Frontal Lobe Epilepsy with

Global Delay Development

and Severe
Bronchopneumonia in A
Child
Oleh : Yenny Susanto
Pembimbing:
dr. Hj. Nurhayati Masloman, Sp.A(K)
1
TIMELINE

2
 Patient’s Record
PATIENT’S IDENTITY
Register number : 49.XX.XX
Patient’s name : MAG
Date of birth : 13th March, 2017
Age : 5 month
Gender : Male
Nationality : Indonesia
Date of admission : 15th August
2017
3
 Parent’s Identity
FATHER MOTHER
Name : LG AM
Age : 28 years 25 years
Occupation : Private employee Nurse
Education : College degree Diploma degree

4
 History
(alloanamnesis on the parent’s and medical record)

Chief complaint: shortness

of breath
Accompanied by bluish discoloration,
cough, fever

Seizure : since 3 weeks, 3x/day, tonic

5
Pedigree

6
PERSONAL/ SOCIAL HISTORY

Antena • Regular ANC, TT 2x

• Head presentation, cried
tal immediately, aterm, 2800
grams
Postnat • Unremarkable
• Breastfed, routinely visit
al health care facility
7
PERSONAL/ SOCIAL HISTORY

Developme • Not able to lift up his

ntal head
milestones • Able to smile and babble

• BCG, polio2, DPT2, Hib2,

Vaccination Hep B2
• Third Pentabio postponed
8
 History of Basic Needs

Physic- • Adequate food, clothing,

biomedic shelter
Emotional • Sufficient affection
needs
Mental • Play with family
stimulation members
9
 SOCIO-ECONOMIC AND
ENVIRONMENT CONDITIONS
• 2nd class government health insurance
• 4 rooms, 7 adults, 2 children
• Restroom inside the house
• Government electrical company
• Local state water company
• Garbage was collected & burned

10
 PATIENT’S HOSPITAL
ADMISSION SUMMARY
Prior to initial observation (15th - 17th
August 2017)
BW : 6.2 kg, BL : Leucocyte :
63cm 10.470/mm3
Shortness of
RR: 78x/m, S: CRP : 12
breath, fever,
cough 38.5oC Chest radiograph :
Thorax: infiltrate on both
Seizure
retractions, ronchi lungs
(+) EEG : abnormal 11
 Diagnosis :
Frontal Lobe Epilepsy
with Global Delay Development
and Severe Bronchopneumonia
Therapy :
• cefotaxime and gentamycine injection,
• dexamethasone injection,
• valproic acid 25 mg/kg/day,
• paracetamol
• diazepam suppositoria prn
12
 PHYSICAL EXAMINATION
(18th August 2017)
General condition : looked ill, compos mentis
Antropometric status
Body weight : 6.2 kg Body length : 63 cm
Based on the WHO Z-score weight for length curve : Between -1 and -2 SD
 Nutritional status: good nutritional status
General condition : Looked ill Consciousness : Compos mentis
Pulse rate : 95 times/minutes, regularly
Respiratory rate : 28 times/minutes
Temperature : 37°C
13
 Head and neck
Head : LK 41 cm  normocephaly, black colour hair, not easily pulled out,
head lag (+)
Eyes : Conjunctiva was not anemic, sclera was not icteric. Pupil was round,
isocoria, 3-3 mm, light reflex normal
Ears : Clear meatus acusticus externus, normal ear drums, no discharge
Nose : There was no discharge and no nasal flaring.
Mouth : There was no cyanosis, tonsils T1/T1 without inflammatory sign,
pharynx no inflammatory sign
Neck : There was no lymph node enlargement, trachea position was in the
midline, no thyroid enlargement
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Head circumference

Normocepha
l

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 Thorax
Heart : within normal limit
Lung :
- Inspection : symmetrical respiration
movement on the both side hemithorax,
with subcostal retractions
- Palpation : equal vocal fremitus right = left
- Percussion : sonor percussion right = left

-Auscultation : rough bronchovesicular breath

sound, rales +/+, wheezing -/- 16
 Abdomen and extremities
• Abdomen :
• - Inspection : flat
• - Palpation : no tenderness, no pain on palpation, no guarding, no enlargement of the
liver and spleen
• - Percussion : tympanic percussion, no sign of ascites
• - Auscultation : normal bowel sound
• Extremities : warm, capillary refill time (CRT) ≤2”, no deformity, no cyanosis, normal muscle
tone, physiological reflexes normal, no pathological reflexes, edema -/-
• Genitalia : male, no abnormality
• Lymph node : no lymph node enlargement
• Skin : no petechiae, no cyanosis
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 Diagnosis

• Frontal lobe epilepsy (G40.209)

• Global delay development
(R62.50)
• Severe bronchopneumonia
(J18.0)
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 List of problems

Diagnostic
• Waiting for result of blood culture and
susceptibility test.

Manageme • Empirical antibiotic for bronchopneumonia

should be adjusted with blood culture and
nt
Monitorin
susceptibility test result.

• Monitoring of side effects of the medications.

g
Prognosis
• Prognosis of the bronchopneumonia.
• Prognosis of frontal lobe epilepsy.

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 MANAGEMENT PLANS
• O2 1-2 L/m
• IVFD KAEN 4B (maintenance rate according to Holliday Segar) = 15 micro
drops per minute
• Cefotaxime injection 3 x 300 mg iv
• Gentamycine injection 1 x 30 mg iv
• Dexamethasone injection 3 x 1 mg iv
• Paracetamol syrup 3 x cth ½
• Depakene syrup 2 x 1.5 mL (dosage 25 mg/kg/day)
• Stesolid suppositoria 5 mg prn seizure
20
 Pediatric nutritional assessment
and care
Determination of nutritional status
Body weight : 6.2 kg Body length : 64 cm  Nutritional status: good
nutritional status
Nutritional requirement : based on Recommended Daily Allowance (RDA)
Calories = 108 x 6.2 = 669.6 kcal/day
Protein = 2.2 x 6.2 = 13.64 gram/day
Fluid = maintenance rate according to Holiday Segar = 620 ml/day
Administration route : parenteral and enteral
Monitoring and evaluation : tolerance, adverse reaction, body weight
monitoring. 21
 Monitoring plans

• General state, vital signs, anthropometry.

• Monitoring antibiotic response to
bronchopneumonia
• Side effects administration on given
medications, antiepileptic drugs in particular.
• Nutritional monitoring
22
 Education Plan
• Describes the illnesses of the patient: causes, treatment,
prognosis, complications and treatment plans.
• Educate the family members about importance of family
support for patient recovery.
• Educate the impact on the child's social life, and family
economic situation because of long-term treatment

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 19th August 2017
(Observation day - 2, 5th day
P : of hospitalization)
IVFD KAEN 4B (maintenance
S : Fever (-), seizure (+) twice, the
seizure was described as left hand and
left feet was lifted up slowly, intake (+)
O : General condition : look sick
Conciousness : compos mentis
Vital sign : HR : 108 x/m, regular
RR : 38 x/m S : 36.4°C
Thorax : Symmetrical chest expansion,
no retractions
A : Bronchopneumonia (J18.0) +
Frontal lobe epilepsy (G40.209) +
Global delay development (R62.50)
rate according to Holliday Segar)
= 8 micro drops per minute
Cefotaxime injection 3 x 300 mg iv
(4)
Gentamycine injection 1 x 30 mg iv
(4)
Dexamethasone injection 3 x 1 mg
iv (4)
Paracetamol syrup 3 x cth ½
Depakene syrup 2 x 1.5 mL
(dosage 25 mg/kg/day)
Stesolid suppositoria 5 mg prn
seizure
Monitoring : clinical symptoms,
vital signs. 24
Nutritional care : RDA
Plan: wait for blood culture
 20th – 22nd August 2017
Consultation to Child Development
(Observation day 3 – 5, 6th – 8thPday
Division (23rd August 2017)
IVFD of hospitalization)
KAEN 4B (maintenance
rate according to Holliday Segar)
Developmental delay :
= 8 micro drops per minute
Personal social : according to 2
Smonths
: Fever (-), seizure (+) twice, the Cefotaxime injection 3 x 300 mg iv
seizure was described as left (5-7)
Language : according to hand
4 and
left feet was lifted up slowly, intake (+) Gentamycine injection 1 x 30 mg iv
months
(5-7)
OFine
: General condition :: look
motoric/adaptive sickyet
had not
Dexamethasone injection 3 x 1 mg
developed
Conciousness : compos mentis iv (5)
HRGross
: 94motor
x/m RR : 30 : had
x/mnotSyet: 36.4°C Paracetamol syrup 3 x cth ½ prn
developed
Thorax : Symmetrical chest expansion, Depakene syrup 2 x 1.5 mL
Suggestion :
no retractions (dosage 25 mg/kg/day)
TORCH tests
: Bronchopneumonia (J18.0) +
ARehabilitation Stesolid suppositoria 5 mg prn
seizure
Frontal lobe epilepsy
Blood culture: (G40.209)
No bacterial growth+
Monitoring : clinical symptoms,
Global delay development (R62.50)
vital signs. 25
Nutritional care : RDA
Plan: wait for blood culture
 23rd – 25th August 2017
(Observation day 6 – 8, 9th – 11th day of hospitalization)

S : Fever (-), seizure (+) once, the Cefotaxime injection 3 x 300 mg iv

Laboratory
seizure result
was described as left hand and (8-10)
leftHemoglobine:
feet was lifted12.3
upg/dL
slowly, intake (+) Gentamycine injection 1 x 30 mg
O :Trombocyte
General condition : look sick iv (8-10)
: 405.000/mm3
Conciousness Paracetamol syrup 3 x cth ½ prn
Leucocyte :: compos
10.300/mmmentis
3
HR : 100 x/m RR : 32 x/m S : 37°C Depakene syrup 2 x 1.5 mL
Thorax
CRP : Symmetrical
: <6 chest expansion, (dosage 25 mg/kg/day)
no retractions Stesolid suppositoria 5 mg prn
seizure
A : Bronchopneumonia (J18.0) +
Monitoring : clinical symptoms,
Frontal lobe epilepsy (G40.209) +
Global delay development (R62.50) vital signs.
Nutritional care : RDA 26
 4th October 2017
(Observation on outpatient clinic)
Denver II test : Depakene syrup 2 x 2
S : Fever (-), seizure (+) 2 – 5 times per
Personal
day, shorter social
duration,: accompanied
according to with
mL (dosage 25
2 months
crying. The patient was then able to mg/kg/day)
Language
move aside to :prone
according toand
position, 4 lift up
his head to 45o
months Monitoring : clinical
OFine
: General condition : look sick
motoric/adaptive :
Conciousness : compos mentis
symptoms.
according to 2 months Nutritional care :
HR : 100 x/m RR : 32 x/m S : 37°C
Gross motor : according to 2
Thorax : Symmetrical chest expansion, RDA
months
no retractions
A : Frontal lobe epilepsy (G40.209) +
Global delay development (R62.50) 27
 Prognosis

• Ad vitam : bonam
• Ad functionam : dubia ad malam
• Ad sanationam : dubia ad malam

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30
 DISCUSSION

EPILEPS Most frequent chronic neurologic

Y condition  0.5% - 1%
Frontal lobe epilepsy (FLE)  2nd
most common epilepsy
Neuropsychology  not well defined

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 Frontal lobe epilepsy (FLE)
• Unilateral clonic seizures
• Tonic asymmetric seizures with preserved consciousness
• Hypermotor seizures
• Brief (30”- 2’)
• Begin with screaming, severe agitation, stiffening and
kicking, or bicycling movements of the legs.

32
 The Patient
• Recurring tonic seizure since 3 weeks  the left hand and
leg was stiff throughout the seizure episode and the right
extremities was flaccid
• Happened while asleep
• 3 times/day
• < 1 minute
• Fully alert between seizures
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 Electroencephalogram (EEG)
Recording on the sleep phase  2-3 Hz delta wave on the
background, high amplitude, symmetrical and reactive.
Spikes was often found on the independent bilateral
frontopolar area, the right area was more than the left
area, with 2-2.5 Hz high amplitude focal deceleration.
Conclusion : abnormal EEG, supporting a diagnosis of
frontal lobe epilepsy, possibly a symptomatic epilepsy

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 Diagnosis

• Frontal lobe epilepsy

 Treatment : valproic acid

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 Problem
• Seizure control
• Developmental delay  present in this patient :
• 5 mo  head lag (+)
• Delay of personal social and language development, and a
significant or almost no development on the fine and gross motor
development
 Continuous rehabilitation

36
 Discussion

Pneumo Greatest contributor to childhood mortality and

morbidity
nia Lower respiratory tract infection  fever,
respiratory symptoms, and evidence of
parenchymal involvement by either physical
examination or the presence of infiltrates on
chest radiography
Riskesdas 2013  decrease period prevalence :
1.8
Burden in North Sulawesi
37
 Clinical sign and symptoms

• Fever
• Cough All
• Increased work present in
of breathing this
• Chest patient
indrawing/cyan
osis
38
 Laboratory evaluation
• Leucocyte
This
• CRP patient :
• Procalcito Increased
nin CRP
39
Frontal Global
Lobe Delay
Epilepsy Developmen
t

Pneumoni
a
40
 Berg et al
Causes and risk of death in children followed from onset of
epilepsy and to contrast the risk of seizure-related death with
other common causes of death in the population

Seizure related

Mostly in young patient  non seizure related 

pneumonia
41
 Concern : The Development
Memory abilities in other childhood common epilepsy syndromes
(frontal lobe epilepsy (FLE), childhood absence epilepsy (CAE), and
benign epilepsy with centrotemporal spikes (BECTS)) and the influence
of epilepsy-related variables, in 90 children with epilepsy (each epilepsy
group consisted of 30 children), compared with 30 control children.
Children with FLE showed significant deficits in verbal
and visual memory. Type of epilepsy, earlier age at epilepsy onset,
and longer active duration of epilepsy were associated with memory
problems. This study indicates that children with FLE show greater risk
Lopes
of developing memory deficits than children et CAE
with al. Behavioural
or BECTSNeurol.
2014
(Level of evidence 2b, B 42

recommendation)
 Concern : The Development
Relationship between cortical brain morphology and cognitive
functioning in a cohort of children with FLE and healthy controls.
Thirty-four children and 41 healthy age-matched controls underwent
neuropsychological assessment and structural brain MRI. The group of
cognitively impaired children with FLE had significantly
smaller left temporal cortex volumes , specifically middle
temporal grey matter volume and entorhinal cortex thickness. These
findings might well explain the broad scale of cognitive domains
affected in children with FLE complicated by cognitive impairment and
highlight that FLE impacts on areas beyond the frontal lobe
Braakman. Acta Neurol Scan. 2014
(Level of evidence 2b, B 43
recommendation)
 Concern : The Development
Executive functioning deficits that might differentiate children with
frontal lobe epilepsy (FLE) from children with temporal lobe epilepsy
(TLE) 19 youth with intractable FLE and 47 youth with intractable TLE.
Participants completed the Wisconsin Card Sorting Test (WCST), verbal
fluency, Trail Making Test (Trails A and B), Digit Span Forward (DSF),
and Digit Span Backward (DSB). Overall, the results indicated that
youth with FLE had significantly greater difficulty with
concept formation compared to children with TLE. Both groups
performed significantly below the normative sample
Longo et levels &
al. Epilepsy onBehaviour.
attention
and working memory tasks. 2014
(Level of evidence 2b, B 44
recommendation)
 Concern : The Development
Cerebral network characteristics are associated with epilepsy and
cognitive comorbidity. 37 children with FLE and 41 healthy age
matched controls. Cognitive performance was determined by means of
a computerized visual searching task. FLE patients displayed a
higher modularity, implying that subnetworks are less
interconnected. Impaired cognition was associated with higher
modularity scores and abnormal modular organization of the brain,
which was mainly expressed as a decrease in long-range and an
increase in interhemispheric connectivity in patients.
Vaessen et al, Cerebral Cortex,
2013
(Level of evidence 2b, B 45
recommendation)
 Challenges

Epilepsy  seizure control

Minimize complication
Proper education to the
family
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