Strange Behavior In A Transgender Teenager

1. Salvador R. Maffei, MD*\n2. Andrea Dean, MD*\n\n\n \n\n1. *Baylor College of Medicine, Texas Children’s Hospital, Houston, TX\n\nA 12-year-old transmale ( transgender male or transmale is the term used for a person who is assigned female at birth [and is, usually, XX genotype] but who identifies as male) presents to the emergency department (ED) from an inpatient psychiatric facility for evaluation of new gait abnormalities and decreased oral intake. He initially presented to the ED 2 weeks earlier with acute onset of confusion, agitation, and suicidal ideation in the setting of a recent disclosure of his gender identity to family and classmates without their acceptance. After medical evaluation for toxic ingestion and intracranial abnormality, he was referred for inpatient psychiatric evaluation and was admitted for 2 weeks.\n\nWhile hospitalized he was started on chlorpromazine, haloperidol, risperidone, and escitalopram. Over the next 2 weeks he developed slowing and stiffening of movements, with progressively impaired motor function and cognitive abilities. For the past 3 days he has demonstrated mutism, minimal oral intake, tongue thrusting, and refusal to walk. At times he would hit himself in the forehead repeatedly. Symptoms did not improve with benztropine, amantadine, and lorazepam use, so he was transferred back to the ED for further evaluation.\n\nOn presentation he is alert but nonverbal and does not follow commands. He is afebrile, his heart rate is 129 beats/min, and his blood pressure is 136/83 mm Hg. He has dry mucous membranes. There is an ecchymosis on his forehead, consistent with described self-injurious behavior. Cranial nerves, strength, and coordination cannot be assessed, but global hypertonia and lower extremity clonus are elicited. Laboratory evaluation demonstrates a serum sodium level of 151 mEq/L (151 mmol/L) (reference range, 135–145 mEq/L [135–145 mmol/L]) …