Case: 9-year-old with altered mental status

Patient Identification
9-year-old male admitted from PMD's office because of a two-week history of confusion, disorientation, and
behavioral changes.
History of Present Illness
Keith was well until two weeks prior to admission when his parents first noticed somewhat odd behavior. As an
early example, Keith showered one afternoon, and 15 minutes later, announced that he was going to take a shower
(again). They also noticed that he began leaving things behind at school, though he was normally very organized.
About one week ago, he became repetitive in conversation and short-tempered. His third-grade teacher noticed that
his attitude was changing gradually, and that he was tangential in conversation. He began having difficulty with
homework, was grumpy, and easily confused.
Keiths parents report that his confusion and disorientation has worsened over the past week. His mother feels that
he has started to talk more and more in circles (repetitive). He is sleeping more than usual, in fact, falling asleep
right after school. His gait became somewhat wobbly two days prior to admission.
On the day of admission, Keith was difficult to wake in the morning, and once awake, he was much quieter than
usual they report that he is normally fidgety, unable to hold still.
No recent travel. No known tick exposures, toxic exposures, or sick contacts. Keiths father recalls that Keith had a
cold sore about one month ago. About three weeks ago he had a stiff, painful neck for about one day. The parents
do not recall if he had fever at the time.
Past Medical History
Born at term. No prior hospitalizations. Uncomplicated varicella, age 2 years. Tonsillectomy, adenoidectomy (for
OSA), and tympanostomy tube placement (for multiple AOM) at age 5 years. Group A strep pharyngitis 11 months
ago.
Review of Systems
Constitutional:
HEENT:
Resp:
CV:
GI/Liver:
Kidney/GU:
Heme:
Musculoskeletal:
Metabolic/Endo:
Neurologic:
Allergic/Immuno:
Skin:
Development/Behavior:

increased sleepiness x 1 2 weeks

negative
negative
negative
negative
negative
negative
poor coordination and stiff gait x 3 4 days
negative
gait wobbly x 2 days
negative
negative
behavioral changes x 2 weeks, see HPI; patient self-report:
sometimes I say things that dont make sense

Family History
Maternal aunt with multiple sclerosis. Maternal cousin with CHARGE syndrome.
Social History
Keith lives in East Palo Alto with a 10-year-old sister, both parents, and an adult uncle. The family has a
Chihuahua. English and Spanish are spoken at home. Both parents are employed full-time. Keith enjoys baseball
and basketball. There are no smokers in the household.

Immunizations
Up-to-date per parent report.
Allergies
NKDA
Medications
None
Physical Exam
Vitals: Temp 38.0 Celsius, HR 104, BP 89/58, RR 20, SpO2 100% RA.
Measurements: Weight 33.3 kg (50th percentile), Height 135 cm (50th% percentile).
General: Initially, lying prone in bed, unresponsive or unwilling to answer questions. Increasingly cooperative
over course of examination.
HEENT: NCAT. PERRL. There is horizontal nystagmus. Sclerae are mildly injected bilaterally. OP benign, no
lesions or exudate. MMM. Neck is supple, full ROM, without appreciable LAD.
Heart: RRR. Normal S1, S2, no murmurs.
Lungs: CTAB.
Abdomen: Soft, nontender, normoactive bowel sounds. No HSM or other masses.
Extremities: Warm, well-perfused, no edema.
Skin: No rashes, bruising, excoriations or petechiae.
Neurologic: GCS 15. Cranial nerve exam normal except for bilateral horizontal nystagmus (left gaze > right gaze).
Vision 20/70 bilaterally. Facies symmetric. Finger-nose-finger difficult to assess due to pain at right-hand IV site,
borderline normal on left (slow). Heel-to-shin is accomplished slowly, only with repeated reminders and coaching.
Unwilling to perform rapid, alternating movements. Normal, symmetric strength and tone in the lower and upper
extremities, bilaterally. 2+ reflexes, upper and lower, bilaterally. Ankle Achilles tendon 2-beat clonus, bilaterally.
Negative Babinski on right, Positive (upgoing) on left. Gait is wide based and unsteady with decreased hip and knee
flexion and symmetric foot shuffling. Sensation intact in all four limbs. Positive Romberg, with loss of balance
after 5 seconds.
Mental Status Examination: Lying quietly in bed, intermittently turning away (whole body) from interviewer.
Able to state full name; unable to report place, year, month, or date of the week. Responsive to simple commands.
Affect relatively flat, irritable mood. Speech difficult to evaluate given resistance to conversation (turns away from
interviewer), but when speaking spontaneously, demonstrates tangential, flight of ideas. Assessment of short term
memory reveals inability to recall three words (dollar, policeman, purple) after 5 minutes. Naming intact. Able to
perform 2-digit calculations and to spell name backwards. Per evaluation by LPCH Speech Therapy, the patients
age-equivalent for receptive and expressive language is 5 years, 0 months.
Laboratory Data
WBC 9.7 (59% neutrophils, 24% lymphocytes), hemoglobin 13.8, hematocrit 39.3, platelets 509k.
Na 140, K 3.8, Cl 106, HCO3 27, BUN 6, Cr 0.5, glu 91. Ammonia 31.
CSF: glu 55, prot 38, Gram stain negative. WBC 43 (89% lymphocytes), 2 RBC. Bacterial culture, HSV PCR,
West Nile virus PCR, cryptococcal antigen, Lyme Western Blot, and enteroviral PCR pending. CSF also sent to CA
Encephalitis Project.
ESR 11, CRP 1.0
TSH 0.58, T4 10.2 (normal)
ASO titer 202 IU/mL (reference range < 160)
Anti-DNAse B 1:960 (reference range < 1:170); ANA Neg
Mycoplasma IgG > 3.18 (reference range < 0.90); IgM 2,267 (reference range < 770 units)
Other Studies
Non-contrast Head CT: Negative for evidence of hemorrhage or mass effect.
EEG: Excessive slowing of background rhythm during aroused and awake states consistent with mild
encephalopathy. No seizure activity noted.
DIFFERENTIAL DIAGNOSIS?

(See last page of this topic submission for discussion)

2

Altered Mental Status (AMS)

Children with AMS present across a continuum ranging from subtle cognitive difficulties
(shortened attention span, impaired memory, perceptual deficits, personality changes), to
agitation, disorientation, florid delirium (confusion with superimposed hyperactivity of the
sympathetic limb of the autonomic nervous system with consequent tremor, tachycardia,
diaphoresis, and mydriasis), lethargy, obtundation, stupor, and ultimately, loss of arousal and
awareness, or coma.
Coma refers to unarousable unresponsiveness. It is a transient state and has been defined as a
Glasgow Coma Score below 12 for more than six hours. Patients recover, die, or evolve into a
more permanent state of impaired consciousness (Persistent vegetative state, minimally conscious
state, brain death).
Incidence of nontraumatic coma:

30 per 100,000 children per year;

Incidence of traumatic coma: 140 per 100,000 children per year (United States)

Etiologic Considerations
Causes of altered mental status are diverse and include structural brain disease and systemic disease; the
most common etiologies in children include trauma, infections, metabolic derangements, and
intoxications. The differential should be guided by history, when available, and may include:
Infection: Meningitis, Meningoencephalitis, Intracranial abscess, Subdural empyema
Trauma:

Cerebral concussion, Subdural/Epidural hematoma, Drowning, Heat Stroke

Toxic exposure:

Sedative-hypnotics, Narcotics, Alcohol, Salicylates, CO, Lead

Post-infectious/Autoimmune: Acute disseminated encephalomyelitis/ADEM (demyelinating),

autoimmune cerebritis (e.g., SLE)
Seizures/Post-ictal state
Vascular conditions:

Subarachnoid hemorrhage, Hypertensive encephalopathy, CVA

Endocrine/Metabolic: Hypoglycemia, DKA, Hyperosmolar coma, Hypo-/Hypernatremia,

Renal failure, Reyes encephalopathy, Addison crisis, inborn errors of metabolism
Intracranial neoplasms and paraneoplastic syndromes
Intussusception
Psychiatric conditions:

Acute psychosis, psychogenic etiology

History
Substance use: alcohol, marijuana, stimulants (cocaine, amphetamines, ADHD medications),
sedatives/hypnotics, opiates, prescription analgesics, hallucinogens (LSD)
Toxic (e.g., lead, CO) or animal (e.g., bat, tick) exposures
Commonly ingested home medications: Amphetamines, Anticholinergics, Anticonvulsants,
Barbiturates, Benzodiazepines, Clonidine, Cocaine, Ethanol, Haloperidol, Narcotics,
Phenothiazines, Salicylates, Selective serotonin uptake inhibitors (SSRIs), Tricyclic
antidepressants

Physical Exam
Vital signs look for Cushing triad (hypertension, bradycardia, and irregular respiratory pattern)
Stabilize cervical spine if injury suspected
Glasgow coma score (see below); intubate if GCS 8 or respiratory failure
Detailed neurologic exam, including cranial nerves, sensory, motor, reflexes, cerebellar, gait
o

Also look for: photophobia, neck stiffness, pupillary response, cranial nerve dysfunction,
papilledema, abnormal posturing

Detailed physical exam, look for signs of trauma (including NAT)

Mental status exam (see below)

Considerations for Diagnostic Work-Up

Patients presenting with altered mental status should undergo a rapid bedside test for blood glucose and
basic laboratory testing including:
Serum electrolytes, calcium, magnesium,
Liver function tests, Ammonia, Blood urea nitrogen, Creatinine
CBC with differential, Blood culture
Urine / Blood Toxicology (substances of abuse, blood alcohol level), Lead
Arterial Blood Gas
+/- Head CT before +/- Lumbar puncture (exclude an intracranial mass lesion prior to LP to
avoid precipitating transtentorial herniation)
o

Always perform head CT with history of loss of consciousness

If unrevealing, MRI is more sensitive for early evidence of encephalitis, infarction,

diffuse axonal injury from head injury, petechial hemorrhages, cerebral venous
thrombosis, and demyelination)

+/- Carboxyhemoglobin screen for possible carbon monoxide exposure

+/- Screen for metabolic abnormalities (urine porphyrins, ketone bodies, plasma free fatty acids,
carnitine, CK, lactate, pyruvate, serum amino acids, urine organic acids)
+/- Lead screen
+/- EEG for coma of unknown etiology

Early Treatment Considerations

Airway, Breathing, Circulation
Consider empiric oxygen, glucose, naloxone (could be diagnostic)
Treat hypoglycemia emergently (blood glucose < 80 mg/dL)

Mental Status Examination (MSE)

The patients initial mental status examination at presentation and fluctuations should be documented
carefully in every case of altered mental status. Consider remembering the acronym ABSTACI
(appearance, behavior, speech, thought, affect, cognition, insight/judgment).
The following is review of features of the mental status examination use aspects that are appropriate for
your patients baseline developmental stage:
Appearance:
o Dress, including props of interest
o Grooming/hygiene (well-groomed, disheveled), appearance relative to age
o Apparent nutrition level/ body weight
o Facial expressions, gait, breathing, eye contact, other notable mannerisms
o Level of psychomotor activity, restlessness
o Level of consciousness (alert, distracted, somnolent, obtunded)
Behavior & Attitude:
o Rapport (cooperative, uncooperative)
o Overall relationship to interviewer (hostile, seductive, clinging, guarded,
suspicious)
Speech:
o Loudness, rhythm, prosody, intonation, pitch, phonation, articulation
o Quantity, rate, spontaneity or latency
5

Fluency: grammar, word choices

Thought:
o Process: tempo (e.g., flight of ideas/mania), form/coherence (logical, formal
thought disorders*), quantity (perseveration, poverty of thought)
*Formal thought disorders: blocking, fusion, loosening of associations,
tangential thinking, derailment of thought, word salad, neologisms,
clang, knight's move thinking
o Content: delusions (false beliefs held firmly bizarre vs. nonbizarre),
overvalued ideas, obsessions, phobias, preoccupations
o Perception: hallucinations (false sensory perceptions), illusions (distortions of
sensory experiences), Control of thought disorders (mind-reading, broadcasting)
Affect:
o Intensity, range, reactivity and mobility (e.g., full, labile, blunted, constricted,
flat, overly dramatic, appropriateness - congruent/incongruent, belle indifference
bland lack of concern for one's disability)
o Subjective mood - in patients own words, reported in quotes
Cognition: (For adults, consider the Mini-mental state examination or Folstein test)
o Alertness: alert, clouded, drowsy, or stuporous
o Orientation: to person, place, time, situation
o Attention/concentration: spelling a 5-letter word backward (WORLD), digit
span, serial sevens
o Memory:
Immediate registration (repeating a set of words),
Short-term memory (current events, recalling the set of words after an
interval, or recalling a short paragraph),
Long-term memory (life events, recollection of well known historical or
geographical facts)
o Visual memory: ability to copy a diagram, draw a clock face, or a map of the
room
o Language: ability to name objects, repeat phrases; observe the individual's
spontaneous speech and response to instructions
o Abstraction: similarities (egg-seed, eye-ear), differences (wall-fence),
mistake recognition (in pictures, sentences), proverbs
o Executive functioning: screen by asking the "similarities" questions ("what do x
and y have in common?") and by a verbal fluency task (e.g. "list as many words
as you can starting with the letter T, in one minute")
Insight/Judgment:
o Insight: the patients explanation of their problem, awareness of impact
o Judgment: the patient's capacity to make sound, reasoned and responsible
decisions and to foresee consequences

Glasgow Coma Scale (E-V-M)

A score of 13 or higher correlates with mild brain injury (some clinicians use 14 or higher); a score of 9 to
12 correlates with moderate injury; and a score of 8 or less represents severe brain injury.
EYE OPENING:

E4 Spontaneous eye opening

E3 To speech
E2 To pain
E1 No response

BEST VERBAL RESPONSE:

V5 Normal, spontaneous/ coos, babbles, smiles, follows objects
V4 Disoriented, Confused / cries, irritable but consolable
V3 Inappropriate words / cries with pain
V2 Sounds / moans with pain or inconsolable crying
V1 No response

BEST MOTOR RESPONSE:

M6 Normal, spontaneous movements
M5 Withdraws to touch
M4 Withdraws to pain
M3 Decorticate to pain (flexion)
M2 Decerebrate to pain (extension)
M1 No response

Diagnosis
History and presentation will guide diagnostic evaluation and revision of the differential diagnosis. Be
certain to consider common Toxidromes. The following Table is from 2010 UpToDate:

[See Table on next page]

Intern Questions Altered Mental Status

1. A 3-year-old (16 kg) boy presents to the ED with slurred speech, disorientation. The i-STAT
reveals a blood glucose level of 20. Which of the following would be the best emergent treatment
for the hypoglycemia?
a. 10% dextrose 2.5 mL/kg IV (0.25 grams/kg)
b. 25% dextrose 1-2 mL/kg IV (0.5 1.0 grams/kg)
c. Glucagon 0.5 mg IM or Sub-Q, prepare to give IV dextrose as soon as possible
d. 50% dextrose 1 mL/kg IV (1.0 grams/kg)
e. All of the above

2. A 25 kg child on 3-South is recovering from spine surgery and using a hydromorphone PCA. His
parents find you in the hallway and tell you that he is suddenly so sleepy he will not wake up.
When you walk in his room his oxygen saturation monitor starts to alarm. Which of the
following would be an appropriate emergent treatment if you suspect opioid overdose?
(one or more correct answers)
a. Naloxone 0.2 mg IV, repeat PRN q 2-3 minutes
b. Naloxone 2 mg IV, repeat PRN q 2-3 minutes
c. Flumazenil 0.2 mg IV, repeat PRN q minute
d. Turn off the PCA
e. Place oxygen mask
f. Call a Rapid Response

3. Which of the following is an indication/are indications for suspension of an athlete from play
following a closed head injury, according to the November 2008 Consensus Statement on
Concussion in Sport? (one or more answer may be correct)
a. Symptoms: somatic (e.g., headache), cognitive (e.g., feeling like in a fog) and/or
emotional symptoms (e.g., lability)
b. Physical signs (e.g., loss of consciousness, amnesia)
c. Behavioral changes (e.g., irritability)
d. Cognitive impairment (e.g., slowed reaction times)
e. Sleep disturbance (e.g., drowsiness)
f. Any one of the above
4. Which of the following may be indicated in cases of MDMA (ecstasy) intoxication? (one or
more answer may be correct)
a. Benzodiazepines for seizures or agitation
b. Activated charcoal
c. Beta antagonists (labetalol) for life-threatening hypertension
d. Consultation with Poison Control
e. Antipyretic therapy for hyperthermia
f. All of the above

5. A 9-year-old-girl is brought to the emergency department in a confused and agitated state. She
has had a sore throat, fever, and abdominal pain for the past 4 days. A few hours ago, after
9

several episodes of vomiting, she became agitated and started talking inappropriately. She
appears toxic and is combative and agitated. Her temperature is 104F (39.6C), heart rate is 150
beats/min, respiratory rate is 40 breaths/min, and BP 84/42. She has dry lips, cold extremities, and
a low-volume pulse. All other physical findings are normal. After rehydration, her sensorium
improves partially and her vital signs normalize. Re-examination shows mild, diffuse abdominal
tenderness with mild guarding. Abdominal computed tomography (CT) was performed and
revealed signs compatible with appendicitis with perforation. What was the most likely cause of
the patients altered mental status?
a.
b.
c.
d.
e.

Gram-negative septicemia
Meningitis
Abdominal pain
Hypoglycemia
Fever

10

Intern Answers Altered Mental Status

1. A 3-year-old (16 kg) boy presents to the ED with slurred speech, disorientation. The i-STAT
reveals a blood glucose level of 32. Which of the following would be the best emergent treatment
for the hypoglycemia?
a. 10% dextrose 2.5 mL/kg IV (0.25 grams/kg)
b. 25% dextrose 1-2 mL/kg IV (0.5 1.0 grams/kg)
c. Glucagon 0.5 mg IM or Sub-Q, prepare to give IV dextrose as soon as possible
d. 50% dextrose 1 mL/kg IV (1.0 grams/kg)
e. All of the above
Answer: a. If there is difficulty obtaining IV access or IV dextrose, answer c would be a
reasonable choice. Answer b is a reasonable choice, but higher doses of dextrose (e.g., 0.5 to
1.0 g/kg) are more likely to cause acute hyperglycemia, hyperinsulinemia, and hyperosmolarity,
which may result in recurrence of hypoglycemia. Answer d is least favorable in the event there is
a problem with the IV - extravasation of higher concentrations of glucose would lead to severe
tissue damage. To avoid acute hyperglycemia with rebound hypoglycemia, the bolus should be
given slowly (2 to 3 mL/min), regardless of age. Somewhat lower doses are often used for
management of hypoglycemia in neonates.

2. A 25 kg child on 3-South is recovering from spine surgery and using a hydromorphone PCA. His
parents find you in the hallway and tell you that he is suddenly so sleepy he will not wake up.
When you walk in his room his oxygen saturation monitor starts to alarm. Which of the
following would be an appropriate emergent treatment if you suspect opioid overdose? (one or
more correct answers)
a. Naloxone 0.2 mg IV, repeat PRN q 2-3 minutes
b. Naloxone 2 mg IV, repeat PRN q 2-3 minutes
c. Flumazenil 0.2 mg IV, repeat PRN q minute
d. Turn off the PCA
e. Place oxygen mask
f. Call a Rapid Response
Answers: b, d, e, f. Naloxone at the 2 mg dose would be appropriate for this 25-kg child. For
children < 20 kg, give 0.01 mg/kg (maximum dose: 2 mg); repeat every 2-3 minutes PRN. The
immediate goal is reestablishing adequate ventilation without inducing significant pain.
Flumazenil should be used in cases with suspected benzodiazepine overdose, at 0.01 mg/kg
(maximum dose: 0.2 mg) given over 15 seconds; may repeat every minute (maximum: 4 doses) to
a maximum of total cumulative dose of 0.05 mg/kg or 1 mg, whichever is lower. Answers d, e,
and f would also be correct. Note that naloxone (Narcan) may be administered IM, SubQ, or
ET, but onset of action may be delayed, especially if patient has poor perfusion. The
recommended PALS ET doses are 2-10 times the I.V. dose.

3. Which of the following is/are required to suspend an athlete from play following a closed head
injury, according to the November 2008 Consensus Statement on Concussion in Sport? (one or
more correct answers)

11

a. Symptoms: somatic (e.g., headache), cognitive (e.g., feeling like in a fog) and/or
emotional symptoms (e.g., lability)
b. Physical signs (e.g., loss of consciousness, amnesia)
c. Behavioral changes (e.g., irritability)
d. Cognitive impairment (e.g., slowed reaction times)
e. Sleep disturbance (e.g., drowsiness)
f. Any one of the above

Answer: f. According to the International Conference on Concussion in Sport, when a player

shows ANY of the above features of a concussion, a full medical and neuropsychiatric evaluation
should be performed and return to play should be postponed (no same-day return to play for
anyone in the pediatric age-range). A detailed clinical assessment tool for sideline evaluation of
concussion is available online (Sport Concussion Assessment Tool/SCAT2 full version; pocket
version).
In 1984 Saunders and Harbaugh described the case of a 19-year-old college athlete who was
medically cleared to play football though still symptomatic from a previous blow to the head.
Although he sustained "no unusual head trauma" on the day he returned to football, he walked off
of the field, collapsed, and later died despite the evacuation of a small subdural hematoma. An
autopsy revealed widespread anoxic changes and transtentorial cerebral herniation. It was
surmised that these effects were caused by an elevated intracranial pressure, secondary to minor
sports trauma, before complete recovery from a previous concussion.1 The term second-impact
syndrome has come to describe such events. (Sources: 1. Meehan WP, Bachur RG. Sportrelated concussion. Pediatrics. 2009;123(1): 114-123 and 2. Saunders RL, Harbaugh RE. The
second impact in catastrophic contact-sports head trauma. JAMA. 1984;252 (4):538 539)

4. Which of the following may be indicated in cases of MDMA (ecstasy) intoxication? (one or
more correct answers)
a. Benzodiazepines for seizures or agitation
b. Activated charcoal
c. Beta antagonists (labetalol) for life-threatening hypertension
d. Consultation with Poison Control
e. Antipyretic therapy for hyperthermia
f. All of the above
Answer: a, b, c, d. Benzodiazepines can help with agitation, seizures, and shivering from
hyperthermia. Though active cooling measures should be administered for hyperthermia, there is
no role for antipyretics such as acetaminophen or ibuprofen because the underlying mechanism
does not involve hypothalamic control. Activated charcoal (1 g/kg) can reduce further absorption
of drug remaining in the stomach. Telephone consultation with California Poison Control (1-800222-1222) is always recommended (document discussions for the medical record).
MDMA (methylenedioxymethamphetamine) is one of the most commonly used designer drugs.
Other names include "Ecstasy," "E," "X-TC," "Adam," "clarity," "Stacy," "lover's speed," and
"essence." The toxicity profile includes the traditional findings of amphetamine intoxication
(hypertension, tachycardia, hyperthermia, CNS stimulation) and also those of serotonin
intoxication (serotonin syndrome, SIADH).

12

5. A 9-year-old-girl is brought to the emergency department in a confused and agitated state. She
has had a sore throat, fever, and abdominal pain for the past 4 days. A few hours ago, after
several episodes of vomiting, she became agitated and started talking inappropriately. She
appears toxic and is combative and agitated. Her temperature is 104F (39.6C), heart rate is 150
beats/min, respiratory rate is 40 breaths/min, and BP 84/42. She has dry lips, cold extremities, and
a low-volume pulse. All other physical findings are normal. After rehydration, her sensorium
improves partially and her vital signs normalize. Re-examination shows mild, diffuse abdominal
tenderness with mild guarding. Abdominal computed tomography (CT) was performed and
revealed signs compatible with appendicitis with perforation. What was the most likely cause of
the patients altered mental status?
a. Gram-negative septicemia
b. Meningitis
c. Abdominal pain
d. Hypoglycemia
e. Fever
Answer: a. Sepsis can progress to organ dysfunction, mental status changes, shock, and death
due to tissue damage caused by host responses to endotoxins from gram-negative bacteria (and to
cell wall antigens in the case of gram-positive bacteria). In this case, the perforated appendicitis
led to sepsis. The patients blood culture grew Escherichia coli. In such a case, the patient may
have alterations in the mental status due to meningeal involvement, CNS bleeding due to
disseminated intravascular coagulation (DIC), or encephalopathy due to renal or hepatic failure.
[Based on Index of Suspicion, Case #1 in Pediatrics in Review. 2002;23:433-438]

13

Senior Resident Questions Altered Mental Status

1. A 16-year-old female was admitted to the hospital with headache, behavioral changes, abnormal
movements, and intermittent inability to communicate (garbled and incoherent speech).
Somnolence, dysphoria, short-term memory problems, confusion, agitation, and symptoms of
depersonalization developed. On hospital day two, a generalized tonicclonic seizure occurred,
associated with bradycardia (30 to 39 beats per minute). The cerebrospinal fluid showed a
pleocytosis, elevated protein, and oligoclonal bands, with negative viral and bacterial studies. On
the 10th day, ultrasonography of the pelvis revealed a hyperechogenic focus, 1.9 cm by 2.8 cm, in
the left ovary that contained fat and internal calcification, findings that were consistent with a
dermoid cyst. Which of the following explanation for the patients mental status changes would
be supported by this ultrasound finding?
a.
b.
c.
d.
e.

Systemic lupus erythematosus

Hashimoto's disease with encephalopathy
Acute limbic encephalitis
Anti-NMDA-receptor antibodymediated paraneoplastic limbic encephalitis
Herpes simplex virus encephalitis

2. A 2-year-old boy is brought to the emergency department at 4 AM because of a fever and a 6hour history of intermittent fits of terror and screaming, with complaints of seeing rats. The boy
is cared for by his father, who had put him to bed that night, at which time he was acting
normally. The child awoke at 11 PM, screaming in terror and pointing to the floor. The father
saw nothing where the boy was pointing and found it difficult to console the child. The only
medication in the home is an oral hypoglycemic agent. Temperature is 40C (104 F), pulse is
190 beats/min, respiratory rate is 28 breaths/min, and blood pressure is 120/80 mm Hg. The
patient's diagnosis was established when his urine toxicology screen was reported to be positive
for cocaine. When confronted, the child's father admitted to having stored crack cocaine in a
dresser drawer. Which of the following is/are indicated? (one or more correct answers)
a.
b.
c.
d.
e.

Beta-blockers
Antipyretics
Oral charcoal
Benzodiazepines
Report to Child Protective Services

3. Signs and symptoms of increased intracranial pressure (ICP) in the toddler or school-age child
include: lethargy or irritability, headache, vomiting, papilledema, and diplopia or an abducens
palsy. The signs and symptoms of increased ICP in infants differ because of the presence of an
open fontanelle. Which of the following are least likely in infants with increased ICP?
a.
b.
c.
d.
e.
f.

Widened sutures and bulging fontanelle

Persistent downward eye deviation ("sunsetting" of the eyes)
Increased head circumference
Papilledema
Abducens palsy
Head tilt

14

4. An 8-year-old soccer player presents to the ED with acute confusion and disorientation which
began during a game. His he is tachypneic, tachycardic, and flushed with a core temperature of
104.9F, consistent with heat stroke. Which laboratory abnormalities might be present? (one or
more correct answers)
a.
b.
c.
d.
e.
f.

Metabolic acidosis
Elevated serum CK and associated hypocalcemia and hyperphosphatemia
Myoglobinuria, increased creatinine and blood urea nitrogen
Electrolyte abnormalities (especially Na+ and K+)
Hypoglycemia
Coagulation studies consistent with DIC

5. What are the most common neurologic features of ADEM (Acute disseminated
encephalomyelitis), in addition to encephalopathy?
6. (BONUS question) Match the immunosuppressive agent with the most-commonly associated
neurologic /mental status side effects they can produce:
1. Corticosteroids

A. anxiety, tremor, vivid nightmares, restlessness

2. Cyclosporin
3. Tacrolimus (FK 506)

B. insomnia, irritability, impaired concentration, mood changes

C. somnolence, headache, dysarthria, visual hallucinations,
depression

15

Senior Resident Answers Altered Mental Status

1. A 16-year-old female was admitted to the hospital with headache, behavioral changes, abnormal
movements, and intermittent inability to communicate (garbled and incoherent speech).
Somnolence, dysphoria, short-term memory problems, confusion, agitation, and symptoms of
depersonalization developed. On hospital day two, a generalized tonicclonic seizure occurred,
associated with bradycardia (30 to 39 beats per minute). The cerebrospinal fluid showed a
pleocytosis, elevated protein, and oligoclonal bands, with negative viral and bacterial studies. On
the 10th day, ultrasonography of the pelvis revealed a hyperechogenic focus, 1.9 cm by 2.8 cm, in
the left ovary that contained fat and internal calcification, findings that were consistent with a
dermoid cyst. Which of the following explanation for the patients mental status changes would
be supported by this ultrasound finding?
a. Systemic lupus erythematosus
b. Hashimoto's disease with encephalopathy
c. Acute limbic encephalitis
d. Anti-NMDA-receptor antibodymediated paraneoplastic limbic encephalitis
e. Herpes simplex virus encephalitis

Answer: d. Dermoid cysts/Ovarian teratomas are associated with limbic encephalitis and with
N-methyl-D-aspartate receptor antibodies in the blood and cerebrospinal fluid. Inflammatory
autoimmune limbic encephalitis develops rapidly over a period of days or weeks and is
characterized by inflammation, usually centered in the medial temporal lobes, but other structures
may be affected. It is usually a paraneoplastic syndrome in which a non-neural tumor containing
an antigen normally present in the nervous system triggers an autoimmune attack on neural tissue.
In this case, the ovarian tumor, containing primitive neural tissue, is thought to provide the
antigen responsible for the presence of NMDAR (N-methyl-D-aspartate receptor) antibodies.
Autoantibodies attack components of the neuronal membrane and cause reversible loss of
function. Improvement may occur with immunotherapy, and with removal of the ovarian tumor.
[This question is derived from NEJM Case 26-2008: N Engl J Med 359:842, August 21, 2008
Case Records of the Massachusetts General Hospital]

2. A 2-year-old boy is brought to the emergency department at 4 AM because of a fever and a 6hour history of intermittent fits of terror and screaming, with complaints of seeing rats. The boy
is cared for by his father, who had put him to bed that night, at which time he was acting
normally. The child awoke at 11 PM, screaming in terror and pointing to the floor. The father
saw nothing where the boy was pointing and found it difficult to console the child. The only
medication in the home is an oral hypoglycemic agent. Temperature is 40C (104 F), pulse is
190 beats/min, respiratory rate is 28 breaths/min, and blood pressure is 120/80 mm Hg. The
patient's diagnosis was established when his urine toxicology screen was reported to be positive
for cocaine. When confronted, the child's father admitted to having stored crack cocaine in a
dresser drawer. Which of the following is/are indicated? (one or more correct answers)
a.
b.
c.
d.
e.

Beta-blockers
Antipyretics
Oral charcoal
Benzodiazepines
Report to Child Protective Services

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Answer: c, +/-d, e. Beta-blocking agents are not recommended for routine use because of their
potential for exacerbating cardiac ischemia, but they may be used to treat life-threatening
arrhythmias. Benzodiazepines, especially diazepam, may help to counter the effects of CNS
excitation. The hyperpyrexia may be unresponsive to antipyretics and mechanical cooling may be
more effective. [Based on Index of Suspicion, Case #1 in Pediatrics in Review. 1997;18:379382.]
3. Signs and symptoms of increased intracranial pressure (ICP) in the toddler or school-age child
include: lethargy or irritability, headache, vomiting, papilledema, and diplopia or an abducens
palsy. The signs and symptoms of increased ICP in infants differ because of the presence of an
open fontanelle. Which of the following are least likely in infants with increased ICP? (one or
more correct answers)
a. Widened sutures and bulging fontanelle
b. Persistent downward eye deviation ("sunsetting" of the eyes)
c. Increased head circumference
d. Papilledema
e. Abducens palsy
f. Head tilt
Answer: d, e, f. Papilledema, when seen in older children, is usually a sign of elevated ICP that
has been present for weeks or longer. Due to the open fontanelle, both papilledemia and
abducens palsy are unlikely to be seen in infants. Head tilt, as well as meningismus, is associated
with posterior fossa lesions in infants and children.

4. An 8-year-old soccer player presents to the ED with acute confusion and disorientation which
began during a game. His he is tachypneic, tachycardic, and flushed with a core temperature of
104.9F, consistent with heat stroke. Which laboratory abnormalities might be present? (one or
more correct answers)
a.
b.
c.
d.
e.
f.

Metabolic acidosis
Elevated serum CK and associated hypocalcemia and hyperphosphatemia
Myoglobinuria, increased creatinine and blood urea nitrogen
Electrolyte abnormalities (especially Na+ and K+)
Hypoglycemia
Coagulation studies consistent with DIC

Answer: All of the above. All of these lab results are possible, reflecting systemic inflammatory
response and end-organ damage due to heat stress. Mental status usually improves when
normothermia, oxygenation, and normal tissue perfusion are achieved. Cooling measures should
be stopped once core temperature reaches 100.4F, to prevent rebound hypothermia. [Source:
Ishimine P. Heat Stroke in Children. 2010 UpToDate]
5. What are the most common neurologic features of ADEM (Acute disseminated
encephalomyelitis), in addition to encephalopathy?
Answer: The most common features of ADEM include the following: Long tract (pyramidal)
signs, acute hemiparesis, cerebellar ataxia, cranial neuropathies including optic neuritis, seizures,
and spinal cord dysfunction (transverse myelitis). Aphasia, movement disorders, and sensory
deficits are less common.
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6. (BONUS question) Match the immunosuppressive agent with the most-commonly associated
neurologic /mental status side effects they can produce:
1. Corticosteroids

A. anxiety, tremor, vivid nightmares, restlessness

2. Cyclosporin

B. insomnia, irritability, impaired concentration, mood changes

3. Tacrolimus (FK 506)

C. somnolence, headache, dysarthria, visual hallucinations,

depression

Answers: 1B, 2C, 3A. [Source: Myer E. Acute toxic-metabolic encephalopathy in children.
2010 UpToDate]

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Key Articles on Altered Mental Status

Kanich W, et al. Altered mental status: evaluation and etiology in the ED. Am J Emerg Med.
2002;20 :613 617.
Avner J. Altered States of Consciousness. Pediatrics in Review. 2006;27:331-338.
Osterhoudt, KC, Burns Ewals, M, et al. Toxicologic emergencies. In: Textbook of Pediatric
Emergency Medicine, 6th ed, Fleisher, GR, Ludwig, S, Henretig, FM (Eds), Lippincott Willliams
& Wilkins, Philadelphia 2006.
Vale, JA. Position statement: gastric lavage. American Academy of Clinical Toxicology;
European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol
1997; 35:711.
Sroufe NS, et al. Postconcussive Symptoms and Neurocognitive Function After Mild Traumatic
Brain Injury in Children. Pediatrics. June 2010; 125: e1331 - e1339.
Larsen GY, Goldstein B. Consultation with the Specialist: Increased Intracranial Pressure.
Pediatrics in Review. 1999;20:234-239.

Follow-up Discussion of Case (continued from page 2)

TBA (Please email noellevcj@gmail.com if still not posted by the time you read this!)

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