Jeremy Root MD, Children’s National Health System
With Sabrina Guse MD, Children’s National Health System

The Case
17 yo F with a complex medical history presents with a constellation of strange neurologic symptoms. While respondents agreed that the patient would eventually receive an extensive inpatient workup, the challenge of this case lay in determining how much of it should be performed in the ED. Dave Mathison put it best in his comment: “You could spend 3 hours on this case, or 5 minutes.”

Here’s How You Answered Our Questions

Denouement
Neurology was consulted; they recommended inpatient admission for MRI/MRA along with addition of CK. Neurology felt her presentation did not fit a neurologic distribution or etiology. Patient’s language centers in brain were functioning well and her exam was more consistent with poor effort rather than weakness. No indication for spinal tap for aseptic meningitis as the patient’s symptoms were exacerbated upon receiving IVIG rather than days to weeks after infusion which is typical for aseptic meningitis. Brain MRI and spine with and without contrast were eventually obtained and were normal. While primary team was concerned for hyperreflexia, neurology noted that global hyperreflexia can be seen with many non-neurological issues such as anxiety or pain.

Cardiology was consulted and noted to have normal ejection fraction on echo while inpatient. PICC eventually placed for long-term fluid management. Patient refused SCD’s and hematology was consulted and she was started on prophylactic anticoagulation given history of PICC line thrombus.

Genetics was consulted to evaluate for mitochondrial disease and screening labs sent for mitochondrial dysfunction. Plasma and urine organic acids were unremarkable.

PM&R were consulted who were concerned for possible interaction of escitalopram, tramadol and vyvanse causing mild serotonin syndrome. Overall they felt her presentation was most consistent with mutism related to conversion disorder and somatization. Family refused psychiatric consult and expressed outrage when a somatoform disorder was discussed. Patient eventually transferred to National Rehabilitation Hospital.

Teaching Points

• For a stable patient with a complex medical history who presents to the ED, speaking with a provider who knows the patient well (in this case, a consulting service) can help focus the workup and decrease the time to disposition.
• Discussing a possible psychiatric etiology for patients with somatic complaints is a difficult but important part of our job in the ED. When starting this conversation, it can be helpful to validate the patient’s complaints (e.g. “your symptoms are real”) and acknowledge that stress and anxiety can cause physical symptoms.