Presentation: 3 o’clock comes early
Miss T, age 9, presents with decreased sensation and motility in both legs. She cannot walk or stand.
Three days before, Miss T said she was consistently answering the teacher’s questions correctly at school. Because of this, a classmate teased her by calling her a “show off.” Soon after, Miss T began feeling weak and nauseous. The school nurse got a blood sugar reading of 68 mg/dL, slightly below the low-normal range.
Miss T’s mother arrived and convinced her to eat crackers and drink juice. Her blood sugar rose to 139 mg/dL and she began to feel better. When Miss T tried to stand, however, her legs and feet felt weak. She had trouble standing without support and needed help walking even a short distance. The mother brought Miss T home from school early.
Over the next 2 days, Miss T’s lower-extremity symptoms worsened. Her mother brought her to the pediatric emergency room.
Initial physical exam showed normal vital signs with no gross abnormalities. Neurologic exam revealed no lower-extremity masses, lesions, or deformities. Laboratory tests were normal. Cranial nerves were grossly intact. Right and left upper and lower extremities exhibited good tone, normal reflexes, and good strength against resistance. Miss T, however, said she could not feel sharp or dull objects against her lower legs.
ER pediatricians then called on the child psychiatry department to evaluate Miss T for possible psychiatric causes.
At intake, Miss T sits with her legs dangling from a stretcher. She is pleasant, articulate, and well-mannered. She spontaneously moves both legs and does not seem distressed when asked about her sudden disability. Her mood is euthymic, but she reports that constant teasing at school sometimes causes intense stress. She says that her sister sometimes “gets mean” with her but does not elaborate. She adds that she is sometimes sad because her parents recently separated, but she denies resultant emotional effects.
No suicidal/homicidal ideations or psychotic symptoms are present. Miss T’s thought process is logical and goal-directed. She is alert and oriented with good memory, language, concentration, and impulse control.
Neither Miss T nor her family has a significant psychiatric or medical history. Miss T has not been taking medications or over-the-counter supplements. Upon questioning, the mother denies that her daughter has been physically or sexually abused.
Despite a lack of positive neurologic findings, the neurology team recommends admission to rule out unseen medical problems.
The authors’ observations
Medical diagnosis.1,2 In Guillain-Barré syndrome, an infection usually precedes symptom onset, and maximum weakness is seen within 7 to 10 days. Respiration may be compromised, and weakness tends to spread throughout the body. Miss T’s symptoms came on more rapidly, her breathing was normal, and weakness was confined to her legs and feet.
In neuromuscular junction disorders such as myasthenia gravis and Lambert-Eaton syndrome, symptoms are not as acute, fluctuate throughout the day, and usually worsen with exertion. By contrast, Miss T’s symptoms steadily worsened without provocation.
Muscular dystrophy and myopathy were ruled out because of Miss T’s rapid symptom onset and lack of prior health problems. Dystrophy usually is seen in early childhood, affects the hip and girdle muscles, and progresses slowly. Myopathy symptoms usually are chronic and progressive, and associated medical disorders overshadow the muscle disease.
Patients with intracranial lesions may present with:
- symptoms of diffuse cerebral disease, such as mental impairment, headache, or seizures
- focal neurologic signs, such as aphasia or hemiparesis
- evidence of increased intracranial pressure, such as headache, vomiting, drowsiness, or papilledema.
Miss T had none of these.
Patients with spinal cord tumors usually have radicular pain, sensory/motor involvement, sphincteric dysfunction, and percussible back tenderness. Symptoms develop over weeks to months.
Psychiatric diagnosis. Factitious disorder, malingering, somatization disorder, and conversion disorder (Box) also were considered:
- In factitious disorder, the patient exacerbates his or her symptoms to assume the sick role.
- Malingering patients have external motivations behind symptom fabrication.
- Somatization disorder involves multiple organ systems, and patients often are preoccupied with their symptoms.
Miss T’s complaints were not consciously induced, external motivations were absent, a single organ system (musculoskeletal) was involved, and she appeared largely untroubled by her deficit.
Her presentation most closely fit the diagnosis of conversion disorder. Patients with this disorder complain of symptoms or deficits affecting voluntary muscles or of sensory function deficits that suggest a neurologic or medical condition. The symptoms’ temporal relationship to a stressful event suggests psychological factors. Symptoms:
- are not intentionally produced
- cannot be attributed to an organic cause
- cause significant functional impairment
- are not limited to pain or sexual dysfunction
- cannot be explained by another mental disorder.