A 16-year-old boy with altered mental status.

and colleagues discuss hard-to-diagnose cases. A 16-year-old boy was transferred from an outside hospital for evaluation of altered mental status. Earlier in the month, he had begun having feelings of nervousness and anxiety. He reported hearing voices and having visual hallucinations. According to his parents, these symptoms had begun after the patient had been out clubbing with his friends; he may have been given a drink that contained an unknown substance. He stated that he thought that he was turning into his uncle who has Trisomy 21. His physician prescribed valium and Prozac; he took those for several days before they were discontinued because of the development of possible side effects, including stuttering and oral movements. On review of systems, he reported poor appetite, inability to sleep, crying spells and fluctuations in his mood. Four days prior to his transfer, he was admitted to a psychiatric hospital because he became violent toward his family. He received several medications including Ativan and several antipsychotics. Subsequently, he was transferred to that hospital's medical unit because of concerns of dehydration and rhabdomyolysis. CPK at that time was 5,000 IU/L. Early the morning of transfer, he was found to have altered mental status, eye flickering, face twitching, hand and feet shaking, tachycardia and temperature of 101°F. He was given dantrolene for presumed malignant neuroleptic syndrome and transferred here. Medical history was unremarkable. He was currently in 9th grade, but his parents reported that he wasn't doing well at school. He had a history of anxiety related to being touched inappropriately at age 6 years. He underwent counseling at that time, but he had no previous history of psychiatric hospitalization or treatment. According to his parents, he was a happy, normal child prior to the onset of this illness. Family history was unremarkable for any significant medical or psychiatric diseases. On examination upon transfer, he was afebrile, respiratory rate 21, heart rate 106, blood pressure 130/88 mm Hg. In general, he had waxing and waning intervals of alertness and altered mental status. HEENT examination was unremarkable. Neck was supple without lymphadenopa-thy or thyromegaly. Lungs and heart exam were unremarkable with the exception of tachycardia. Abdomen was soft without or-ganomegaly. Neurologic exam was limited due to lack of cooperation. Cranial nerves, deep tendon reflexes and strength were normal. Intermittently he sat up and moved his feet and arms in bicycling movements. On mental status exam, he …