Hot Seat Case #127: 8 yo with auditory hallucinations
Posted on: March 5, 2019, by : Rachael Batabyal MD
Rachael Batabyal, MD with Caleb Ward, MD
HPI: 8 yo M presents with complaint of hearing a voice that tells him to “kill himself”. He reports that yesterday during the day he first heard the voice. It went away and then he began hearing it again last night. He was not asleep when he heard the voice. He reports that he does not want to kill himself, but the voice scares him. He has otherwise been well. He has not had any visual or olfactory hallucinations. Patient reported intermittent headaches that do not wake him from sleep; they have progressed from occasional to a few times weekly. He has a history of staring spells with a previous negative EEG, but has had no episodes in the last 6 months.
ROS:
Const: No fevers. No weight loss.
Skin: No rashes
Respiratory: No SOB
Cardiovascular: No chest pain. No palpitations
GI: No abdominal pain
Neuro: Headaches, more recently than usual. Not waking him from sleep. No vomiting/nausea associated. No abnormal movements. No confusion.
Psychiatric: Command Auditory Hallucinations of a voice telling him to kill himself.
PMHx: He has been seen in the ED twice in the past two years for staring episodes. The first time he was admitted and had a negative EEG. The second episode he was seen in the ED and this was thought to be behavioral. No psychiatric diagnoses.
Social: Parents are divorced. Denies any unusual school or home stressors.
Surgeries: None
Medications: None
Allergies: NKDA
Physical Exam:
VS: normal for age
Gen: well appearing, fearful and crying, does not seem to be responding to internal stimuli
HEENT: PEERLA. OP clear. No meningismus
CV: Regular rate and rhythm. Nl S1, S2. No murmurs, rubs, or gallops on exam. Normal peripheral perfusion.
Chest: Clear to auscultation bilaterally, no wheezes, rhonchi or rales
Abd: Soft, Nontender, Nondistended. No organomegaly.
Neuro: Alert and oriented to person, place, and time. Cranial Nerves 2-12 intact. Normal strength. Normal sensation. Normal finger to nose and heel to shin. Normal gait. Neg. Romberg. Normal reflexes. Negative Babinski.
Initial Lab Results:
CBC: 9>13.2/39.1<416 Normal Diff.
CMP: WNL
TSH: 5.6, T4: 6.9
Utox: negative
UA: Blood: neg. Protein: neg. Ketones: neg. Nitrite: neg LE: 3+ Spec Grav 1.029 WBC: 96 RBC: neg Epithelial Cells: none Bacteria: None
Head CT: No acute abnormality
The patient denied any dysuria, urinary urgency, urinary frequency. No abdominal pain.
Neuro was consulted who recommended no further workup given neg CT, no recent staring episodes, no signs of catatonia, no abnormal movements, no seizures, no leukocytosis.
It is now 2am. Psych evaluates the patient and determines that the patient does not want to kill himself and the voices have stopped at this point. Since the patient is no longer hearing voices and he states that he would resist the voices, the psych SW states he is safe for discharge. He was given a phone number to arrange for follow up.
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This is a classic case of don’t get a test if you don’t want the answer. The UA in this asymptomatic child just doesn’t mean much. I definitely wouldn’t treat right now and I’m plus/minus on sending a culture even. This article from Canadian Family Physician suggests you should not treat asymptomatic bacteriuria. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6234948/
And as for discharging this child home, I’m all for it. He doesn’t appear to be a danger to himself or others. He’s already tearful and scared. He’s eight years old. Admitting him to the psych unit isn’t going to help his fear.
True command hallucinations to kill oneself are almost always the onset of a psychotic disorder (classically schizophrenia) or an affective disorder with psychotic features (i.e., schizoaffective disorder, bipolar disorder). This could also represent a behavioral disorder (attending seeking, faking) or somatoform disorder (conversion disorder).
However, I think that temporal lobe (partial-complex) seizures need to be explored with a discussion with the Neurology attending. These can present with headaches, staring spells, and auditory hallucinations (albeit not typically command hallucinations). This evaluation doesn’t have to be emergent, but should be followed up on an urgent basis given the concerning nature of these command hallucinations.
One final thing to always keep in the back of your mind (no pun intended!) is lupus cerebritis, which presents (for lack of a better word) funny — sometimes with overt psychosis. I don’t think the UA is consistent with lupus nephritis, but screening tests for SLE might be considered after the additional discussion with Neurology.
Agree with discharge with outpt followup for neuro and psych.
Regarding the urinalysis results, WBC 96 is significant pyuria. First thing to rule out would be UTI, and so I would send a urine culture. In a child without fever or urinary symptoms, and if the family can be reliably contacted for follow up results, I would hold off on antibiotics till urine culture results. Along the bacterial route, one can also consider GC/Chlamydia/STI, although less likely in this age, but consideration of sexual abuse is in the differential, if lower. I’d interview the child separately about this, especially given the chief complaint.
If urine culture is negative, then consider viral cystitis, or even interstitial nephritis (due to viruses, meds such as NSAIDs). In interstitial nephritis, the WBC count isn’t so high.
So we have 8 y/o male with remote hx of staring episodes (negative EEG), presenting with acute onset command hallucinations without any other red flags re psychosis who has a normal neurology exam, is not suicidal/homicidal and whose workup thus far includes a negative CT head and urine toxicology screen, and UA suspicious for sterile pyuria (not asymptomatic bacteruiria as was stated above). Psych consulted and cleared for outpatient follow-up.
My first decision point: are some/all of the pertinent POS findings of staring spells, hallucinations and sterile pyuria related or separate? Always like a parsimonious diagnosis – but things that would explain all 3…? All I have is SLE (as Dewesh notes) and disseminated TB (great mimic – can cause a sterile pyuria and psychosis) but no risk factors we are told of. I would probably park the pyuria to one side – send a urine culture, not treat and flag need for follow up with PCP re that. Side note: cases with seemingly disparate complaints like this are great for Isabel (per Jim’s recent plug – available in FirstNet: CNMC Intranet -> Formulary -> Isabel Diagnosis).
That leaves me with command hallucinations and previous staring spells of uncertain significance. Agree with Dewesh that this does make me suspicious for temporal lobe seizure – I would consult Neurology from ED – would EEG now possible capture something that was not seen previously? Might they want to expedite MRI? If they opt for outpatient management, and family also OK with that – then discharge home.