Hot Seat #59: 4yo AMS, weakness, and abnormal eye movements
Posted on: August 17, 2015, by : Jamie Martin
by Jamie Martin, Children’s National
The Case
4 year old previously healthy female presents via EMS with altered mental status, weakness, and abnormal eye movements for a few hours. Mom reports patient was in usual state of health until this evening when she noted altered mental status, weakness, and an abnormal gait. During this time, mom also reported eye “twitching” and “jumping.” No LOC. No known trauma. She reports sore throat and subjective fever this afternoon for which mom gave OTC fever/cold medication.
ROS: No weight loss. No recent neck pain. No recent polydipsia/polyuria. No cough/chest pain/shortness of breath. No vomiting/abdominal pain/diarrhea. No urinary complaints. No rashes.
PE: Temp 37.3; HR 118; BP 123/66; RR 20; sat 100% on RA
Gen: somnolent but arousable. Intermittently following commands and answering questions.
Head: Normocephalic, atraumatic
Eyes: Pupils 4 mm to 2 mm reactive, bilaterally; vertical/horizontal nystagmus; unable to assess EOMI; no conjunctival injection
ENT: TMs clear, no hemotympanum or effusion; nares clear; throat without lesions or exudate, symmetric tonsils
Neck: Supple, no apparent pain with ROM
CV: Tachycardic, no murmur or gallop; 2+ radial and DP pusles bilaterally; cap refill 2 sec
Pulm: Clear bilaterally, no increased WOB
Abd: Soft, nontender/nondistended, NABS, no organomegaly
Neuro: altered, can state name at times, slowed speech. Follows commands intermittently. normal tone, no abnormal movements noted, Reflexes 2+ thoughout. Gait not able to be tested due to altered mental status.
Skin: No rashes; no cyanosis.
Bedside POC lab: Glu 106, Na 142, K 4.4, iCa 1.42, HCO3 25, Lactate 1.65
VBG: pH 7.36, CO2 45, base deficit +1
You order a normal saline bolus and additional labs.
Questions for you:
Other = comprehensive tox screen; assess time of day, observe for longer time to determine severity/urgency; utox; 1. Better Neuro exam. 2. Better history (toxic exposure). 3. Neuroblastoma w/u
Re-examination
CT Head prelim reading: Unremarkable. CBC: WBC 7.2K, Hg 13, Plts 226K. BMP: Na 142, K 4.2, Cl 103, HCO3 24, BUN 12, Creat 0.3, Glu101. LFTs unremarkable. Serum Tylenol, Ethanol, Salicylates negative. You are awaiting urine drug screening.
After 2 hours, the patient’s BP, HR remain within normal limits. T 37.8 ax. She is now more alert than prior but still altered and somnolent. She continues to have slow, slurred speech and vertical/horizontal nystagmus, otherwise neuro exam unchanged.
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
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you describe opsoclonus-myoclonus syndrome pretty well here. This can be a paraneoplastic syndrome associated with neuroblastoma or can happen in isolation as its own syndrome (to my understandings). But these patients need comprehensive evaluation so while my general approach is to use consultants about never, for this I would admit to neuro (with oncology consult) or the neuro-cns-inc team directly. They can determine mri vs Mibg vs lp etc….
Btw, horizontal nystagmus can be a normal finding but vertical is always pathologic….
I agree with Dave. Smells like opsoclonus-myoclonus-ataxia syndrome. Work up for neuroblastoma should be strongly considered. A possible toxic ingestion from the OTC cough and cold medication should also be evaluated. Sometimes these kids get admitted to the Academic Team for further evaluation. Also we have Neuro-ophthalmology consultation available in house.
I always thought opsoclonus myoclonus was a problem that came on slowly–it wasn’t a thunderclap sort of thing. Also, I didn’t think those children were altered. They are irritated because the opsoclonus is distressing, but alert and oriented.
Lots of ingestions can make you disoriented with nystagmus and most won’t show up on a tox screen. Time to go back and ask about every med that could be in the house. 🙂 And unfortunately, unless this kid is getting better in front of you, I don’t think there is a chance she gets out of your ED without an LP.
I felt it unfortunate that the second poll had very explicit options. With these neuro findings in this age, I think there can be a lot of confusing symptoms that can have different explanations based on the exact pathology. In past cases, in discussing with Neuro, when you (ok, they) really piece things together, many disparate OR “scary” symptoms can actually be tied back to a single finding (like a CN VI palsy, the opsoclonus, or weakness in a certain distribution or the such). I would have preferred to call neuro to have them evaluate or at least help me think about the patient, consider an MRI (depending on time of day, cooperativeness of child) (rather than original CT), send off the urine studies for neuroblastoma and then make a dispo. The difficult to describe symptoms really make me concerned for tox, as Katie states, and a tincture of time can go a long way. I know we like to dispo kids, but these vague/confusing symptoms sometimes do need a little time to sort themselves out/declare themselves as serious or not.
The hyperacuteness of the symptoms, especially without fever, would make me fight tooth and nail to avoid putting in a needle in this child’s back without having had the benefit of time. The H&P don’t suggest bacterial meningitis, so let’s see what develops….
If the child has constant rapid and random eye movements, then it does sound like opsoclonus-myoclonus — if so, an assessment can be done as an inpt with CT of the head/chest/abdomen.
Also agree with Katie that the rapidity of onset seems to fit more with an ingestion, with PCP being the classic drug that causes vertical nystagmus. Her somnolence would suggest a possible coingestion, since PCP intake usually causes more excited symptomatology.
Altered mental status makes me think about encephalitis, though the nystagmus suggests a more specific part of the brain being affected, while viral and autoimmune encephalitides usually affect the brain more globally – altered thinking, altered level of alertness. So before performing an LP, I would ask our Neuro colleagues about the likelihood of encephalitis presenting with these symptoms.
And, if we were in Arizona, children can develop rotary eye movements after a scorpion sting.
In ED: baseline labs, urine comprehensive drug screen, discussion with Neuro/ Onc, and admit to hospital.