Convulsions with mild gastroenteritis

Yousuke Higuchi, Toshihide Kubo , Toshiharu Mitsuhashi , Naoko Nakamura , Ichiro Yokota , Osamu Komiyama , Isamu Kamimaki , Shigenori Yamamoto, Yasushi Uchida , Kyoko Watanabe, Hironori Yamashita, Shigeki Tanaka, Kosei Iguchi, Ryouji Ichimi , Shinichiro Miyagawa, Toshimitsu Takayanagi ,  Hiroshi Koga, Akinori Shukuya , Akiko Saito. Keizo Horibe.  Clinical Epidemiology and Treatment of Febrile and Afebrile Convulsions With Mild Gastroenteritis: A Multicenter Study.  Pediatric Neurology.  Article in Press.

Abstract

Background

We investigated features and responses to treatment in patients with febrile and afebrile convulsions with mild gastroenteritis and characterized convulsions with rotavirus and norovirus gastroenteritis.

Methods

We conducted a prospective, observational study to evaluate patients with febrile and afebrile convulsions with mild gastroenteritis who were hospitalized between November 2011 and March 2014 at 13 facilities in the National Hospital Organization. We classified the patients into two groups: presence or absence of fever. We investigated the background, clinical and laboratory characteristics, viral antigen in stool, and efficacy of anticonvulsant drugs.

Results

Of 126 patients enrolled in this study, 50 were febrile (Fc group) and 76 were afebrile (aFc group). A family history of febrile seizures was significantly more frequent in the Fc group than in the aFc group (28.0% vs 9.2%, P = 0.005). Clinical characteristics were similar between the rotavirus and norovirus groups, but fever was significantly more frequent in the rotavirus group (46.2% vs 8.3%, P < 0.001). Serum sodium levels were significantly negatively related to the number of seizures in the aFc group (β = −0.13; 95% confidence interval, −0.24, −0.03; P = 0.01). Carbamazepine was significantly more efficacious than diazepam suppositories in the aFc group (odds ratio = 49.3, 95% confidence interval, 2.35, 1037; P = 0.01).

Conclusion

Febrile convulsions with mild gastroenteritis show characteristics of both febrile seizures and convulsions with mild gastroenteritis. Carbamazepine is optimal for convulsions with mild gastroenteritis. Clinical features of convulsions with rotavirus and norovirus gastroenteritis are similar, except for fever. Serum sodium levels may play a major role in the onset of convulsions with mild gastroenteritis.

From the article

Serum sodium levels (range: 128 to 143 mmol/L) were low in both groups, and were significantly lower in the Fc group than in the aFc group ( P = 0.03). Serum aspartate aminotransferase (AST) and alanine transaminase (ALT) levels were significantly higher in the aFc group ( P = 0.008 and P = 0.02, respectively). Serum LDH levels were significantly higher in the Fc group than in the aFc group ( P = 0.02). The correlation coefficient between AST and LDH levels was 0.56 ( P < 0.001) in the Fc group and 0.28 ( P = 0.01) in the aFc group, whereas that between ALT and LDH levels was 0.45 ( P = 0.001) in the Fc group and 0.17 ( P = 0.14) in the aFc group. Comparison of laboratory data between the Fc and aFc groups is shown in Table S2 (see the supplemental files for additional information)…

Percentage Distribution of Gastroenteritis Virus Antigens in Stool

Virus Type	Febrile (n = 50)	Afebrile (n = 76)
Rotavirus	18 (36.0)	21 (27.6)
Norovirus	3 (6.0)	33 (43.4)
Adenovirus	1 (2.0)	5 (6.6)
Rotavirus and norovirus	2 (4.0)	0 (0.0)
Rotavirus, norovirus, and adenovirus	0 (0.0)	2 (2.6)
None	26 (52.0)	15 (19.7)

Data are shown as number (%)…

Mild hyponatremia was observed in the Fc and aFc groups, which were comparable with previous studies, and serum sodium levels were significantly lower in the Fc group than in the aFc group (although clinically insignificant).  However, there was a significant negative association between the number of seizures and serum sodium levels in the aFc group. Previous studies have reported that mean serum sodium levels are not significantly different in patients with febrile or afebrile seizures with mild gastroenteritis.  These results suggest that hyponatremia or rapid decline in serum sodium levels (but a mild degree of hyponatremia) may result in seizures. Elevated AST and ALT levels with rotavirus and norovirus gastroenteritis have been reported, but the mechanism is still not completely understood.  In our series, AST and ALT levels were significantly higher in the aFc group than in the Fc group, but the clinical significance is uncertain. The correlation between ALT and LDH levels was not significant in the aFc group. AST levels are abundantly expressed in several nonhepatic tissues, whereas ALT is found at low concentrations in tissues other than the liver (but not absolute specificity).  LDH is present in all tissues, where levels in the kidney are highest, followed by the heart, skeletal muscle, pancreas, spleen, liver, lung, and placenta.  Our results suggest that elevated AST and ALT levels may represent not only hepatic injury but also nonspecific tissue damage by inflammation, such as fever or gastroenteritis.