Pediatric Status Epilepticus Differential Diagnoses

Updated: Jun 15, 2023
  • Author: Marvin H Braun, MD, PhD; Chief Editor: Dale W Steele, MD, MS  more...
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Diagnostic Considerations

Always consider the possibility of infections in pediatric patients presenting with convulsive status epilepticus (CSE). Sources of infection often, but not always, are obvious (eg, otitis media, pneumonia). Treat these infections appropriately because they contribute to lowering the seizure threshold in predisposed patients.

Infections can be the precipitating factor for both CSE and nonconvulsive status epilepticus (NCSE). Patients with CNS infections and mental status changes should not be assumed to have infection-related neurologic dysfunction before EEG findings rule out NCSE.

Early initiation of broad-spectrum antibiotics and acyclovir for suspected bacterial and viral (eg., HSV) CNS infections is appropriate therapy and should not be delayed while awaiting laboratory results. 

Consider catscratch, particularly in a school-aged child with a cat or kitten at home who presents with a history of unexplained mental status changes, status epilepticus (SE) of unknown etiology, prolonged seizures, or persistent fatigue. Catscratch fever is an infection acquired from cats (often from kittens) infected with Bartonella henselae via the cat flea. Although the disease may be transmitted by any close contact with a cat, scratches or bites cause 75% of cases.

Psychogenic seizures

Occasionally, nonepileptic seizures can be confused with CSE. They may occur in patients with a previous diagnosis of epilepsy. [42]

Patients with nonepileptic seizures can reproduce an outward clinical seizure pattern as a manifestation of an unresolved psychological conflict (psychogenic seizure), or the seizure may be a manifestation of malingering, providing the patient with a clear secondary gain. Psychogenic seizures occur less commonly in younger children than in adolescents. Symptoms of true psychogenic seizures resemble conversion symptoms.

In many cases, details of the presentation can help differentiate nonepileptic seizures from GTCSE. Features suggesting nonepileptic seizures include the following:

  • No loss of consciousness in the presence of bilateral movements

  • Asynchronous, side-to-side, and out-of-phase movements

  • Pelvic thrusting

  • Inconsistency of movement patterns and waxing and waning patterns

  • Persistent eye closure

  • Crying during the seizure

On the other hand, no loss of consciousness in the presence of bilateral movements, pelvic thrusting, and asynchronous and thrashing movements can also be part of frontal lobe seizures, which may lead to SE in some cases. Only careful observation of the patient (eg, video) with simultaneous EEG (ie, EEG video monitoring) allows the physician to differentiate between sustained nonepileptic seizures and GTCSE.

Differential Diagnoses