Laura L.

Brown
May 28, 2014

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 spell
lasting ~ 1 minute, followed by about 10 minutes of
frantic flailing during which he screamed in panic
about having to get the orange and black bugs out
from 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

What else would you like to know?
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 po
immediately 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 thinking
somebody tripped him
More tired than normal today
Only medications in home = Naproxen and erythromycin face cream; father
checked garage and cabinets
Nothing out of place
No history of trauma
Additional History
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, eye
discharge/redness, vomiting, abdominal pain, diarrhea/constipation, rashes.
Additional History
T 36.7, P 100, BP 92/60, RR 20, saturating 95% on RA
Gen: Initially gives tentative high-five but will not talk, then abruptly starts
thrashing violently and screaming in panic about getting the orange and black bugs
out of inside of me, picks at himself frenetically. Lucid between episodes.
HEENT: Normocephalic, atraumatic. Dilated pupils. PERRL, no conjunctival injection or
discharge, 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 facial
expressions, normal tone throughout, Goliath-like strength in upper and lower
extremities bilaterally, reflexes 2+ in upper and 1+ in lower extremities bilaterally. No
clonus. Babinski absent b/l. Sensation intact to light touch throughout. No ataxia with
spontaneous movements. Unable to assess gait.
Physical Exam
Differential?
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 vasculitis
Substrate 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
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
Received lorazepam 0.1mg/kg with calming effect initially followed by
disinhibition, 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
Psychiatry consulted on 2
nd
day of hospitalization
Back to baseline, cheerily reported that he killed the
bugs with a hundred-mile scream
Spent interview typing large numbers into a
calculator and reporting, This is how many
insects/sharks/alligators/spiders/etc. there are on
planet earth!
Likely anticholinergic delirium brought on by
Benadryl leading to a
hyperdopaminergic/hypocholinergic CNS state
exacerbated by underlying Autism/anxiety
Seroquel discontinued
Went home and lived happily ever afterwe hope


The Story
Continues
History: setting suggestive of drug overdose, medications, constitutional
symptoms (fever, chills, HA), known history of SLE, head trauma, new onset
neurologic deficits, seizure disorder, prior episodes, family history of
psychiatric 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 in
Children
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 CNS
abnormality
CT head
LP for signs of meningitis AND fever or other infectious symptoms (or if
symptoms 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
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 Childhood
Psychosis
Babu et al, 2012. Emergency department evaluation of acute onset
psychosis in children. UpToDate.com
Findling, R.L. 2002. Use of quetiapine in children and adolescents. J Clin
Psychiatry 63 Suppl 13:27-31.
Politte and McDougle, 2014. Atypical antipsychotics in the treatment of
children and adolescents with pervasive developmental disorders.
Psychopharmacology 231(6):1023-36.
Prybylo et al, 2005. Acute psychosis after anesthesia: the case for
antibiomania. Paediatr Anaesth 15(8):703
References