Case Presentation: The patient is admitted after an episode of unresponsiveness and tremulousness at home. At an outside hospital, the patient was found to be hypertensive, tachycardic, tachypneic, with muscle stiffness and flexed posture. He was given lorazepam and cyproheptadine, which seemed to help his symptoms. He was transferred to the PICU, at which point he became febrile with an elevated CK. Over the next several days, the patient’s tremulousness resolved and he became more interactive. While his father said that this patient had reached baseline mentation, his mother said that he was very different than before he started having these episodes.This was the patient’s third such presentation of similar symptoms within one month; at prior hospitalizations, he had been given both lorazepam and started on levetiracetam. He had also been sent to an inpatient psychiatric hospital for concern of serotonin overdose, which both the patient and his parents denied. Between hospitalizations, the primary hospital team transitioned, and on the patient’s third presentation, a workup for other etiologies was started, including carcinoid tumors, neuroendocrine tumors, and pheochromocytoma. Neurology was consulted for concern of seizure-like activity, and endocrinology was consulted for an elevated TSH level; oncology was also consulted out of concern of a paraneoplastic process.This patient has a past medical history of constipation, and his home medications included polyethylene glycol and sennosides. His immunizations are up to date. His parents are on SSRIs. There was past concern for suicidal messaging. His physical exam was unremarkable except for evidence of dysautonomia. Laboratory findings were notable for an elevated TSH, low T4, TPO antibodies, and anti-thyroglobulin antibodies. Head MRI was notable for focal areas of gyral signal hyperintensity/abnormality in the anterior frontal cortex/leptomeninges bilaterally; EEG showed a severely abnormal EEG due to lack of reactivity, generalized slowing and asynchrony and non-specific findings indicative of a generalized encephalopathy.
Discussion: The patient presented on three separate occasions. On the first and second admissions, the patient was diagnosed with serotonin syndrome and suicidal ideation. On the third hospital admission, a new medical team assumed care of the patient and identified the following features that were inconsistent with serotonin syndrome: symptoms (including altered mental status and dysautonomia) persisted longer than expected; patient and parent denial of the patient intention to hurt himself; a child psychiatrist did not endorse suicidal ideation; abnormal thyroid laboratory studies; abnormal MRI findings; abnormal EEG Findings. With these findings, the final diagnosis was determined to be Hashimoto Encephalopathy.
Conclusions: 1. Avoid premature closure: Despite having a diagnosis, patients who re-present for medical care deserve consideration of other causes for their clinical presentation. 2. Beware of confirmation bias: A pubertal boy with a complex social history and access to SSRIs may not always have a psychiatric condition.3. Although continuity of care is beneficial in many cases, switching teams – and therefore getting new opinions – can be beneficial in addressing complex diagnostic dilemmas.4. It is important to use clinical, laboratory, and imaging findings to guide the search for alternative diagnoses.