.

Expert Witness Response E-005591

I have been practicing pediatric emergency medicine over the last 25 years. I frequently see, diagnose, and treat pediatric patients with fever, including patients with meningitis and encephalitis. In addition, I am a reviewer of the national guidelines on the assessment and management of children with fever, and I developed the fever guidelines for our institution. Pediatric fever is one of the most common complaints from patients presenting to the emergency department. One of the main diagnoses that emergency physicians need to rule out in every child presenting to the emergency department is life-threatening infections, such as meningitis or encephalitis. That could be done based on history and physical examination, but at times requires further testing, such as a lumbar puncture to evaluate the cerebral spinal fluid for infections (viral, bacterial or others). Appropriately assessing and managing children presenting with fever are a few of the most common problems encountered in the emergency room settings.