Future physician Sophie Samson, Dr. Kristen Bastug, and Dr. Beth Thielen discuss a case of a 7 year old girl who presented with new onset seizure, headache, and fever in Minnesota.

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Febrile is produced with support from the Infectious Diseases Society of America (IDSA)

Hi everyone, welcome to Febrile, a cultured podcast about

all things infectious disease.

We use consult questions to dive into ID clinical reasoning, diagnostics,

and antimicrobial management.

I'm Sara Dong, your host and a MedPeds ID doc.

First, I did just want to announce some wonderful news.

Febrile is now partnering with IDSA, who will be helping to produce

and expand the podcast platform.

So, super excited to continue to share ID knowledge with you and

excitement about the field of ID.

So I, of course, would love to just add a plug that I would always love

to hear from you, especially if you want to join an episode of Febrile.

Febrile really likes to highlight trainees and junior faculty in particular.

So if you would like to come on as a representative for your fellowship

program, or as an individual, I would love to welcome you to the show

for an episode, just let me know.

All right.

So today we have a great multi level learner team from

the University of Minnesota.

Let's meet them.

First up, we have Sophie Samson.

Sophie is currently a third year medical student at the University

of Minnesota Medical School.

She plans to train in pediatrics and has a particular interest

in pediatric ID and neurology.

Hi, my name is Sophie, and I'm happy to be here.

Next, we have Dr.

Kristen Bastug.

Kristen is a pediatric ID fellow from the University of Minnesota.

She is interested in the intersection of ID, global child health, climate

change, and environmental health.

Hi, this is Kristen.

Excited to be doing this.

And last but not least, we have Dr.

Beth Thielen.

Beth is an adult and pediatric ID physician scientist at

the University of Minnesota.

She was previously on episode number 19, Finding a Needle in a Haystack from 2021.

She currently leads a lab that is particularly interested in understanding

the factors that influence the severity of respiratory viral infections.

In addition to that, she has clinical interest in the care of immunocompromised

patients, travel and tropical medicine, and clinical immunology.

Hi, this is Beth.

Happy to be back.

All right.

And as everyone's favorite cultured podcast, we would love

to hear a little piece of culture that brings you happiness.

Well, I am a pretty avid reader.

So one of my favorite books in the past year is called Cloud Cuckoo Land.

And it is, um, set in multiple different centuries with a cast of characters and

they're all intertwined in some way.

And it's kind of a, a book that's an ode to book lovers in

a way, so I really enjoyed that.

I love that.

So someone mentioned that on Febrile before and I bought it and it's

actually sitting like right off camera as my like next selection to read.

I love it.

I think I heard about it from one of the

Curbsiders podcasts, actually.

Yeah, it's good.

It means multiple people liked it.

Just another endorsement.

Well, that's great.

Um, I like to read as well, but I actually saw a really cool Netflix show recently.

Life on our planet.

Um, so it's a documentary style film with some CGI graphics.

Um, actually Morgan Freeman narrates it, but they go through some of the

really interesting geologic changes of our planet and then the ecosystem

changes that were part of it.

But I just really loved seeing the reimagined like graphic

representation of these weird animals that like hadn't quite evolved yet.

Um, I thought it was a lot of fun.

Very cool.

Well, one of my culture moments is that during the pandemic,

I took up a new hobby, which was learning to play the accordion.

Just a little bit of a realization of a lifelong dream.

And I play in an accordion group, and we had an opportunity for our group

to travel together to eastern Italy to a small town called Castelfidardo,

which is home of both the Guinness Book of World Records world largest

accordion, which I was able to play, um, and we were able to tour an accordion

factory, which is a kind of ground zero for the manufacturer of accordions.

And so, uh, that is, that is the, my, my piece of culture for today.

That is amazing.

I love it so much.

Awesome.

Well, I will hand it over to Sophie to get us started.

Yeah.

So I will start by telling you all a little bit about our patient..

So, our patient is a seven year old girl who presented to the ED a few days before

with an acute onset seizure, headache, fever, and largely intact cognition.

On the morning of admission, she experienced a right

sided temporal headache.

She then developed abdominal pain with one episode of emesis.

She laid down and was found drooling and chewing with the right side of her mouth.

Her eyes were open, but not focused, and she developed left sided, circular

arm movements with associated urinary incontinence and tongue biting.

She was not interactive, and the episode lasted about one hour, terminating

with benzodiazepine given by EMS.

In the ED, she had a low grade fever to 104 degrees Fahrenheit, and initial

workup showed mild leukocytosis, elevated absolute neutrophil count, normal CMP

except for elevated phosphorus, and inflammatory markers within normal limits.

Infectious workup included a group A strep PCR, and a respiratory viral

panel, which were both negative.

Kristen, if you got a call based on this information, what are you

thinking about at this point in terms of differential diagnosis, and what are

you thinking about doing for management?

Yeah, thanks Sophie.

Um, so at this point, I think we need to keep our differential

pretty broad and consider first any etiologies that could be emergent.

When I hear her presentation, the symptoms of headache, emesis, and

focal seizure like activity raise my concern that there could be an

intracranial process occurring.

An intracranial hemorrhage could present this way, so I think we

need to consider some head imaging to rule out an acute bleed.

Her low grade fever and leukocytosis in the context of a seizure could

be due to the seizure itself.

However, I also want to consider infectious etiologies that could

have triggered the seizure.

At 7 years old, she is older than I would expect for someone having a febrile

seizure, so I would like to obtain some additional diagnostic studies

to help us investigate the etiology.

I would recommend a lumbar puncture so that we can obtain the cerebrospinal

fluid studies in order to evaluate further for an infectious cause.

I would send meningitis and encephalitis PCR panel in addition to the standard

cell count, glucose, protein, and aerobic culture on the CSF fluid.

The meningitis encephalitis panel doesn't test for all pathogens, but

it can test for several pathogens that are on my differential.

These would include Streptococcus pneumoniae and Herpes Simplex Virus.

Listeria and E.

coli are less common at her age of seven, but are still possible.

I would also consider Staphylococcus aureus, and if she is unvaccinated,

then Haemophilus influenzae would be a higher possibility.

Enterovirus is another one that comes to my mind, particularly in the summertime.

Thanks, Kristen.

That's a great, uh, kind of, discussion of your thought process.

Um, I did also wanna highlight that since we're discussing the possibility of both

head imaging and an LP in a patient whom we're, uh, ruling out bacterial meningitis

that we should, uh, think, you know, think about some of the literature around this.

And specifically I wanted to bring up a, uh, a, that the topic of CT and, and

lumbar puncture was recently discussed in the Choosing Wisely campaign, uh,

as something that we do for no reason.

And, uh, importantly I think they make this dis-, we make this distinction

between patients at high risk and at low risk for abnormal imaging.

And both the IDSA and ESCMID guidelines for bacterial meningitis do include

new seizures as a high risk feature.

So this is a patient definitely we'd be considering as high risk.

So with what we know at this time, would you recommend

empiric antibiotic treatment?

I think that in order to help me answer that, it would be

really helpful to have a, an updated understanding of her neurologic status.

Because in a patient who's minimally responsive, I would have a lower

threshold to start antibiotics and even acyclovir as soon as possible.

If her symptoms have resolved and she is stable, then I think it's reasonable

to first obtain the lumbar puncture promptly and then start the empiric

antibiotic therapy with, um, I would choose ceftriaxone and vancomycin for her.

Given that the meningitis encephalitis panel will result fairly quickly,

typically within a few hours, if her clinical status is stable,

then I would not start empiric acyclovir at this time for her.

Finally, when considering the differential diagnosis for a seizure, we should

also be thinking about alternative causes in case the patient doesn't

respond to treatment as we expect.

A focal seizure could be caused by a focal brain lesion, such as a brain tumor, which

is another reason I favor pursuing head imaging as part of the initial workup.

Other possibilities that are less likely at this time include autoimmune

etiologies, such as acute disseminated encephalomyelitis, toxic substance

ingestion, or a traumatic injury.

A lumbar puncture was performed due to persistent headache

that migrated to the back of her head and neck and was notable for CSF neutrophil

predominant pleocytosis, 42 nucleated cells with the normal range being

between 0 to 5 cells per microliter, and normal glucose and protein levels,

and a meningitis encephalitis panel, and aerobic CSF cultures that are in process.

MRI was performed later that day and revealed multiple

bilateral T2 hyperintensities.

MRA showed no vascular lesions.

After the initial LP was performed, she was started on ceftriaxone, 100 mg

per kg per day, divided every 12 hours.

She had a clinical seizure captured on EEG lasting 90 seconds, and she was

subsequently started on levetiracetam.

She then spiked two discrete high fevers up to 104.

2 degrees Fahrenheit, prompting a formal pediatric infectious disease consultation.

Cultures are negative to date after 48 hours in the hospital.

Kristen, as the ID fellow on the team with this new information, how

does this change your differential?

Yeah, I'm glad we got the lumbar puncture because those results will

really help us adjust our differential.

So, her normal CSF glucose, normal protein, and mild to moderately elevated

white blood cell count suggest to me that this is an aseptic meningitis,

which would include viral processes.

The MRI findings of multiple T2 hyperintensities also seems

more consistent with a viral process rather than bacterial.

The aerobic CSF cultures have been negative for 48 hours at this point

without any antibiotic pretreatment, which further supports that a bacterial

cause such as Staph aureus, Strep pneumoniae, or meningococcus are unlikely.

The negative meningitis encephalitis panel offers some reassurance that this

patient does not have HSV or enterovirus, though the sensitivity of the ME panel is

not as high as other testing modalities, such as an HSV 1 or HSV 2 specific PCR.

I would be interested to hear my attending's perspective on when

we should consider ordering those additional specific PCR tests

in addition to the ME panel.

Finally, I note that her fever curve is uptrending to 104, though given

that we have good evidence that this is not a bacterial process, I would not

add any new antibiotics at this time.

We also have good evidence this is not HSV, and so I

would not add acyclovir either.

What I would make sure to do is to follow her neurologic exam closely, and

if she develops any new symptoms, such as areflexia or paralysis, then I would

want rapid imaging of her spinal cord and a neurology consult in order to

evaluate for inflammatory or demyelinating diseases, such as transverse myelitis.

She should be monitored closely if those processes are suspected

because respiratory status can rapidly decompensate in that setting.

Thanks, Kristen.

Yeah, I agree that at this point, 48 hours into illness, I think my suspicion

for atypical bacterial meningitis is much, much lower and particularly

given we have negative cultures and negative meningitis encephalitis panel

and fevers that have persisted despite appropriately doses of ceftriaxone.

I think at this point where I'm thinking about going is moving on to our next

tier testing for more unusual pathogens.

Um, but I also want to spend a couple minutes just talking about the performance

characteristics of the testing thus far.

And so I'm a little bit less reassured that we've adequately ruled out HSV

when the clinical picture and in this case, new onset focal seizures would

potentially be clinically compatible.

And so it's well described that HSV PCR can be falsely negative,

particularly early in the disease course.

Um, and I think there's also, there's also been several systematic reviews

now with increasing number of patients that have showed lower sensitivity

of the multiplex panels for HSV.

So I'm really thinking about wanting to repeat the LP, both for more

specific testing for things like HSV, but also to see how the CSF

parameters have evolved over time.

And I think this would also have the benefit of allowing us to get additional

specimen volume to send for that second tier testing, and oftentimes we're

limited in terms of CSF volume for the things that we we want to test for.

And so we have to be a little bit strategic sometimes about

prioritizing our testing and making sure that we have enough sample

to get those high priority tests.

Um, in terms of specific microbes, and I'm thinking about, so I think things

like arboviruses, LCMV, and Lyme disease or some of the pathogens that aren't

included on those multiplex panels.

Um, certainly respiratory viruses like flu are associated sometimes

with neurological symptoms.

Like in her case, we have a negative respiratory panel on admission,

so those seem less likely.

Um, I think I also want to ask about TB risk factors, and so that's one of the

other, uh, you know, disease processes that wouldn't come up on routine

testing and could present with seizures and, and a meningitis type picture.

And a big question brought up by the neurology team was

whether to treat with steroids or IVIG for a possible autoimmune encephalitis.

Beth, what were the considerations there?

Yeah, so I think I'd want to know a bit more about how

consistent the neurology team thinks the features are with an autoimmune process.

Um, and in this case, talking with them, I feel like they, um, were not, really

super convinced that this is what they thought was going on and at this point, I

don't feel like we have a clear diagnosis and so in cases like that when we have

the two immunomodulatory therapies mentioned, I think IVIG would be the

safer option, but it still has downsides.

Um, so some of the infectious processes that I'm thinking about,

maybe we may need serology to diagnose them and IVIG would impact, um, our

ability to make those diagnoses.

Um, furthermore, when an untreated infection is in the differential,

I prefer to hold off on steroids.

There's definitely some infections where steroids may make things look better

for a while before they get worse due to the impairment to the immune control.

And so I think if there's not a compelling reason why urgent treatment

is needed, I would, really focus our efforts on making the diagnosis

before we embark on a treatment.

Yeah, it sounds like we are in agreement that a viral process is

at least very likely, um, and we want to recommend additional studies at this time.

It would be helpful to also obtain additional exposure history for

this patient, particularly outdoor exposure, travel history, animal

exposures, and social history.

Sophie, do you have any more of that for us?

Yeah, um, and the neurology team doesn't feel strongly

that this looks like an autoimmune process, but don't have any other ideas.

They've sent autoantibodies, but these will take days to come back.

Um, so to fill you in on some of the social history, it's currently mid July.

The patient lives in a suburb of the Twin Cities and has been

regularly active outside around the family's home this summer.

The family has dogs, cats, and chickens.

And one of the dogs had ticks earlier in the spring, but no

ticks were found on family members.

She did not have any rodent or bat exposures.

Her family camped along a river five days before symptom onset.

The patient's mom recalls that there was a transient red bump on her torso

present at the time of her initial seizure, but has since resolved.

She has not traveled outside of Minnesota, notably.

How does this additional information influence the differential

diagnosis and management?

Thanks, Sophie.

That history is really helpful.

It stands out to me that her symptoms started five days after

the family went camping in July.

I wonder if the skin bump that was described could be a mosquito bite.

The outdoor exposure brings into question if her illness is potentially caused by

a vector borne disease, which we do see more of in the summer months in Minnesota.

There are many diseases in this category, so I'm glad that we have

obtained her travel history to help narrow the list down a little bit.

It sounds like she and her family have only been in in Minnesota, so I

would start building my differential with this location in mind.

Given that we already suspect a viral process based on her CSF results, I'm

suspicious of an arboviral infection.

West Nile virus, Western Equine Encephalitis, and La Crosse encephalitis

are considered endemic to Minnesota.

More recently, Jamestown Canyon virus is also emerging as a

cause of disease in our state.

Of these possibilities, La Crosse encephalitis more often affects

children compared to adults.

In fact, the most common arboviral cause of central nervous system

infection in children in the United States is La Crosse virus.

There are about 80 to 100 cases reported annually in the U.

S., and 90 percent of those occur in children.

This is in contrast to West Nile virus, which shows a peak incidence

in adults over 60 years old.

Jamestown Canyon epidemiology also indicates a lower percent of children

with these cases, at about 7%.

These viruses are all spread from animal reservoirs to humans through mosquitoes.

However, we do have other important vector borne diseases in Minnesota.

With the outdoor exposure, I think it's worth considering if there are

other etiologies we could be missing.

Sophie, what are some additional vector borne diseases that we could consider?

Well, Kristen, thanks for covering viruses spread by mosquitoes

that we think about in Minnesota.

We also want to think about vector borne diseases spread by ticks in this area.

This includes Lyme and other Borrelia species, Anaplasma and

Babesia, as well as tularemia, ehrlichiosis, and Powassan virus.

It's important to note that lacking known exposure has a low negative

predictive value for these vector borne diseases since bites often go unnoticed.

Knowing a patient is in a general location where they may have been

exposed to a specific tick or mosquito is more helpful to keep in mind.

Thanks, Sophie.

At this point for our patient, I think we need to obtain additional testing

to evaluate for arboviral disease.

I want to contact the Minnesota Department of Health at this time

because their laboratory will be the one to process the studies.

I often find it helpful to know ahead of time what types of specimens

they'll require for the testing.

Particularly for samples such as cerebrospinal fluid, I want

to make sure that it's processed appropriately and not wasted.

The Minnesota Department of Health requested blood, serum, and CSF samples

for IgM antibody and RNA detection.

They had listed some specific tests, such as an IgM for West Nile virus,

Powassan virus, Jamestown Canyon, Western and Eastern Equine Encephalitis,

California Group Encephalitis, and St.

Louis encephalitis, which was ordered.

Urine, blood, and urine RT PCR for West Nile virus was also ordered.

Given this large panel of viruses, I'm bracing myself for the potential of

some cross reactivity and I'll need to discuss these results carefully with my

attending in order to interpret them.

In the event that we had used our in house laboratory for testing, I

think it's important for everyone to note that arbovirus disease is

reportable, at least in Minnesota, to our state health department.

And it has to be reported within one working day.

A lumbar puncture was repeated for this patient due to her

high grade fevers despite starting ceftriaxone, as well as the seizures.

Opening pressure of the repeat lumbar puncture was 21.

5 centimeters of water.

CSF studies show evolution over time with an increase to 578 nucleated cells per

microliter with 78 percent lymphocytes, stable glucose, and now protein elevation.

Kristen, how does this new information impact your diagnostic thinking?

This lumbar puncture shows an increased white blood cell

count that is predominantly lymphocytic.

As long as her clinical status is stable, this is consistent with the evolution

of a viral central nervous infection.

I'm glad that we can send a CSF to the health department and

hopefully identify the etiology.

You mentioned that both serology and nucleic acid based testing

was sent to the health department.

What is the role of serology versus molecular or nucleic acid

based tests in arboviral disease?

Yeah, so for many arboviral infections, the period during

which virus can be detected in any body fluid is typically quite short.

And for this reason, PCRs can be helpful if they're positive, but

are not necessarily sensitive enough to rule out disease.

So our health department offers a PCR for West Nile virus, but not the

other viruses in our differential.

And so therefore, serological testing is the mainstay for diagnosis.

Focusing in on those serologies, a single positive IgG is difficult to

interpret given the relatively high risk of past undiagnosed exposure

in our region, but a fourfold rise between an acute and a convalescent

collected sample would be supportive.

For this case where we're looking at acute testing, we're really looking for

positive IgMs to indicate that acute infection, but they may be falsely

positive in other inflammatory disorders or cross reactive against related viruses.

And so, uh, typically a positive result in an IgM is followed up with a plaque

reduction neutralization assay in which serial dilutions of patient serum or

CSF are incubated with virus in vitro to determine the concentration of the virus

at which antibodies are able to inactivate viruses such that they can no longer

infect cells and replicate in culture.

So in this case, higher titers would be indicate a more specific

reaction against a particular virus and would support it being a true

pathogen and not cross reactive.

So such confirmatory plaque neutralization assays are really commonly used

in arbovirology to distinguish between cross reactive viruses.

So, examples would be the California serogroup bunyaviruses, which

would include Jamestown Canyon virus and La Crosse virus, and then

also the flaviviruses like West Nile, yellow fever, and dengue.

So, for our patient, an initial screening arbovirus IgM

IFA that tests for California group encephalitis viruses, EEEV, WEV, and SLEV

was positive for the California group.

Initial IgM EIA testing done at MDH on serum was positive for Jamestown

Canyon virus, equivocal for Powassan and negative for West Nile virus.

Serum PCR was negative for West Nile virus.

CSF IgM EIA testing was positive for Jamestown Canyon virus and

Powassan and negative for West Nile virus by both IgM and PCR.

Urine PCR for West Nile virus was also negative.

Confirmatory testing was sent to Arboviral Diseases Branch Diagnostic and Reference

Laboratory in Fort Collins, Colorado.

Serum testing revealed positive IgM for Jamestown Canyon Virus

and La Crosse by IgM capture ELISA and negative for IgM for Powassan.

La Crosse plaque reduction neutralization occurred at a greater than 1:4096 titer,

but unfortunately there was not sufficient sample for Jamestown Canyon virus testing.

Plaque duction, neutralization testing was also performed on CSF

and was positive at a 1:128 titer against La Crosse, 1:4 for Jamestown

Canyon and was negative for Powassan.

Beth, can you discuss the interpretation of these results?

Sure

In this case, our initial testing was a little bit

confusing because the results supported, uh, potential, potentially

either or both, uh, California group encephalitis virus, of which Jamestown

Canyon was one, uh, and Powassan.

Uh, and there's, uh, since there was not a specific screening IgM for La

Crosse, uh, we, we were not able to test for that and then specifically

in the initial round of testing.

And this is an example where the confirmatory plaque

reduction neutralization assays were really critical.

So the results came back with very high titers against La Crosse virus

encephalitis pathogen with much lower titers against the Jamestown

Canyon virus and a negative capture IgM against Powassan.

So overall, these results were interpreted as being confirmatory

of La Crosse virus infection being the primary pathogen in this case.

And Beth, what do we know about the epidemiology

of La Crosse encephalitis?

Yeah, so this, uh, this pathogen was first described

in the literature in 1965, uh, in a 4-year-old child from south southeastern

Minnesota who sought care in La Crosse, Wisconsin, and ultimately died

from an acute neurological illness.

So that's the, hence the origin of the name.

Um, so as, as Kristen mentioned, there's really a range of any, anywhere

as low as 30 up to 90 or, or more, uh, cases per year of neuro invasive

disease reported in the United States.

Uh, and the vast, vast majority of those are among children.

Um.

The neurological disease is probably just the tip of the iceberg as there's

substantial under-diagnosis and under-reporting of less severe cases.

And so, so how do we know this?

So there was a serological survey that was done, um, in, in a town in

southeastern Minnesota called Winona, and they had sero positivity rates of

up to 28% in some of the rural areas.

So I think in places where there's the right geographic exposure in

sort of a high risk population, like residents in a rural region, there's

probably quite a lot of exposure on an infection that we're not - it's not,

it's not coming to medical attention.

Um, and so there's really a couple of pockets of this, of where this

disease is predominantly diagnosed.

So it's the upper Midwest, so Minnesota and Wisconsin are really high, high areas,

and then also through, through Appalachia.

So Ohio, Kentucky, West Virginia, North Carolina are big pockets of this disease.

Um, it's really not clear why only a small fraction of the people who are

exposed develop neuroinvasive disease.

Um, And something that my lab is particularly interested in

is, is host susceptibility.

Um, and there's really been some interesting data that have come out

in the last year, looking at, uh, the prevalence of auto antibodies against

type one interferons in patients who develop neuroinvasive West Nile.

And so I think there's more, more to come and more to learn about what,

why it is that some people are more susceptible to these severe manifestations

of viral pathogens than others.

So Sophie, you had some time to interact with our health department.

Uh, what can you tell us about what can be done to prevent lacrosse encephalitis?

Yeah, so as the medical student on the team, I was able to

speak with an epidemiologist on the Vector Borne Disease Unit at the

Minnesota Department of Health and learn more about the follow up and

prevention measures taken at this case.

So early on, MDH involved the Metropolitan Mosquito Control District and the family

allowed them to inspect their property.

The initial evaluation involved removal of old tires and

containers from the family's yard.

The mosquito control district removed 8 tires, 4 of which had larvae, and

32 containers, 20 of which had larvae.

Aedes triseriatus was found in seven of the larval habitats.

The family was educated on the importance of dumping standing water in toys and

containers since they can serve as a breeding site for this mosquito.

They filled one tree hole near the residence with soil, although mosquito

larvae was absent upon further inspection.

The Mosquito Control District also sampled adult mosquitoes and sprayed

adulticides the following day.

They attempted similar surveillance and control measures in the surrounding

area and notified neighboring houses about lacrosse risk in the area.

The neighborhood will have continued surveillance for

several years to eliminate larvae that may carry lacrosse virus.

MDH provided their unique perspective on the epidemiology of

previous La Crosse cases they've been involved in and educated the

family on mosquito bite prevention.

Kristen, can you tell us more about standard mosquito precautions?

Absolutely, Sophie.

There are several approaches to reduce the risk of mosquito bites.

First, bug spray can be used on the skin whenever there's a risk for

exposure to mosquitoes or ticks, particularly during the months of

April through November in Minnesota.

There are many products available, but you want to make sure it's a

product registered by the Environmental Protection Agency, or the EPA.

The most common active ingredients include DEET, picaridin,

and oil of lemon eucalyptus.

The American Academy of Pediatrics recommends selecting a concentration

of DEET that matches your expected outdoor exposure time.

For example, 10 percent DEET provides protection for about 2

hours and 30 percent DEET provides protection for about 5 hours.

The maximum concentration you should buy is 50 percent because anything

beyond that does not actually provide longer protection, despite

a potentially higher price for something that says 100 percent DEET.

Picaridin is another active ingredient that can repel mosquitos and ticks.

Similar to DEET, the concentration correlates with duration of protection.

5 percent picaridin provides about 3 4 hours of protection, while 20 percent

can provide protection for 8-12 hours.

Oil of lemon eucalyptus is the other option I mentioned, but

it's important to know that this is not the same as lemon oil.

You should make sure that your OLE product is registered by the EPA and it should

not be used in children under 3 years old.

OLE of a concentration of 8-10 percent can protect for up to 2

hours and 30 percent concentration, up to 40 percent concentration

can protect for about 6 hours.

For all of these products, it's important to read the label and avoid applying them

directly to a child's hands because we all know that the hands are going to end

up in the mouth and the eyes and increase risk for ingestion or eye irritation.

When using insect repellent with sunscreen, the sunscreen

should be applied first.

Other than topical bug spray, you can also choose to wear long sleeve clothing and

pre treat the clothing with permethrin.

You could also choose to avoid areas with dense vegetation.

Finally, mosquito nets are a great option and you can pre treat

those with an insecticide as well.

So for our patient, it sounds like Sophie, you had some excellent communication with

the Department of Health and they worked with the family to talk about prevention.

What did you learn from talking to the family or from MDH about

how the child's doing now and what the future might look like?

Well, when I was able to speak with the family, they updated

me on her six week follow up after discharge and shared that at that time

she was having headaches about every two weeks, but she has had no new seizures.

She's doing well in school and remains social and active with

some activity modification to follow seizure precautions,

but overall is doing excellent.

Repeat brain imaging, um, both MRI and EEG done at the follow up

showed resolution of prior lesions.

She's tapering off levetiracetam and will continue to follow up with neurology.

The parents shared that while seeing their daughter so sick and having seizures was

incredibly scary, they felt supported by all the teams involved in her care,

and they're happy to see her back on track and doing the things she enjoys.

Thanks again to Sophie, Kristen, and Beth

for joining Febrile today.

Febrile is produced with support from the Infectious Diseases

Society of America, or IDSA.

Don't forget to check out the website, febrilepodcast.

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Thanks for listening.

Stay safe and we'll see you next time.