2025 – PAGE 406 – NEUROLOGY
BREAKTHROUGH SEIZURE
Don’t always blame the mom for breakthrough seizures! Kids can outgrow their seizure medication dose, so order drug levels for all breakthrough seizures.
STATUS EPILEPTICUS
Status epilepticus refers to continuous seizures, or multiple repeated seizures, lasting greater than 5 minutes in which the child does not return to his or her baseline afterwards. This is an emergency and can cause long-term brain damage.
(DOUBLE TAKE) TODD PARALYSIS (AKA TODD’S PARALYSIS)
If a child presents with focal motor weakness after a seizure, pick TODD PARALYSIS (AKA Todd’s Paralysis)!
PEARL: There is often NO HISTORY of a witnessed seizure, so have a high index of suspicion for this diagnosis in any child presenting with an acute onset of unilateral weakness of an extremity.
NAME ALERT: This is not TICK PARALYSIS.
(DOUBLE TAKE) TICK PARALYSIS: Tick paralysis can present with a child who has a clinical picture very similar to that of Guillain-Barre Syndrome (GBS). That means you’re looking for an acute ascending paralysis in which there are absent reflexes. It will likely be preceded by ataxia. It’s caused by a neurotoxin produced by ticks, and the solution is to remove the tick!
PEARL: If you are presented with a child who seems to have Guillain-Barre Syndrome (GBS), but they mention a trip, the woods, or the summertime, they are probably talking about this! Other KEY differentiating factors include the lack of fever, normal CSF, and a quicker progression of symptoms (hours – 2 days). Other confusing choices may be Botulism (DESCENDING paralysis) or PoliomyeLITIS (+CSF findings and possible viral syndrome).
ATAXIA AND RELATED CONDITIONS
ACUTE CEREBELLAR ATAXIA
Children with acute cerebellar ataxia present with trouble coordinating movement between the neck and the hip (truncal ataxia) at about 1–2 weeks after a viral syndrome. Patients can also have difficulty coordinating speech (dysarthria), horizontal nystagmus, and trouble walking. The viruses most commonly implicated are Varicella (VZV), Coxsackie virus, and Echovirus (possibly EBV too). The condition usually resolves in a few weeks to a few months and should be high on your differential for any child with an acute onset of ataxia. This is very common, usually very benign, and is very testable for the pediatrics exam.
(DOUBLE TAKE) ATAXIA TELANGIECTASIA
Ataxia telangiectasia is an autosomal recessive disorder involving defective repair of damage to DNA. Cerebellar ataxia is usually the first sign, noted around the time the child begins to walk. Visual motor disturbances, telangiectasias (especially on the sclera but can be elsewhere), immune deficiency, cognitive deficits and other neurological problems follow in the ensuing years. In ataxia telangiectasia, patients can have recurrent pneumonias or sinusitis + high AFP. The telangiectasias are flat, red networks of dilated capillaries. They blanch on pressure (diascopy), though this isn’t practical to demonstrate in the eye. Patients have worsening T-cell function later in life, but in childhood the symptoms are mainly neurologic. It is a combined immunodeficiency, since patients have reduced numbers of both T- and B- lymphocytes. There is an increased risk of malignancy in the 3rd decade of life.
PEARL: Remember that elevated AFP levels are also found in hepatocellular carcinomas as well as in pregnant women when the fetus has a neural tube defect.
PEARL: RECURRENT PNEUMONIAS are seen all over the exam. You will have to pick out other findings to help you narrow your differential.
MNEMONIC: Ataxia = Unsteady Gait = Imagine a homeless, drunk, and wheelchair-bound teen (neural tube defect) who frequently comes to your ED for recurrent pneumonias or sinusitis.