A Young Child with Subacute Onset of Behavioral Changes.

1. Sarah Pradhan, MD*\n2. Jessica Goldstein, MD†\n3. Erin Frank, MD*\n4. Allayne Stephans, MD*\n\n\n \n\n1. *Department of Pediatric Hospital Medicine,\n\n2. †Department of Pediatric Neurology, Rainbow Babies and Children’s Hospital, Cleveland, OH\n\n\n \n\n1. Address Correspondence to Sarah Pradhan, MD; E-mail: sarah.pradhan6{at}gmail.com\n\nA 5-year-old healthy boy presents with a 3-week history of new onset aggression, obsessive-compulsive behavior, and nocturnal enuresis. One month ago he sustained a minor head trauma when he was sliding down the slide at a local playground. He was initially diagnosed with a mild concussion. His symptoms have now progressed and include frequent night waking, hand wringing, and behavioral outbursts. This prompts his pediatrician to refer him to the emergency department for evaluation.\n\nHe undergoes computed tomography scan of the head, which is unremarkable. Laboratory evaluations include electrolytes, liver enzymes, complete blood cell count, rapid group A streptococcal antigen, thyroids studies, and heterophile antibody test, which are unremarkable. Urine and blood toxicology screens are negative. He is admitted to the inpatient unit.\n\nVital signs are appropriate for age. He has difficulty answering questions and following commands. He is restless and disoriented. He intermittently gets up to run around the room and occasionally bangs his head on the wall. His cranial nerve, motor, reflexes, sensory, coordination, and gait examinations are normal.\n\nBrain magnetic resonance imaging is unremarkable. On video electroencephalogram he has bilateral fronto-temporal spikes that correspond with his abnormal movements and subclinical seizures arising from the right and left frontotemporal areas independently (arrows in Fig 1). Fosphenytoin is started, which controls his seizures, but he continues to have abnormal behavioral outbursts. Over the course of the week, he develops dysarthria, oral-facial …