Case 5: A 7-year-old Autistic Boy with Altered Movements and Mental Status

Presentation

A 7-year-old boy with autism and attention-deficit/hyperactivity disorder transfers from an outside hospital adult emergency department to our inpatient unit for concerns of change in mental status for the past 2 days. His initial symptoms include sluggishness and disorientation, slowly progressing to drooling with forced jaw opening, gait abnormalities, left-sided truncal deviation, stiffness in extremities, broken speech, and body tremors. No history of fever, trauma, or ingestion of an unknown substance is identified on questioning. At baseline, the child is energetic, outspoken, and talkative. He was transitioned from an outpatient psychiatric partial hospitalization program to his regular school on the day of onset of symptoms. His home medications include lisdexamphetamine, clonidine, and aripiprazole.

On his way to the adult emergency department, the child complains to emergency medical services of back and neck pain, so a cervical collar is placed. On arrival, the child has stable vital signs and a Glasgow Coma Scale score of 14 (of a total possible score of 15). Physical examination reveals an awake child, drooling with a protruding tongue, with varying levels of alertness and visible tremors in his extremities. He …