Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists.
I'm Pradip Kamat and I'm Rahul Damania and we are coming to you from Children's Healthcare of Atlanta - Emory University School of Medicine.
Welcome to our episode of a 14-year-old girl with sudden acute outbursts of aggression and severe agitation.
Here's the case presented by Dr. Damania:
A 14-year-old previously healthy teenager with no significant past h/o presents to the PICU with a three-day h/o of aggressive behavior, agitation, and screaming. Her mother reports that her daughter has recently developed insomnia, abnormal movements and is more irritable with temper tantrums and episodic unintelligible verbal output. Parents report no recent stressors at home or at school. She has been also complaining of headaches for the past week along with things "being too loud". She denies any vertigo symptoms or tinnitus. The patient is brought to the ER due to persistent auditory/visual hallucinations followed by agitation, aggressive behavior, and catatonia. There is no h/o of recent illnesses, head trauma, fevers, rash, abdominal pain, diarrhea, or vomiting. Social history is negative for drugs of abuse in the home. Family h/o negative for seizures, and psychiatric disorders.
The patient is sent to the ED and upon arrival has an unprovoked convulsive episode concerning a GTC seizure. The patient was initially admitted to the floor but transferred to the PICU for management of severe agitation, aggressive behavior, and fluctuations of blood pressure and heart rate.
Initial vitals in the PICU were notable for tachycardia. The patient was found to be afebrile, normotensive for age, and SpO2 96% on RA. Her physical exam though limited by her aggressive behaviors was normal. The heart, lung, and abdominal exams are normal with no rash or bruising on her body.
Initials lab work includes a negative:
U preg
Serum and Urine tox screen
CBC, CMP, and UA are all within normal limits
Inflammatory markers — including ESR CRP are unremarkable.
A head CT which was normal and an A lumbar puncture revealed colorless CSF with 8 white and 0 red cells. Serum and CSF glucose were within normal limits and protein count in CSF was negligible.
An extended multi-disciplinary work-up is initiated.

To summarize key elements from this case, Rahul this teenage girl has:
Sudden outbursts of agitation, and aggression
Recent difficulty in sleeping
Irritability, and decreased verbal output
Auditory and visual hallucinations
Potential autonomic dysfunction as she has fluctuating BP and HR All of which brings up a concern for neuropsychiatric symptoms that could be organic in nature.
Let's transition into some history and physical exam components of this case?
Rahul, what are key history features in the patient presented this case.
Seizures, Agitation, and aggressive behavior which could reflect CNS dysfunction are seen in this case.
The patient additionally has concern for hallucinations which point to a primary psychiatric disturbance as well. Remember the incidence of new-onset psychosis or schizophrenia in a child <13 is increasingly rare — 1 in 40K and thus identification and thorough workup for an organic cause is increasingly important.
Rahul, are there some red-flag symptoms or physical exam components which you could highlight?
The physical examination (although limited by her behavior) in this patient is negative
I would particularly stress the need for a detailed neurological and skin exam.
For many of the differentials we will discuss, we must evaluate for rashes, changes in nails or hair, bruising or cutting marks in her arms, and even evidence of trauma to the (head and spine), and considering both an abdominal exam to r/o organomegaly as well as bi-manual pelvic exam is important to perform.
Pradip, to continue with our case, the patient’s labs were consistent with?
Rahul, actually her labs were normal. Besides the CBC, CMP...