Fever with seizures

A previously healthy 13-month-old girl presented at a local hospital with altered consciousness, seizures, and a 3-day history of fever. She had received her MMR vaccination a month prior and had a febrile illness ten days before presentation. On admission, her pupils were equal and bilaterally reactive to light; she had no cranial nerve palsies, but she had decorticated posturing and a Glasgow Coma Scale of 5. She required intubation, intravenous antibiotics, acyclovir, fluid boluses, and levetiracetam and was transferred to our Critical Care Unit. She remained ventilated for 4 days and developed hypertension, needing treatment. Due to episodes of episodic right-hand twitching, she had an EEG, which showed diffuse slow-wave background activity, in keeping with encephalopathy, but no epileptiform discharges. Nasopharyngeal (NPA) PCR was initially positive for SARS-CoV-2 and adenovirus, but only SARS-CoV-2 remained positive for the following 2 weeks. CSF analysis showed 10/mm3 white cells, being negative for SARS-CoV-2 RNA. CT head showed bi-hemispheric white matter hypodensities, posteriorly more than anteriorly. The subsequent MRI of the brain, on day 4 of admission, showed bilateral widespread white matter high-signal abnormalities, including the splenium of the corpus callosum with associated diffusion restriction and high signal in the thalami and pons. Spinal MRI was normal. However, she was treated clinically with steroids She continued to respond well to the steroid therapy. She initially presented drowsy, with poor central tone and unsafe swallow. Progressively, she became increasingly alert, and her tone improved. On discharge, she was able to sit, took a few steps, clapped with songs, recognised voices, and was able to eat and drink normally. However, she was not fixing and following consistently, and after a normal ophthalmic examination, it was presumed that she had cortical visual impairment. Four months following her presentation, her vision had improved, she was walking, and she showed good developmental progress, with no further seizures on levetiracetam.