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- Dina Sztein, MD, MPH
- Carol Vidal, MD, MPH
- Amy Lowe, MD
- Sarah Edwards, DO
- Department of Psychiatry and Department of Child and Adolescent Psychiatry, University of Maryland, Baltimore, MD.
AUTHOR DISCLOSURE
Drs Sztein, Vidal, Lowe, and Edwards have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.
Case Presentation
A 17-year-old boy presents to the emergency department with nausea and abdominal pain of 1-day duration. He has had 3 episodes of emesis, along with intermittent epigastric abdominal pain, fever, and a sore throat. Two weeks ago, he began to have decreased energy. In addition, his parents report decreased appetite and oral intake for more than a year.
The patient was diagnosed as having nephrotic syndrome at age 3 years. He subsequently had several flairs of proteinuria treated successfully with prednisone. At age 5 years, he began daily treatment with immunosuppressants and prednisone as needed for flairs; however, he had not received any corticosteroids for 18 months before the current hospitalization. At age 14 years, he presented with a similar episode of weakness, nausea, and abdominal pain, was diagnosed as having adrenal insufficiency by an adrenocorticotropic hormone (ACTH) stimulation test, and discharged with a 4-day prednisone taper. After the corticosteroid taper, on subsequent testing he was found to have normal adrenal function. After this hospitalization, his grades began to decline, and he developed psychiatric symptoms. He was anxious, avoided food for fear of poisoning, thought he had “special powers,” and believed he was “The One.” He was referred by his nephrologist to a psychiatrist for a diagnosis of schizophrenia, which was supported by a comprehensive psychological evaluation.
On examination in the emergency department, his blood pressure is 100/55 mm Hg with a pulse of 120 beats per minute. His weight has decreased from the 90th percentile to the 49th percentile during the last 6 months. He does not appear to be in acute distress, and his physical examination …
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