When school staff checked on a 4-year-old girl as she woke from a nap, they found her in a position her doctors say had never been reported in her type of epilepsy. She was on all fours with her elbows on the ground and her neck bent sharply backward, and she did not respond when staff called her name.
Physicians at JFK University Medical Center in Edison, New Jersey, later diagnosed self-limited epilepsy with autonomic seizures (SeLEAS), a childhood epilepsy syndrome formerly called Panayiotopoulos syndrome. Niranjana Kesavamoorthy and Savitra Bandari described the girl in a case report in Case Reports in Neurological Medicine, published Feb. 15, 2026, writing that the all-fours presentation had not been previously reported.
From a Classroom Nap to the Emergency Room
The episode unfolded quickly. When staff turned the girl over, her right arm shook for about a minute. Her eyes were open, but she did not react to her name or other stimulation. She then vomited.
Emergency medical services took her to the hospital. During the ride, she stared with what the report described as a "glossed-over look" and barely interacted with her parents. She remained unresponsive for a long time and took about an hour and a half to return to her usual self.
The girl was developing typically and had no significant medical history. She was born at full term, had no family history of seizures and had never had a similar episode. Her one notable event was a 2022 fall down 15 steps, after which a head CT showed no abnormalities. Her neurological exam at the hospital was normal.
A video electroencephalogram (EEG), which records brain waves, captured spike-and-wave discharges in the back and front regions of both sides of the brain, more prominent on the right. The pattern was consistent with SeLEAS. A brain MRI was normal. She was started on the antiseizure drug levetiracetam, and her dose was raised at a follow-up visit after blood levels of the drug came back low.
A Seizure Syndrome Better Known for Vomiting
SeLEAS usually begins between ages 3 and 6, although it can start anywhere from age 1 to 14, according to the International League Against Epilepsy's diagnostic manual. Boys and girls are affected equally, and development is normal. Seizures are usually infrequent. A quarter of children have only one, most have five or fewer in total, and the seizures usually stop within one to two years.
The syndrome's hallmark is autonomic symptoms, meaning effects on the body's automatic functions. The case report lists vomiting, dry heaving, sweating, pallor, dilated pupils and heart rate changes. Seizures often occur in connection with sleep, as this girl's did. The ILAE manual adds that the seizures are often prolonged and that EEGs commonly show high-amplitude spikes activated by sleep.
Doctors have documented plenty of odd features before, including laughter followed by unconsciousness, hiccups, eye deviation, coughing followed by vomiting, high body temperature, vertigo-like symptoms and cardiac arrest. What set this case apart was the prone, all-fours position.
The authors offered one possible explanation: the posture could be an instinctive response to retching or vomiting during sleep. That is a hypothesis, not a finding. No video of the event was available, which the authors acknowledged as a limitation.
Why Odd Presentations Can Send Doctors Down the Wrong Path
SeLEAS has a long record of being mistaken for other conditions. A 2006 paper in Pediatrics described the syndrome as frequently imitating encephalitis, fainting, migraine, sleep disorders and gastroenteritis.
The pattern still shows up. In a 2024 case report in Cureus, Portuguese doctors described a 6-year-old girl who had a seizure on waking that lasted more than five minutes, followed by vomiting and confusion. She was misdiagnosed with acute gastroenteritis and sent home, and she was diagnosed with the syndrome only after another seizure.
The New Jersey authors also noted that SeLEAS is the most common cause of nonfebrile nonconvulsive status epilepticus in children, a prolonged seizure that occurs without fever and without obvious convulsions. That, they argued, is why clinicians need to recognize the full range of ways the syndrome can look, so that treatment isn't delayed by a wrong diagnosis.
What One Unusual Case Can and Cannot Tell Parents
This is a single case report, so it cannot show how often the all-fours posture occurs or whether it carries any special meaning. It does not change treatment guidance.
Because SeLEAS is self-limited, antiseizure medication is not automatic. The authors wrote that medication is indicated when seizures are frequent, when they begin before age 4, or when they affect quality of life. Decisions about treatment belong with a child's neurologist.
The school's decision to call for help matched federal advice. The CDC's seizure first aid guidance says to time a seizure and seek immediate help if it lasts longer than five minutes. It also says to call 911 for a person who has never had a seizure before, who has trouble breathing or waking afterward, who has another seizure soon after the first, who is injured, or whose seizure happens in water.
Parents who notice episodes of unresponsiveness with vomiting, especially around sleep, should describe them to a pediatrician in detail, including any unusual body positions.
Key Questions Answered
What happened to the girl?
After a school nap, she was found on all fours and unresponsive, with her neck bent backward. Her right arm then shook for about a minute, and she vomited.
What is SeLEAS?
Self-limited epilepsy with autonomic seizures, formerly called Panayiotopoulos syndrome, is a childhood epilepsy whose seizures often involve vomiting, pallor or sweating.
Why is this case unusual?
The authors say an all-fours presentation had not been reported before.
Is the posture a common warning sign?
There is no evidence for that. The report describes one child, and the reason for the posture has not been confirmed.
When should someone call 911 for a seizure?
The CDC lists a first-ever seizure, a seizure lasting over five minutes, trouble breathing or waking, a second seizure soon after, an injury, or a seizure in water.
What is the outlook for children with SeLEAS?
Generally good. Most children have few seizures, and the seizures usually stop within one to two years.
