ABSTRACT
Acute encephalopathy with biphasic seizures and delayed diffusion changes (AESD) is an extremely rare syndrome outside Asia. AESD is diagnosed based on clinic-radiological correlation. Influenza or human herpesvirus 6 infection have been most commonly isolated in previously healthy children with AESD and there is possible correlation with genetic abnormalities such as mutations in the SCN1A gene. We report a 2 year old previously fit and well white female who presented febrile status epilepticus at day 3 of an upper respiratory tract infection with subsequent prolonged left facial palsy and left hemiparesis. Brain MRI on day 4 showed swelling and diffusion restriction of the right hippocampus, without any other focal abnormality or signs of ischaemia. On day 6 she presented clusters of focal left sided seizures, non-responding to treatment Levetiracetam and sodium valproate add on. Repeated brain MRI on 7 showed prolonged and diffuse diffusion restriction over the whole right hemisphere, which along with the characteristic clinical presentation led to the diagnosis of AESD. She received high dose IV steroids with taper over 6 weeks starting on day 9. The seizures stopped on day 10 but motor function recovery was slow. CSF analysis showed no signs of infection. Nasopharyngeal swab was positive for Bocavirus and she had positive antibodies for SARS-COV-2 with negative PCR. Genetic investigations were requested and are pending. This case illustrates the importance of repeated brain imaging in abrupt onset refractory seizures with abnormal neurological examination which can lead to early diagnosis and treatment. More studies are needed to investigate the correlation between SARs-COV-2 or Bocavirus and AESD.
ABSTRACT
Background The SARS-CoV2 pandemic and initial public health response led to significant changes in health service delivery, access and utilisation. The SARS-CoV2 illness burden in children and young people (CYP) is significantly lower than in adults. To inform effective child public health interventions we aimed to compare patterns of paediatric emergency department presentations. Objectives Describe the ED attendance pattern of CYP during COVID-19 compared to the same period in 2019. Methods Retrospective review of all attendances (0-18yrs) over the initial pandemic (02/03/20-03/05/20) compared to 2019. Outcome measures included demographics, number of attendances, source of referral, presenting complaint, discharge diagnosis and disposal. Descriptive statistics, with subgroup analysis by age/sex/ethnicity and pandemic time-periods (prelockdown, lockdown weeks 1-3 and lockdown weeks 4-6) were performed. Results 4417 attendances (57% illness;43% injuries) occurred between 02/03/20-03/05/20, compared to 8813 (57% illness;43% injuries), a reduction of 50%, maximal in lockdown week 2 (-73%). Presenting complaints 2529 (57%) attendances were illnesses and 1868 (43%) injuries, compared to 5005 (57%) and 3764 (43%) respectively in 2019. The top five illness complaints were breathing difficulty, fever, abdominal pain, diarrhoea & vomiting and rash, unchanged from 2019. Ranking of top 3 illness presentations changed across the pandemic weeks. Breathing difficulty dropped from 1st (300;25%) to 2nd (117;21%) to 3rd (59;11%);(p<0.001). Abdominal pain rose from 3rd pre-lockdown (87;7%) and lockdown weeks 1-3 (37;7%) to 2nd in weeks 4-6 (62;12%;p=0.004). Fever ranked 2nd (235;19%) pre-lockdown, 1st (134;24%) in week 1-3 and week 4-6 (94;18%;p=0.035). Triage category 88 (2%) attendances were triaged as a category 1 (CAT1) and 544 (12%) attendances as a category 2 (CAT2);this is compared to 146 (2%) and 1134 (13%) in 2019. There was no variation in CAT1 across pre-lockdown (2%), lockdown weeks 1-3 (2%) and lockdown weeks 4-6 (2%) and minimal variation in CAT2 (12%, 13% and 11% respectively across pandemic weeks), indicating no change in severity of presentations. Source of referral (SOR) 3065/4417 attendances (69%) were by self-referral, proportionally the same as in 2019 (6149/8813;70%). Emergency services/urgent care were the second most common SOR for 487 (11%) attendances, similar to 2019 (762/8813;9%). NHS111 referral ranked third (416/4417;8%) and GP ranked 4th (315/4417;7%). This was different to 2019, where GP referral ranked 3rd (755/8813;9%) and NHS111 ranked 4th (734/8813;8%). Disposal 708 (16%) attendances resulted in admission, 3647 (83%) were discharged, 61 (1%) did not wait (DNW) and 1 patient died during the pandemic period. This was compared to 1675 (19%) admissions, 6755 (77%) discharges, 383 (4%) who DNW and no deaths in 2019. Conclusions Despite a 50% reduction in attendances there was no significant change in proportions of illness/injury, acuity of illness, source of referral or disposal. Rank of illness presentations changed, with abdominal pain ranking second, and fever first, an important change which should prompt further research into causes. Clear public health messaging for CYP and collaborative guidance for primary care is required in this second wave to ensure CYP have access to appropriate emergency, routine and mental health services.