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.
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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