An 8-year-old boy is brought to the emergency department 45 minutes after falling out of bed. He had been asleep for about 10 minutes when his mother heard a thud and immediately ran to his room. She found him unconscious on the floor with a blue discoloration around his lips that resolved after a few seconds. The patient regained consciousness after a few minutes but seemed excessively sleepy. He has had no fever, vomiting, diarrhea, or change in appetite. The patient has no chronic medical conditions and takes no medication. He was drowsy but responsive on the drive to the hospital and was able to walk in unassisted. Vital signs are normal for age. The patient is now alert and interactive but does not remember anything about the event. Which of the following is the most likely diagnosis?

Question

An 8-year-old boy is brought to the emergency department 45 minutes after falling out of bed.  He had been asleep for about 10 minutes when his mother heard a thud and immediately ran to his room.  She found him unconscious on the floor with a blue discoloration around his lips that resolved after a few seconds.  The patient regained consciousness after a few minutes but seemed excessively sleepy.  He has had no fever, vomiting, diarrhea, or change in appetite.  The patient has no chronic medical conditions and takes no medication.  He was drowsy but responsive on the drive to the hospital and was able to walk in unassisted.  Vital signs are normal for age.  The patient is now alert and interactive but does not remember anything about the event.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d297_e791_bc81_6924b2f0088a_MD0003_00 This patient had sudden loss of consciousness (LOC) followed by a period of sleepiness and confusion, findings suggestive of a seizure. Seizures are classified as focal or generalized. Focal seizures arise from one cerebral hemisphere but can spread to the entire brain (ie, focal seizure with impaired awareness); generalized seizures involve both cerebral hemispheres from the onset. A first-time seizure can occur at any age and time, including during sleep; as seen in this patient, muscle stiffening during the initial tonic phase of a generalized tonic-clonic seizure can cause the patient to fall and have difficulty breathing (due to contraction of chest wall muscles), leading to perioral cyanosis. Tongue biting is common with clonic movements, and urinary incontinence can also occur. The entire episode may be unwitnessed and brief, lasting from a few seconds to minutes. After a seizure, patients often have a postictal state of sleepiness and confusion. This delayed return to baseline neurologic functioning can help differentiate seizure from other causes of sudden LOC. For instance, vasovagal syncope (the most common cause of syncope in children) is characterized by transient LOC that typically occurs after prolonged standing or a stressful experience and is followed by an immediate, spontaneous return to baseline mental status (Choice E). (Choice A) Breath-holding spells occur in children age 6 months to 5 years and present with either cyanosis or pallor (ie, pallid breath-holding spell) following physical or emotional distress. Although a period of confusion can follow a pallid breath-holding spell, this patient's age makes the diagnosis unlikely. (Choice B) Cardiogenic syncope results from decreased cardiac output in the setting of structural heart disease (eg, hypertrophic cardiomyopathy) or arrhythmia (eg, pre-excitation syndrome). The event typically occurs during exertion (rather than sleep) and is not followed by a period of drowsiness. (Choice D) Hypnagogic hallucinations, a feature of narcolepsy, occur while falling asleep and can be associated with a sensation of falling. Although they may cause a sudden, brief jerk, falling out of bed and a delayed return to baseline would not be seen. In addition, this patient has no history of other narcolepsy symptoms (eg, daytime sleepiness, cataplexy). Educational objective: Seizure should be considered in any patient with an episode of sudden loss of consciousness followed by a postictal state of sleepiness and confusion. Other common findings include perioral cyanosis, evidence of tongue biting, and urinary incontinence. References: Pediatric syncope: is detailed medical history the key point for differential diagnosis? (http://www.ncbi.nlm.nih.gov/pubmed/24759488) The evaluation and management of pediatric syncope. (http://www.ncbi.nlm.nih.gov/pubmed/26706050)

An 8-Year-Old Boy Is Brought to the Emergency Department 45