LAUSR

A 13-year-old previously healthy male presented to the emergency department (ED) with 48 hours of altered mental status. Two days prior to presentation, the patient had left for school in his usual state of good health. Upon returning home, he complained of intermittent blurry vision. His mental status gradually declined over the next 24 hours, and the patient exhibited repetitive speech, difficulty counting, and severe anxiety. His mother gave him her own prescribed benztropine in hopes of calming him down. When his altered mental status persisted, he was brought to the ED. On presentation to the ED, history was obtained exclusively from his mother. Review of symptoms was positive for a history of cough, nasal congestion, and myalgias 2 weeks ago that had since resolved. His mother denied any known stressors at home or school. She also denied any known toxin or drug ingestion (except for the previously mentioned benztropine) nor any recent travel, camping, or hiking. The patient did have a dog at home who was not ill. Exposure to other animals was limited to a petting zoo visit 3 weeks prior with no known animal bites. The patient’s 11-year-old sister presented to the emergency room at the same time after having demonstrated several days of abnormal behavior. Onset was concurrent with the changes in her brother’s mentation, although symptoms were much less severe and limited to emotional lability. In the ED, our patient was able to identify himself by name. While he could follow simple commands including sitting up, he often required repeated prompting or assistance. He was able to identify several colors but could not properly count how many fingers were being displayed. His vital signs were significant for a temperature to 38.1°C and tachycardia with a heart rate of 110. Physical exam was notable for pinpoint pupils, drooling, and repetitive speech stating, “I feel like I’m shrinking.” Glasgow Coma Scale (GCS) was 14 due to patient’s confused conversation but ability to obey motor commands. No meningismus. Cranial nerves II-XII were grossly intact and patient had normal reflexes. Pertinent laboratory findings revealed a positive COVID-19 polymerase chain reaction (PCR) test and urine toxicology was only positive for tricyclics (presumed due to benztropine). Further studies including complete blood count, comprehensive metabolic panel, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), creatine kinase, and urinalysis were normal. Owing to his altered mental status, a lumbar puncture was obtained which was normal. A CSF meningoencephalitis panel was also sent, which was negative. A computed tomography (CT) brain and magnetic resonance imaging (MRI) brain did not reveal any significant findings. A chest X-ray demonstrated subtle ground-glass opacities in bilateral lower lungs. Owing to further deterioration in his mental status 2 days after admission, he was transferred to a tertiary pediatric medical center for further workup.