Case 4: Altered Mental Status in a 6-year-old Boy

Kabelo Thusang; Chineyere Onyearugbulem; Jennifer Chao; Davor Skaricic

doi:10.1542/pir.2016-0190

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Kabelo Thusang, MD*,^†
Chineyere Onyearugbulem, MD*,^†
Jennifer Chao, MD*,^†
Davor Skaricic, MD*,^†

^*Division of Emergency Medicine, Department of Pediatrics, Kings County Medical Center, Brooklyn, NY
^†State University of New York, Brooklyn, NY

AUTHOR DISCLOSURE
Drs Thusang, Onyearugbulem, Chao, and Skaricic 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.

Presentation

A previously healthy 6-year-old boy presents to the emergency department with a 5-day history of fever, sore throat, and worsening cough. One day before presentation he was found to be difficult to arouse. On the day of hospital admission he is restless and minimally responsive to his mother's commands.

On physical examination his vital signs are normal. He is minimally responsive, does not follow commands, and opens his eyes to noxious stimuli. His neck is supple, with no neck stiffness, and his pupils are 3 mm, symmetrical, and reactive to light. He is uncooperative for a funduscopic examination, and extraocular muscle movements are full and intact, without nystagmus. There is no facial asymmetry, his tongue is midline, and his palate elevates symmetrically with a strong gag response. His power is greater than 3/5 in all muscle groups, with normal tone and bulk. Deep tendon reflexes are 2+ throughout. Toes are down going to plantar stimulation bilaterally.

A blood glucose level, a complete blood cell count, and results of a basic metabolic panel are normal. A routine urine toxicology screen is negative, and acetaminophen and salicylate …