(010) Keeping your eyes open: Misdiagnosis of a pediatric patient presenting with psychosis and catatonia

Abstract: Background/Significance
Missing signs and symptoms can lead to misdiagnosis of medical conditions presenting with psychiatric symptoms. Systemic lupus erythematosus (SLE) is one disease that can present with neuropsychiatric symptoms including catatonia (1, 2). An inaccurate diagnosis can be delay critical treatment. In this case, a pediatric patient with an underlying medical disorder presented with primarily psychiatric symptoms, with a timely diagnosis being complicated by missed signs and symptoms.

Case
A 16-year-old previously healthy female with abrupt onset of symptoms presented to a psychiatric unit with psychosis and catatonia. The basic workup on admission was normal, except for leukopenia and anemia that were missed at that time. Autoimmune panel results were not available at the time of discharge. Catatonia improved with lorazepam, she was diagnosed with schizophreniform disorder, and psychotic symptoms improved with olanzapine. A month after discharge she presented again with an inability to perform activities of daily living, poor oral intake, hypersomnia, fever, sweating, and tremors, as well as signs of malignant catatonia with autonomic instability versus neuroleptic malignant syndrome. Multiple teams noted vision changes in their documentation but no workup was pursued until the psychiatry consultation-liaison team suggested an ophthalmology consult which revealed retinal vasculitis with Purtscher-like retinopathy. SLE was confirmed following additional medical workup. Aggressive treatment with steroids, plasmapheresis, and cyclophosphamide, as well as lorazepam for catatonia, led to gradual improvement of symptoms.

Discussion
In this case, diagnosis of an underlying medical condition was delayed partly due to the initial presentation being primarily psychiatric and a number of missed or ignored signs and symptoms. Vision and eye changes documented during the initial and subsequent admission, as well as leukopenia and anemia were overlooked. In addition, given the acute onset two months prior further initial workup may have been warranted. Underlying medical conditions masquerading as psychiatric disorders do occur (3) and awareness, careful attention to detail, and appropriate medical workup are critical for timely and accurate diagnosis. In addition, the psychiatric consultant can play a critical role in ensuring that a comprehensive workup takes into account the possibility of both psychiatric and medical etiologies.

Conclusions/Implications
This case highlights the importance of a comprehensive review of systems and close attention to signs and symptoms while considering underlying medical causes for psychiatric symptoms to ensure an accurate and timely diagnosis.

References
Boeke A, Pullen B, Coppes L, Medina M, Cooper JJ. Catatonia Associated With Systemic Lupus Erythematosus (SLE): A Report of Two Cases and a Review of the Literature. Psychosomatics. 2018. 59(6):523-530.

The American College of Rheumatology nomenclature and case definitions for neuropsychiatric lupus syndromes. Arthritis Rheum. 1999 Apr;42(4):599-608.

McKee J, Brahm N. Medical mimics: Differential diagnostic considerations for psychiatric symptoms. Ment Health Clin. 2016 Nov 3;6(6):289-296.

Presenting Author(s)
EK

Emily Kane, n/a

Post Pediatric Portal Fellow
University Hospitals
University Heights, Ohio, United States

Co-Author(s)

Mohammed T. Islam, MD

Child and Adolescent Psychiatry Fellow
University Hospitals
Cleveland, Ohio, United States

SL

Sarah Lytle, MD

Assistant Professor
University Hospitals Cleveland Medical Center
Cleveland, Ohio, United States