Post-Surgical Febrile Seizure and Vomiting
Radiology Cases in Pediatric Emergency Medicine
Volume 4, Case 10
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
     This is a 3-year old male presenting to the E.D. 
following a 5-minute generalized tonic-clonic seizure at 
home associated with a high fever.  He underwent a 
surgical procedure to excise a neck mass three days 
ago and was placed on cephalexin.  The operative 
report indicates that the neck mass is felt to be a 
calcified masseter muscle, however, the pathology 
report on the specimen excised is still pending.  He 
developed fever yesterday and was evaluated for a 
possible wound infection yesterday.  However, the 
wound appeared to be healing well, and his fever was 
attributed to a viral infection.  He vomited twice last 
night.  His fever was noted to be 38.9 degrees at home 
last night.  He was not given any antipyretics after he 
was put to bed.  He experienced a seizure in the 
morning at 7:30 a.m. and was brought to the E.D. by 
ambulance.  His appetite has been noted to be poor, 
and his parents also noted that he was complaining of 
right-sided abdominal pain.  He denies any 
headache or dysuria.  His parents have not noted any 
respiratory symptoms.  An acetaminophen suppository 
is administered by the nursing staff.
     Exam:  VS T39.7 (oral), P160, R22, BP 114/74, 
oxygen saturation 98% in room air.  He is alert and not 
toxic.  He is not irritable when observed from across the 
room.  He begins to cry when he is approached.  Head 
without evidence of trauma except for the surgical 
wound of his right jaw region.  The wound is healing 
well without signs of infection.  Eyes:  PERRL, EOMI, 
conjunctiva clear.  TM's normal.  Oral clear and moist.  
Neck supple.  No meningismus.  Heart regular without 
obvious murmurs.  Lungs clear.  He is not noted to be 
coughing.  Abdomen, soft, flat, bowel sounds active.  
He is crying a lot, but he appears to have some 
reproducible tenderness in his right lower quadrant.  No 
hernias.  Testes normal.  No obvious back 
tenderness.  He ambulates well and uses all his 
extremities well.  When asked to jump or cough, he is 
too apprehensive to cooperate.
     Laboratory studies:  CBC WBC 9,000, 14% bands, 
72% segs, 7% lymphs, 3% monos, 2% eos, 2% atypical 
lymphs.  Hgb 13.3, Hct 38.0, platelet count 398,000.  
Glucose 95 mg/dl.  Electrolytes 135/4.0/100/21.  UA SG 
1.035, 1+ ketones, otherwise negative.
     An abdominal series is obtained.

View abdominal series:  Flat (supine) view.

Upright view.

     Consider the differential diagnosis at this time in 
view of the febrile seizure.  Is appendicitis a possibility?  
Although anything is possible, the diagnosis of 
appendicitis is not immediately obvious, but it is a 
possibility.  While localization of tenderness to the right 
lower quadrant is a sign highly predictive of 
appendicitis, this is not easy to determine in very young 
children.  The tenderness may be poorly localized or its 
localization may be deceiving.  A poorly cooperative 
child is difficult to examine, but most children with 
appendicitis prefer to lie still since crying and moving 
about result in more pain.  Our patient's signs and 
symptoms suggestive of appendicitis include anorexia, 
fever, vomiting, and right lower quadrant abdominal 
tenderness.  Signs not consistent with appendicitis 
include a crying and moving child and a normal gait.  A 
leukocyte count of 9,000 is not very high (this does not 
necessarily rule out appendicitis).
     When viewing the abdominal radiographs in a 
patient suspected of having appendicitis, the findings 
are often non-diagnostic unless they demonstrate free 
air or a fecolith.  Other radiographic signs suggesting 
appendicitis include thickening of the cecal wall, 
indistinct psoas shadows, scoliosis concave toward the 
right (patient splinting from RLQ pain), focal obliteration 
of the adjacent properitoneal fat stripe, presence of air 
in the appendix, sentinel loops in the right lower 
quadrant (dilated loops in the RLQ in an otherwise 
relatively gasless abdomen), ileus, etc.

     Are the radiographic findings helpful in this case?
     If so, what radiographic findings are evident?
     What diagnostic study, if any, should be ordered 

     This patient's abdominal radiographs demonstrate 
the presence of a fecolith.  There is a spherical 
calcification in the right lower quadrant.  It is easier to 
appreciate on the flat view.  It is difficult to appreciate 
on the upright view.  Turn the room lights down and 
adjust the contrast and brightness on your monitor

Close-up of the fecolith in the two views:

     The presence of a fecolith on an abdominal 
radiograph is highly predictive of appendicitis.  Thus, no 
other diagnostic studies are indicated at this point.  A 
surgeon should be consulted at this point.  It may be 
difficult to distinguish other RLQ circular densities from 
a fecolith.  A fecolith may display laminations 
(concentric circles) on magnification.  However, I have 
never been able to appreciate this myself.
     While we order many radiographs for possible 
appendicitis, these radiographs are rarely helpful.  In 
this case, a young child who is difficult to examine 
presents with a febrile seizure and non-specific 
symptoms.  His surgical procedure three days ago is 
distracting and totally unrelated to his current illness (a 
red herring).  It is not obbious that he has appendicitis 
and in such a case, the examiner may not scrutinize the 
radiographs as carefully as in other cases when the 
diagnosis of appendicitis seems more likely.  Avoid this 
pitfall.  If you're going to order an abdominal series, 
scrutinize it well.  Abdominal films are notorious for 
revealing an unsuspected serious diagnosis in an occult 

     Schnaufer L, Mahboubi S.  Abdominal Emergencies.  
In:  Fleisher GR, Ludwig S (eds).  Textbook of Pediatric 
Emergency Medicine, third edition.  Baltimore, William 
and Wilkins, 1993, pp. 1307-1313.
     Swischuk LE.  Emergency Radiology of the Acutely 
Ill or Injured Child, second edition.  Baltimore, Williams 
and Wilkins, 1986, pp 191-209.

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Web Page Author:
Loren Yamamoto, MD, MPH
Associate Professor of Pediatrics
University of Hawaii John A. Burns School of Medicine