Lumbar puncture after febrile convulsion
Date First Published:
July 7, 2006
Last Updated:
July 19, 2006
Report by:
Claire Ives, Medical Student (Manchester University)
Search checked by:
Claire Ives, Manchester University
Three-Part Question:
In [children presenting to hospital with febrile convulsions] does [routine lumbar puncture] [detect unsuspected cases of meningitis]
Clinical Scenario:
An 11 month old child presented to the emergency department after just having a febrile convulsion. The child does not like to look at the lights in the department but otherwise appears well. You wonder whether this child should be investigated for meningitis, and whether a lumbar puncture is necessary.
Search Strategy:
OVID Medline <1966-June week 3 2006>
EMBASE < 1980 to 2006 week 26>
CINAHL <1982 to June week 5 2006>
EMBASE < 1980 to 2006 week 26>
CINAHL <1982 to June week 5 2006>
Search Details:
Paediatric filter applied
([lumbar puncture.mp. OR exp. Lumbar Puncture/ OR spinal puncture.mp. OR spinal tap.mp. OR dural puncture.mp. OR dural tap .mp.]) AND (febrile convulsion.mp. OR exp Febrile convulsion/ OR febrile fit.mp. OR fit.mp. OR febrile seizure.mp. OR pyrexia.mp. OR exp Fever/) AND (bacterial meningitis.mp. OR exp Bacterial Meningitis/ OR exp BACTERIAL MENINGITIS OR meningitis.mp. OR exp VIRUS MENINGITIS/ OR exp MENINGITIS/ OR viral meningitis.mp. OR meningitis,listeria.mp. OR meningitis, meningococcal.mp. OR meningitis, haemophilus.mp. OR meningitis, pneumococcal.mp.) Limit to (human and english language)
([lumbar puncture.mp. OR exp. Lumbar Puncture/ OR spinal puncture.mp. OR spinal tap.mp. OR dural puncture.mp. OR dural tap .mp.]) AND (febrile convulsion.mp. OR exp Febrile convulsion/ OR febrile fit.mp. OR fit.mp. OR febrile seizure.mp. OR pyrexia.mp. OR exp Fever/) AND (bacterial meningitis.mp. OR exp Bacterial Meningitis/ OR exp BACTERIAL MENINGITIS OR meningitis.mp. OR exp VIRUS MENINGITIS/ OR exp MENINGITIS/ OR viral meningitis.mp. OR meningitis,listeria.mp. OR meningitis, meningococcal.mp. OR meningitis, haemophilus.mp. OR meningitis, pneumococcal.mp.) Limit to (human and english language)
Outcome:
Medline: 44 papers found
EMBASE: 21 papers found
CINAHL: 6 papers found
Cochrane: 0 relevant papers found
When febrile seizures etc not included in search:
Medline: 523 papers found
EMBASE: 286 papers found
CINAHL: 6 papers found
Cochrane: 0 relevant papers found
6 relevant papers found, 4 from medline, 1 from EMBASE and 1 from references from
EMBASE: 21 papers found
CINAHL: 6 papers found
Cochrane: 0 relevant papers found
When febrile seizures etc not included in search:
Medline: 523 papers found
EMBASE: 286 papers found
CINAHL: 6 papers found
Cochrane: 0 relevant papers found
6 relevant papers found, 4 from medline, 1 from EMBASE and 1 from references from
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Convulsions with fever as a presenting feature of bacterial meningitis among preschool children in developing countries. Akpede, G.O. and Sykes, R.M. 1992 Nigeria | 522 infants between 1month and 6yrs presenting to emergency dept between Oct 1988 and Oct 1989. | Cohort and mini case study | Multiple seizures p< 0.05 and focal seizures p<0./001 more freq in children with meningitis | 22 | Study only on children in developing country with higher incidence of bacterial meningits |
| Number of children with meningitis | 6 | ||||
| Number who had meningitis but lacked meningeal signs | |||||
| Analysis of the results of routine lumbar puncture after a first fevrile convulsion in Hofuf, Al-Hassa, Saudi Arabia. Laditan, A.A.O. 1995 Saudi Arabia | 95 children presenting with their first febrile convulsion between July 1993 and June 1994. aged 6 months to 6 years | Retrospective cohort | Number who had LP | 95 | No tests for statistical significance carried out. |
| Number of children whose CSF analysis revealed meningitis | 6 | ||||
| Number of children who were diagnosed with meningitis without having meingeal signs | 6/95 = 6.3% of LP yield for meningitis | ||||
| Number of complex febrile convulsion cases | 8 | ||||
| Number with meningitis | 01-Aug | ||||
| Number of simple febrile convulsion cases | 87 | ||||
| Number with meningitis | May-87 | ||||
| Lumbar puncture following febrile convulsion Carrol, W. & Brookfield, D 2002 UK | 15 papers | Systematic review | Risk of bacterial meningitis in absence of other signs | Extremely small less than 1 in 200. | Search strategy and outcome not documented. Some of articles in review of low grade evidence. |
| The role of lumbar puncture in children with suspected central nervous system infection. Kneen, R. Solomon, T. & Appleton, R. 2002 UK | 52 children with unsuspected CNS infection 43 with suspected meningococcal septicaemia. Children 9 days to 16 years old. |
Retrospective cohort | Number of children who had LP | 25/47 (53%) | Doesn't mention if meningeal signs present. |
| % CSF abnormal | 7/25 (28%) | ||||
| CSF bacterial culture positive | 03-Jul | ||||
| Number of patients CSF excluded bacterial meningitis. | 15/25 | ||||
| Routine lumbar Puncture in children with febrile seizures in Ghana should it continue? Owusus-Ofori, A. Agbenyego, T. Amsong, D. & Scheld, W.M. 2004 Ghana | Children 3 months to 15 years hospitalised at teaching hospital; in Kumasi Ghana. 608 admissions 186 pts had LP |
Retrospective cohort | Routine lumbar punctures | Positive yield of 10.2% for bacterial meningitis | |
| Meningitis is a common cause of convulsive status epilepticus with fever. Chin, R.F.M. Neville, B.G.R. & Scott, R.C. 2005 UK | Children between 29 days and 15 years with convulsive status epilepticus with fever. | Retrospective cohort study | Number of children with CSE with fever | 49% (24/49) | Small sample size Says 49 incident cases 44 notified by telephone hotline, 29 notified by surveillance, 25 notified by both-figures don't add up. Not all children had CSF sample taken No details given on how the children were chosen to have CSF sampling done. |
| Number of children above who had LP | 8 children | ||||
| Number with acute bacterial meningitis | 4 children (16.7%, 95% CI 15%-18%) | ||||
| Number of above children who had meningitis and signs of meningism. | 0 children |
Author Commentary:
Meningitis is an important cause of convulsions with fever and the usual signs of meningitis are often absent in such children, especially children younger than 12 months. The lack of clinical experience should not justify a lumbar puncture whilst on the other hand we need not to avoid necessary lumbar punctures. Prolonged febrile seizures (>15 minutes) are more likely to be associated with meningitis and therefore require a lumbar puncture6. In contrast Laditan2 concluded that the type of febrile convulsion should not serve as a guideline for LP but no statistical tests were carried out.
Bottom Line:
Meningitis can present with febrile convulsions and no matter what the clinical expertise cannot always be excluded on clinical grounds. An experience paediatrician may be able to distinguish between acute bacterial meningitis and other diagnoses but it is generally difficult to exclude meningitis without a lumbar puncture. It must be remembered that a previously normal lumbar puncture does not rule out bacterial meningitis.
References:
- Akpede, G.O. and Sykes, R.M.. Convulsions with fever as a presenting feature of bacterial meningitis among preschool children in developing countries.
- Laditan, A.A.O.. Analysis of the results of routine lumbar puncture after a first fevrile convulsion in Hofuf, Al-Hassa, Saudi Arabia.
- Carrol, W. & Brookfield, D. Lumbar puncture following febrile convulsion
- Kneen, R. Solomon, T. & Appleton, R.. The role of lumbar puncture in children with suspected central nervous system infection.
- Owusus-Ofori, A. Agbenyego, T. Amsong, D. & Scheld, W.M.. Routine lumbar Puncture in children with febrile seizures in Ghana should it continue?
- Chin, R.F.M. Neville, B.G.R. & Scott, R.C.. Meningitis is a common cause of convulsive status epilepticus with fever.