A 14-year-old girl is brought to the emergency department after throwing a notebook at her teacher, rambling about "bats on the ceiling," and trying to run out of school. Medical history is significant for asthma, for which she uses albuterol as needed, and attention-deficit hyperactivity disorder, for which she takes extended-release mixed amphetamine salts on school days. There has been no recent change in the patient's medications. Family history is significant for Graves disease in her mother and schizophrenia in her maternal aunt. The patient says, "There are bats everywhere. They can hurt me now that all sorts are involved." She is alert but appears fearful and distracted and makes poor eye contact. Her father says that this behavior is uncharacteristic but that she has been behaving "oddly" for a few days, sleeping poorly, appearing anxious, and staring at her bedroom walls. Several weeks ago, the patient started missing multiple days of school and did not want to go out with friends, saying that her joints hurt too much. She has also recently experienced headaches and poor concentration. Temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, pulse is 98/min, and respirations are 18/min. Laboratory results are as follows: Urine and blood toxicology are negative. Which of the following is the most appropriate next step in management of this patient?

Question

A 14-year-old girl is brought to the emergency department after throwing a notebook at her teacher, rambling about "bats on the ceiling," and trying to run out of school.  Medical history is significant for asthma, for which she uses albuterol as needed, and attention-deficit hyperactivity disorder, for which she takes extended-release mixed amphetamine salts on school days.  There has been no recent change in the patient's medications.  Family history is significant for Graves disease in her mother and schizophrenia in her maternal aunt.  The patient says, "There are bats everywhere.  They can hurt me now that all sorts are involved."  She is alert but appears fearful and distracted and makes poor eye contact.  Her father says that this behavior is uncharacteristic but that she has been behaving "oddly" for a few days, sleeping poorly, appearing anxious, and staring at her bedroom walls.  Several weeks ago, the patient started missing multiple days of school and did not want to go out with friends, saying that her joints hurt too much.  She has also recently experienced headaches and poor concentration.  Temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, pulse is 98/min, and respirations are 18/min.  Laboratory results are as follows:  Urine and blood toxicology are negative.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

The acute onset of psychosis in a child or adolescent is rare, and it is essential to rule out medical or substance-induced conditions that are potentially reversible. This patient's history of arthralgia and psychosis, together with thrombocytopenia, hematuria, and proteinuria, is concerning for systemic lupus erythematosus (SLE). The classic malar rash seen in SLE is often absent and should not be relied on for diagnosis. Inflammatory disorders such as SLE can affect the CNS and manifest with both acute and chronic psychiatric symptoms, including psychosis, depression, mania, and anxiety. conditions systemic lupus erythematosus (SLE) Other neuropsychiatric manifestations seen in SLE include seizures, headaches, peripheral neuropathy, strokes, and chorea. Biological mechanisms of these manifestations are thought to include immune-mediated inflammation and vasculitis. The most appropriate next step is to check for antinuclear antibodies to aid with the diagnosis of SLE. If these are positive, further testing for more specific antibodies (eg, anti-double-stranded DNA, anti-Smith, anti-U1 ribonucleoprotein) should be undertaken. (Choice A) A diagnosis of primary psychiatric illness requires ruling out medical conditions first. This patient's physical symptoms and abnormal laboratory results suggest a medical cause of her psychosis. (Choice B) Many medications and illicit drugs (eg, amphetamines, corticosteroids, cocaine, hallucinogens, marijuana, bath salts) can cause psychosis via their CNS effects. However, amphetamines rarely cause psychosis when used in therapeutic dosages, and this patient has a normal creatinine level and no recent dosage changes. In addition, her drug screen is negative, indicating that she has not recently taken her amphetamines. Because amphetamine-induced psychotic disorder would not explain this patient's arthralgias, thrombocytopenia, proteinuria, and hematuria, checking antinuclear antibodies is the most appropriate next step. (Choice D) Thyroiditis can result in anxiety, insomnia, and acute psychosis; however, the patient's TSH level is normal, making this diagnosis unlikely. (Choice E) A urethral swab could be used to detect gonococcal infection, which commonly presents as a migratory polyarthralgia in young people. Other manifestations include tenosynovitis, genitourinary symptoms, and skin lesions. However, gonococcal infection does not cause acute psychosis. Educational objective: The sudden onset of psychosis in a child or adolescent is rare, and it is important to search for potentially reversible conditions such as medical disorders or substance use. Common medical conditions to rule out include systemic lupus erythematosus, thyroiditis, metabolic or electrolyte disorders, CNS infection, and epilepsy. References: New onset psychosis as the first manifestation of neuro-psychiatric lupus. A situation causing diagnostic dilemma. (http://www.ncbi.nlm.nih.gov/pubmed/26664084) Evaluation and treatment of acute psychosis in children with systemic lupus erythematosus (SLE): consultation-liaison service experiences at a tertiary-care pediatric institution. (http://www.ncbi.nlm.nih.gov/pubmed/21051683) Primary psychiatric disorder masking the diagnosis of neuropsychiatric lupus in a patient with altered mental status: a case report. (http://www.ncbi.nlm.nih.gov/pubmed/29423350)

A 14-Year-Old Girl Is Brought to the Emergency Department After