LAUSR

A previously healthy 6-year-old girl presented to a tertiary care children’s hospital emergency department with altered mental status. She was well until the previous evening, when she reported a headache and her family noted emotional lability. Specifically, her siblings noted that she laughed inappropriately during a movie they watched together. She had no nausea or vomiting, abdominal pain, fever, travel, or recent illness. The day prior to presentation was Easter, and the family attended a large Easter celebration at church during the day. On the morning of presentation, the patient’s mother attempted to wake her and found her unresponsive. The patient copresented with her 9-year-old sister, with whom our patient shared a bedroom, and who also woke that morning with lethargy and confusion. The parents initially brought the patients to an urgent care center, where the provider activated 911 as per the community standard; both patients arrived via ambulance. Paramedics involved in transport corroborated the family’s history of events. Blood glucose was within normal limits for both siblings. On initial examination, the 6-year-old was obtunded with a Glasgow Coma Scale (GCS) score of 6 (no eye opening, no verbal response, and withdrawal from pain). Vital signs were as follows: body temperature 36 °C, heart rate 60 beats/min (normal range for age, 75-118 beats/min), respiratory rate 16 breaths/min (normal range for age, 18-25 breaths/min), blood pressure 108/67 mm Hg (normal range for age, 97-115/57-76 mm Hg), and oxygen saturation 100%.1 Pupils were dilated to 6 mm and reactive bilaterally. There was no seizure activity or obvious signs of trauma. Upon application of a nonrebreather mask in preparation for intubation, heart rate improved to 70 to 85 beats/min, and mental status improved to a GCS score of 9 (eye opening to pain, incomprehensible sounds, and localization of pain). She was placed on noninvasive bilevel positive airway pressure. The 9-year-old was confused on initial examination but more awake and responsive, with a GCS score of 14 (spontaneous eye opening, confused, obeyed commands), and vital signs were as follows: body temperature 37.1 °C, heart rate 91 beats/min (normal range for age, 75-118 beats/min), respiratory rate 24 breaths/min (normal range for age, 18-25 breaths/min), blood pressure 123/50 mm Hg (normal range for age, 97-115/57-76 mm Hg), and oxygen saturation 95%. She had no further details to add to the family’s history of events. Venous blood gas analysis on the 6-year-old revealed pH 7.25 and partial pressure of carbon dioxide 62 mm Hg. Computed tomography of the head, electrocardiography, complete blood count, metabolic panel, lactate, thyroid panel, and carboxyhemoglobin level were unremarkable. Laboratory work obtained on the 9-year-old was also unremarkable.