acute pediatric psychosis

8/12/2019 Acute Pediatric Psychosis

1/15


2/15

In the Emergency Department 6 year old boy with mild autism

brought by EMS from an OSH ED with

hallucinations :

Started outside around 4pm with a staring spelllasting ~ 1 minute, followed by about 10 minutes offrantic flailing during which he screamed in panicabout having to get the orange and black bugs outfrom inside of me.

Concerned that he had been bitten by a bug, Mom

gave him 25mg of Benadryl. Proceeded to have 2 more similar violent episodes

OSH ED. Had 3 additional episodes at the OSH

transferred to PCH. No interventions performed or medications given

at the OSH


3/15

What else would you like to know?


4/15

Diagnosed with Strep throat 10 days prior Asymptomatic, but sister with rectal strep Started Augmentin Hives day #7 Augmentin d/cd, started Benadryl

25mg po 2 days prior to presentation, 25mg po 36 hours prior to presentation, 25mg poimmediately after hallucinations started

Frequent staring spells over past year Last ~ 1 minute, 2-4x/day, no Neuro eval

Discoordination over past few weeks falls to the left, gets angry thinkingsomebody tripped him

More tired than normal today

Only medications in home = Naproxen and erythromycin face cream; fatherchecked garage and cabinets

Nothing out of place

No history of trauma

Additional History


5/15

Past Medical/Surgical History: Term birth Mild autism, walked at 15 mo, talked at 3 years S/p distant T&A, bilateral tympanostomy tubes Up to date immunizations

Medications: Occasional melatonin (none recently) Benadryl, Augmentin recently

Allergies: Omnicef emesis; Augmentin - ? hives

FHx: Maternal aunt with epilepsy, Mother with migraines.

SHx: Lives with married parents and 3 sibs. Attends alternative first grade.

ROS: +Headaches. No fevers, cough, congestion, rhinorrhea, eyedischarge/redness, vomiting, abdominal pain, diarrhea/constipation, rashes.

Additional History


6/15

T 36.7, P 100, BP 92/60, RR 20, saturating 95% on RAGen: Initially gives tentative high-five but will not talk, then abruptly startsthrashing violently and screaming in panic about getting the orange and black bugsout of inside of me, picks at himself frenetically. Lucid between episodes.

HEENT: Normocephalic, atraumatic. Dilated pupils. PERRL, no conjunctival injection ordischarge, TMs nl b/l, dry mucous membranes , OP clear.

Neck: Supple, no significant LAD.

CV/PULM: Tachycardic, RRR, nl S1/S2, no murmurs. CTAB, nl WOB.

ABD:Hypoactive bowel sounds , soft, NT/ND, no HSM or masses.

EXTREM: MAEW.

DERM:Dry, flushed. No rashes, petechiae, or unusual bruising.NEURO: Awake, able to state name and age in between episodes, symmetric facialexpressions, normal tone throughout, Goliath-like strength in upper and lowerextremities bilaterally, reflexes 2+ in upper and 1+ in lower extremities bilaterally. Noclonus. Babinski absent b/l. Sensation intact to light touch throughout. No ataxia withspontaneous movements. Unable to assess gait.

Physical Exam


7/15

Differential?


8/15

Drugs/medications: Anticholinergics (e.g. atropine,

diphenhydramine) Antibiotics (e.g. amoxicillin,

clarithromycin, erythromycin) Anticonvulsants (e.g. phenytoin,

topiramate), corticosteroids Hallucinogens, sympathomimetics

Psychiatric Disease Childhood onset schizophrenia

SLE/Other vasculitisSubstrate deficiency Hypoglycemia Hypoxia

CNS abnormality Tumor Seizures/Interictal psychosis Intracranial injury Meningitis, encephalitis, abscess

Metabolic Disease Urea cycle defect (partial) Acute intermittent porphyria Wilson disease Subacute sclerosing panencephalitis

Other Electrolyte abnormality Hepatic failure Uremia Hashimoto thyroiditis Antiphospholipid syndrome

Differential for Acute Psychosis in Children


9/15

Labs: Normal CBC w/ diff, CMP, ESR Serum drug screen positive for tricyclic antidepressants

Imaging: Normal non-contrast head CT

Consultants: Poison control Benadryl unlikely to be the cause given that the first episode occurred

~32 hours after his last dose Positive TCAs = cross-reactivity with Benadryl

Work-up


10/15

Received lorazepam 0.1mg/kg with calming effect initially followed bydisinhibition, incoherence

Admitted to the hospitalist service

Neurology Consulted Migraine w/ inability to process sensory phenomena of aura? Seizures in 20-25% autistic patients but tactile hallucinatory phenomena are typically

NOT epileptic Imaging reassuring against CNS lesion Anxiety likely contributing, ? Primary psychiatric problem Given global effect, metabolic or infectious process most likely, though meningitis

unlikely given very lucid intervals

The Story Continues


11/15

Psychiatry consulted on 2 nd day of hospitalization

Back to baseline, cheerily reported that he killed thebugs with a hundred- mile scream

Spent interview typing large numbers into acalculator and reporting, This is how many

insects/sharks/alligators/spiders/etc. there are onplanet earth!

Likely anticholinergic delirium brought on byBenadryl leading to ahyperdopaminergic/hypocholinergic CNS stateexacerbated by underlying Autism/anxiety

Seroquel discontinued

Went home and lived happily ever afterwe hope

The StoryContinues


12/15

History: setting suggestive of drug overdose, medications, constitutionalsymptoms (fever, chills, HA), known history of SLE, head trauma, new onsetneurologic deficits, seizure disorder, prior episodes, family history ofpsychiatric disease

Physical exam: r/o findings suggestive of hypoglycemia (AMS, diaphoresis,

tachycardia, hypotension) or impaired oxygenation (cyanosis, pallor, shock,respiratory distress) Then consider other vital signs (e.g. fever, tachycardia), miosis/mydriasis, dry vs. moist

mucous membranes, thyromegaly, hypoactive vs. hyperactive bowel sounds,diaphoresis vs. anhydrosis, focal neuro findings vs. encephalopathy

Evaluation of Acute Onset Psychosis inChildren


13/15

CBC with diff, BMP, Mg, Phos TSH, free T4, CMP for children whose psychosis is not clearly psychiatric in origin and

cannot be explained on the basis of substrate deficiency, drug toxicity, or CNSabnormality

CT head

LP for signs of meningitis AND fever or other infectious symptoms (or ifsymptoms not improving and no cause can be identified)

Urine/serum drug screen

EKG in patients with psychosis of unknown etiology, especially if there are

anticholinergic features Presence of R wave in aVR suggests present of TCA or similar substance (e.g.

diphenhydramine)

Other: EEG, special metabolic studies, etc. as indicated clinically

Evaluation


14/15

Remove/Treat the Cause!

Benzodiazepines (Ativan 0.05mg/kg/dose) Paradoxical reactions and/or disinhibition are more common in children with

developmental delay and/or Autism Spectrum Disorders

Haloperidol 0.025mg/kg/dose

Quetiapine (Seroquel)? Approved for bipolar disorder in children over 10 years, schizophrenia in adolescents Seems to be well- tolerated with fewer AEs/paradoxical effects in children with

developmental disability/ASD (small studies) Helpful in patients with underlying anxiety

Management of Acute ChildhoodPsychosis


15/15

Babu et al, 2012. Emergency department evaluation of acute onsetpsychosis in children. UpToDate.com

Findling, R.L. 2002. Use of quetiapine in children and adolescents. J ClinPsychiatry 63 Suppl 13:27-31.

Politte and McDougle, 2014. Atypical antipsychotics in the treatment ofchildren and adolescents with pervasive developmental disorders.Psychopharmacology 231(6):1023-36.

Prybylo et al, 2005. Acute psychosis after anesthesia: the case forantibiomania. Paediatr Anaesth 15(8):703

References

acute pediatric psychosis

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