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Case of a Lethargic Child: Developing a Differential Diagnosis

2018-11-22T15:23:48+00:00

lethargic childA 2-year-old previously healthy boy presents to the emergency department (ED) acting sleepier than usual. Yesterday, he was in his usual state of health, but this morning he didn’t wake up at his usual time of 6 am. When his father went to his room at 7 am, the child was lying in bed. He opened his eyes to look at his father, but did not get out of bed. The mother and father deny any trauma, fever, or seizure activity.

Clinical Presentation

Temperature 36.6C, HR 114, RR 22, BP 112/76, O2 99% on room air

On evaluation, the boy is slow to respond but in no acute distress. His eyes are closed, but open each time he hears someone walk into the room. He allows the nurse to check his blood pressure without withdrawing his arm. His head is atraumatic, and his pupils are reactive (4 mm to 2 mm with light reflex). He has no nuchal rigidity. His lungs are clear, and his abdominal examination is unremarkable. You have seen him move all his extremities, but his tone is diminished. His capillary refill is <2 seconds.

Differential Diagnosis for the Sleepy Child

The evaluation of a child with altered mental status is similar to that in adults. Many resources use the pneumonic, AEIOU TIPS [Patwari whiteboard video], to develop a differential diagnosis.

However, children are not little adults. Here are 3 pediatric-specific critical diagnoses to consider in the sleepy child.

  1. Ileocolic intussusception
  2. Toxicologic: Ethanol, imidazolines, tetrahydrocannabinol (THC)
  3. Non-accidental trauma (NAT): Occult abdominal injury

1. Ileocolic intussusception

Intussusception is referred to as the neurologic presentation of the acute abdomen. Ileocolic intussusception is the telescoping of ileum into the colon, leading to venous congestion and bowel edema. If left untreated, this process may lead to a compromise in arterial blood flow, bowel infarction, necrosis, and perforation. The classic triad of colicky abdominal pain, abdominal “sausage mass”, and currant jelly stools, however, is present in only <20% of cases. More so, in 1979 the literature recognized that listlessness might be in the only presenting symptom of ileocolic intussusception in children.1

2. Toxicologic

Toxicologic exposures are not unique to children; however, several toxicologic exposures and presentations are.

The Exposure

  • Ethanol: Mouthwash, perfume/cologne
  • Imidazolines: Decongestants such as tetrahydrozoline, oxymetazoline, naphazoline (nasal spray, eye drops – i.e. Afrin, Visine).
  • Tetrahydrocannabinol (THC): Cannabis-infused edible products (candy, chocolate, etc.)

The Presentation

  • Ethanol: Intoxicated patients present with altered mental status and the classic triad of hypothermia, hypoglycemia and altered mental status. Ethanol inhibits gluconeogenesis putting younger children at the highest risk for hypoglycemia given their low glycogen stores.2
  • Imidazolines: Clonidine was initially introduced as a mucous membrane decongestant. Subsequently, other imidazoline compounds were developed, including naphazoline, oxymetazoline, tetrahydrozoline, and xylometazoline, which are available over-the-counter as decongestant solutions intended for nasal or ophthalmic use. As expected, based on their chemical and pharmacologic similarity, these agents have similar toxicity as clonidine: hypotension, lethargy, bradycardia, apnea, hypothermia, and miosis. As little as 1-2 mL can lead to significant toxicologic exposure in children.3
  • THC: The most common presenting signs and symptoms are lethargy, ataxia, hypotonia, tachycardia, and hypoventilation. Many cannabis-infused edibles are manufactured in the form that any child would love, including but not limited to cookies, candies, popcorn, brownies, gummies, and cakes.4

3. Non-accidental trauma

Most injuries in children are not the result of abuse or neglect; however, a clinician must have a high index of suspicion to avoid missing cases. Younger children, especially those who are preverbal are at highest risk. There are historical cues that may tip a provider into further evaluation:

  • Inconsistent history
  • Delays in care
  • Previous or ongoing investigation for child maltreatment

Head trauma is the leading cause of child physical abuse fatality and occurs most commonly in infants. However, abdominal trauma is the second leading cause of mortality in children suffering abuse. More so, there is a significant body of literature evaluating the occult abdominal injury. In general, most clinicians assess a child with lethargy would consider brain injury. However, occult injury to the solid or hollow viscus may also present with lethargy.5

Return to Patient Case: Clinical Course

You consider a broad differential diagnosis and initiate an evaluation including laboratory evaluation (complete blood count, comprehensive metabolic panel, ethanol level) and a brain computed tomography (CT).

The child returns from radiology with a negative brain CT. The laboratory evaluation is unremarkable as well.

You decide to order an abdominal ultrasound and the radiologist identifies an ileocolic intussusception. The child undergoes emergent intussusception reduction and returns to his baseline status. He recovers in the hospital for 24 hours and is discharged home without complications.


Join us in Hawaii at the 2019 UCSF High Risk Emergency Medicine Conference to learn more pediatric-specific knowledge.

  • Using point-of-care ultrasound to evaluate for ileocolic intussusception
  • The Rule of 50s for treating the hypoglycemic child
  • Screening for occult abdominal injury

 

 

1.
Singer J. Altered consciousness as an early manifestation of intussusception. Pediatrics. 1979;64(1):93-95. [PubMed]
2.
Ricci L, Hoffman S. Ethanol-induced hypoglycemic coma in a child. Ann Emerg Med. 1982;11(4):202-204. [PubMed]
3.
Eddy O, Howell JM. Are one or two dangerous? Clonidine and topical imidazolines exposure in toddlers. T. 2003;25(3):297-302. doi:10.1016/s0736-4679(03)00206-3
4.
Richards JR, Smith NE, Moulin AK. Unintentional Cannabis Ingestion in Children: A Systematic Review. T. 2017;190:142-152. doi:10.1016/j.jpeds.2017.07.005
5.
Christian C, Committee on. The evaluation of suspected child physical abuse. Pediatrics. 2015;135(5):e1337-54. [PubMed]
Aaron Kornblith, MD

Aaron Kornblith, MD

Assistant Clinical Professor
Department of Emergency Medicine & Pediatrics
University of California, San Francisco
Dan Repplinger, MD

Dan Repplinger, MD

Assistant Clinical Professor
Department of Emergency Medicine
Zuckerberg San Francisco General
University of California, San Francisco
Margaret Lin, MD
Assistant Clinical Professor of Emergency Medicine and Pediatrics
University of California, San Francisco
Benioff Children's Hospital San Francisco