An 8-year-old boy is brought to the office by his father due to concerns at school. His father says, "He was a great student last year, but his grades have slipped this year. His teacher says that he does not pay attention and often 'spaces out' during class. I think he just likes to daydream and gets distracted." At home, the father has noticed that the boy "blanks out" sometimes for a few seconds when he is in the middle of playing, and then he blinks his eyes a lot and quickly resumes his activity. The patient says that he feels sad about his grades. He has had no recent fever or sore throat, and there have been no recent stressors in his life. The patient has gastroesophageal reflux that is controlled with ranitidine. Vaccinations are up to date. He has a 10-year-old sister who is in good health. Vital signs are normal. On physical examination, the patient is alert and interactive. Heart rate is regular with normal S1 and S2. The abdomen is soft and nondistended. Cranial nerves II-XII are intact. Muscle tone and strength are normal in all extremities. There is a small bruise on his left knee but no rashes or pigmented skin lesions. Which of the following is the most accurate statement regarding management of this patient's condition?

Question

An 8-year-old boy is brought to the office by his father due to concerns at school.  His father says, "He was a great student last year, but his grades have slipped this year.  His teacher says that he does not pay attention and often 'spaces out' during class.  I think he just likes to daydream and gets distracted."  At home, the father has noticed that the boy "blanks out" sometimes for a few seconds when he is in the middle of playing, and then he blinks his eyes a lot and quickly resumes his activity.  The patient says that he feels sad about his grades.  He has had no recent fever or sore throat, and there have been no recent stressors in his life.  The patient has gastroesophageal reflux that is controlled with ranitidine.  Vaccinations are up to date.  He has a 10-year-old sister who is in good health.  Vital signs are normal.  On physical examination, the patient is alert and interactive.  Heart rate is regular with normal S1 and S2.  The abdomen is soft and nondistended.  Cranial nerves II-XII are intact.  Muscle tone and strength are normal in all extremities.  There is a small bruise on his left knee but no rashes or pigmented skin lesions.  Which of the following is the most accurate statement regarding management of this patient's condition?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c004_e7c7_8f63_81510541633f_MD0005_00 This patient presents with childhood absence epilepsy (CAE), a common seizure disorder of early school-aged children. Absence seizures typically start abruptly, are provoked by hyperventilation, occur many times a day, and last <20 seconds. Patients frequently describe classroom inattention, frequent "staring spells" interrupting play, eye fluttering, and automatisms (eg, oral tics). Comorbid psychiatric conditions are common, including attention deficit hyperactivity disorder, depression, and anxiety. Diagnosis is based on electroencephalography, which shows a characteristic ~3 Hz spike and wave discharge pattern. CAE is frequently well controlled with ethosuximide monotherapy. In contrast to their effects on other forms of epilepsy, certain common antiepileptics (eg, carbamazepine) can exacerbate CAE, and others (eg, phenytoin, phenobarbital) are ineffective. CAE often spontaneously remits by early puberty with no major long-term sequelae. When the patient has been seizure-free for 2 years, the antiepileptic medications frequently can be tapered. (Choice A) Cognitive behavioral therapy has been shown to reduce the frequency of psychogenic nonepileptic seizures, which are more common in patients with epilepsy with exacerbating psychosocial stressors. Patients with psychogenic nonepileptic seizures often have unusual motor activity (eg, pelvic thrusting, rolling from side to side, opisthotonus), which are not seen in this patient. (Choice B) Stimulant therapy is effective for inattentive symptoms accompanying attention deficit disorder, a common comorbidity in CAE. Stimulant medications carry a theoretical risk of decreasing the seizure threshold but can be used with caution in comorbid disease. This patient, however, ceases all activity with these spells, suggesting that he experiences seizures, not inattention. (Choices C and E) Periodic monitoring of transaminases is recommended for patients on valproic acid, given that it carries a risk of hepatotoxicity. Agranulocytosis has been reported with ethosuximide; however, hepatoxicity and leukocytosis have no such association. Periodic granulocyte count monitoring is recommended for patients on ethosuximide. Educational objective: Childhood absence epilepsy is characterized by brief lapses in consciousness that last <20 seconds and occur multiple times a day. Electroencephalography shows a pattern of ~3 Hz generalized spike and wave activity. Ethosuximide is the first-line treatment. References: Absence seizures in children. (http://www.ncbi.nlm.nih.gov/pubmed/24351614) Benign epilepsy in children. (http://www.ncbi.nlm.nih.gov/pubmed/21497276)

An 8-Year-Old Boy Is Brought to the Office by His