Welcome to this month’s What’s Your Diagnosis Challenge!
But before we begin, check to see if you got last month’s case on Pediatric Septic Shock: Recognition and Management in the Emergency Department right.
Case Presentation: Movement Disorders in Children: Recognition and Management in the Emergency Department
A previously healthy 6-year-old boy presents via EMS with concern for possible seizure-like activity…
According to the boy’s mother, he had been complaining of headache for the past 2 days. This morning, he complained that his “stomach hurt,” he vomited once, and then shortly after stared off to the side with right-sided facial twitching. The mother states that a week and a half ago he had a fever and cold symptoms, and he was diagnosed with a viral infection by his primary physician. She says his symptoms resolved within a few days, and he seemed to have fully recovered.
Upon arrival, the boy’s vital signs are within normal limits for age, and he is afebrile. He is somnolent and not answering your questions, but he is able to follow commands. You are concerned that there may be a very slight facial droop on the right side. The boy’s pupils are equal and reactive, and his extraocular movements are intact. The boy demonstrates 5/5 strength of the extremities on the left, and 4/5 strength of the extremities on the right. His cardiovascular, pulmonary, HEENT, and abdominal examinations are benign.
What tests or treatments should be initiated immediately? Which type of imaging is most appropriate for this patient? What is the correct disposition?
Case Conclusion
Given the fact the patient had headache, vomiting, and new-onset seizures with neurological deficits on examination, a head CT was obtained to look for evidence of a mass or acute bleed. The CT was normal, and the patient was transferred to a tertiary center for pediatric neurology and MRI. MRI was performed on the day of arrival, and it revealed multiple small, nonenhancing white matter lesions. The patient was diagnosed with ADEM, and was treated with 5 days of high-dose IV corticosteroids, during which he returned to his neurological baseline and his headaches resolved. He did not experience any further seizure-like activity. He was discharged home on an oral prednisone taper and set to follow up with neurology.
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Last Updated on January 26, 2023
