A 13-year-old girl is brought to the office by her mother due to abdominal pain. The mother says, "She's had occasional stomachaches for the last few weeks. I thought it was just menstrual cramps, but she has started skipping meals and looks like she is losing weight." Her mother also reports that the patient has become increasingly irritable, locking herself in her bedroom and coming out only to watch television. The patient says that her mother is "freaking out about nothing" and that she feels "fine." She denies nausea, vomiting, or a change in eating or bowel habits. Medical history is significant for seasonal allergies treated with loratadine as needed. Vital signs are within normal limits. A 5-kg (11-lb) weight loss is noted since her last visit 6 months ago. Physical examination is significant for a flaky, eczematous rash around the mouth involving the nasolabial folds. The abdomen is soft and flat with no tenderness to palpation. A bilateral hand tremor is noted, and further neurological examination shows globally decreased reflexes. Which of the following is the most likely explanation for this patient's presentation?

Question

A 13-year-old girl is brought to the office by her mother due to abdominal pain.  The mother says, "She's had occasional stomachaches for the last few weeks.  I thought it was just menstrual cramps, but she has started skipping meals and looks like she is losing weight."  Her mother also reports that the patient has become increasingly irritable, locking herself in her bedroom and coming out only to watch television.  The patient says that her mother is "freaking out about nothing" and that she feels "fine."  She denies nausea, vomiting, or a change in eating or bowel habits.  Medical history is significant for seasonal allergies treated with loratadine as needed.  Vital signs are within normal limits.  A 5-kg (11-lb) weight loss is noted since her last visit 6 months ago.  Physical examination is significant for a flaky, eczematous rash around the mouth involving the nasolabial folds.  The abdomen is soft and flat with no tenderness to palpation.  A bilateral hand tremor is noted, and further neurological examination shows globally decreased reflexes.  Which of the following is the most likely explanation for this patient's presentation?

Quizplus · Accepted Answer

This patient's irritability, abdominal cramps, and anorexia, in combination with perioral dermatitis and neurological signs, are concerning for inhalant abuse. Inhalants are easily accessible and found in everyday products (eg, glue, shoe polish, gasoline, spray paint). They readily cross the blood-brain barrier, resulting in euphoria and intoxication. Use typically begins in childhood or early adolescence via sniffing or inhaling (eg, placing a rag soaked with the substance on the mouth and/or nose). The characteristic perioral dermatitis (ie, "glue-sniffer's rash") is due to the drying effect of hydrocarbons. It extends around the mouth and/or nose, classically involving the nasolabial folds (a highly characteristic feature). Other clues of inhalant abuse include the odor of chemicals on the breath or clothes or finding rags, gauze, or chemical containers in the trash. Acute symptoms of inhalant use include neurologic (eg, tremor, disorientation, headaches, slurred speech, hallucinations), gastrointestinal (eg, stomach cramps, nausea), cardiovascular (eg, arrhythmia), and respiratory (eg, wheezing, coughing) effects. Psychiatric manifestations include irritability, mood swings, aggression, and grandiosity. Chronic use results in weight loss and anorexia, neurocognitive impairment, cerebellar dysfunction, and peripheral neuropathy (eg, decreased reflexes). (Choice A) Acute intermittent porphyria also presents with abdominal pain, personality changes, and peripheral neuropathy. However, it tends to manifest between age 20 and 40 and does not cause perioral dermatitis. (Choice C) Lead poisoning can present with irritability and abdominal distress; however, other features include musculoskeletal disturbances (eg, myalgia, arthralgia) and fatigue. In addition, it would not explain this patient's perioral dermatitis. (Choice D) Stimulant abuse can result in irritability as well as weight loss and tremor from sympathetic overstimulation; however, decreased reflexes and a perioral rash are not typical. Other commonly associated findings include dilated pupils, tachycardia, and diaphoresis. (Choice E) Although systemic lupus erythematous (SLE) can cause CNS manifestations, the most common rash in SLE has a malar distribution that spares the nasolabial folds. In addition, other typical manifestations of SLE (eg, fever, fatigue, myalgia, arthralgia) are absent in this patient. (Choice F) Wilson disease may present in childhood with psychiatric symptoms and neurological dysfunction in addition to signs of liver disease. It would not explain this patient's perioral dermatitis, which is highly characteristic of inhalant abuse. Educational objective: Inhalant abuse typically begins in childhood or early adolescence. Perioral dermatitis involving the nasolabial folds is characteristic. Presenting features include irritability, anorexia, abdominal cramps and neurological dysfunction. Chronic use can result in long-term neurocognitive impairment. References: Inhalant use and inhalant use disorders in the United States. (http://www.ncbi.nlm.nih.gov/pubmed/22003419) Adolescent inhalant use prevention, assessment, and treatment: a literature synthesis. (http://www.ncbi.nlm.nih.gov/pubmed/26969125)

A 13-Year-Old Girl Is Brought to the Office by Her