This article requires a subscription to view the full text. If you have a subscription you may use the login form below to view the article. Access to this article can also be purchased.
- Tara M. Kopp, MD, MS*
- Jacob M. Redel, MD†,‡
- Holly E. Depinet, MD, MPH§,¶
- *Department of Pediatrics, University of Louisville, Louisville, KY
- †Division of Endocrinology, Children’s Mercy Hospital, Kansas City, MO
- ‡Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO
- §Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- ¶Department of Pediatric, College of Medicine, University of Cincinnati, Cincinnati, OH
AUTHOR DISCLOSURE
Drs Kopp, Redel, and Depinet 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 5-year-old fully immunized girl with a history of tuberous sclerosis, localization-related epilepsy with remote resection of a seizure focus, developmental delay, oral aversion with gastrostomy tube dependence, and necrotizing pancreatitis presents with reported episodes of gait instability and altered mental status described as her head falling down, sudden diffuse loss of muscle tone, and unresponsiveness lasting 15 to 45 seconds. During the past few hours, the mother has noticed that the child appears wobbly. She had 1 episode of wobbliness with subsequent fall but denies any head injury, loss of consciousness, or tonic-clonic movements. On presentation to the emergency department she had 2 additional episodes of hypotonia and unresponsiveness to verbal stimuli lasting less than 1 minute. She had not recently missed any of her antiepileptic medications, which included levetiracetam, perampanel, vigabatrin, and taurine. In addition, her medications had not been changed in the past 6 months. Due to her oral aversion, her mother assures us that she would not have accidentally ingested any medications or other household substances.
Initial temporal temperature is 98.2°F (36.8°C), heart rate is 124 beats/min, blood pressure is 107/77 mm Hg, respiratory rate is 24 breaths/min, and oxygen saturation is 96% on room air. Physical examination reveals a wakeful crying girl fighting medical personnel and intermittently becoming hypotonic and unresponsive to verbal commands. Mucous membranes are moist, and extremities have brisk capillary refill. Respiratory effort is normal except for episodes of periodic shallow breathing. Pupils are midline and reactive but become dilated with minimal responsiveness during the episodes of hypotonia and unresponsiveness. Upper and lower extremity hypotonia is noted (with intermittent worsening during …
Individual Login
Institutional Login
You may be able to gain access using your login credentials for your institution. Contact your librarian or administrator if you do not have a username and password.
Log in through your institution
Pay Per Article - You may access this article (from the computer you are currently using) for 2 days for US$25.00
Regain Access - You can regain access to a recent Pay per Article purchase if your access period has not yet expired.