Beware of the Booby Trap: Behavioral and Psychiatric Symptoms May Mask Serious Endogenous Pathology in Children

Background: Pediatric patients present to the Emergency Department (ED) with a wide variety of pathology. In case of altered behavior in children, fast recognition, diagnosis and treatment are indicated. In pediatric patients presenting with "abnormal behavior", it may be very difficult to differentiate between real psychiatric disorders – a growing problem in Western countries – or abnormal behavior masking other underlying organic pathology.

Methods: Cases of pediatric ED patients, initially diagnosed with mood and behavioral changes, but whom developed severe organic pathology during admission, were reviewed regarding initial symptoms, final diagnosis, time from initial to final diagnosis, length of stay (LOS) in the hospital and days in the PICU, and outcome.

Results: Nine patients were included. The median age was 11 years old (range 1 to 18 years-old, 5 were female and 4 were male. Although initial symptoms rather resembled psychological-behavioral disorders, the final diagnoses were Anti-N-methyl-D-aspartate receptor encephalitis (ANMDAR), 1 case due to Mycoplasma pneumoniae and 1 case due to toxoplasmosis, two cases with acute disseminated encephalomyelitis (ADEM), Guillain Barré syndrome, epileptic state, partial convulsions, confusion due to AKI and a cerebral tumor. Median hospital LOS was 12 days, and median ICU stay was 7 days. Median time to final diagnosis was 2 days. All patients` neurological outcome improved over time.

Conclusion: Pediatric patients presenting to the ED with behavioral changes or psychiatric symptoms, may suffer from more serious organic pathology than initially suspected.

Physicians need to pay attention to this "booby trap", in order to prevent long-term neurologic damage, an increasing risk of debilitating complications, or even death.