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Correspondence to Dr Rebecca Arvier; [email protected]
Background
Drug ingestion is an important differential to consider early in the presentation of abnormal movements and altered levels of consciousness in children. It is a differential which often does not present with a clear history, particularly in cases of non-accidental administration, and there is often a delay while awaiting results of extensive testing such as cerebrospinal fluid (CSF) results, PCRs and MRIs before a urine drug screen is considered and then a further delay while awaiting the results of urine drug analysis. These are important cases not to be missed, particularly in the case of non-accidental ingestion.
We report a case with an unusual constellation of symptoms given the two different classes of medications which were administered. A history of drug ingestion was not initially provided. Given repeat positive urine drug screens over 5 days, it was highly suspicious that the medication was continued to be inappropriately administered in hospital, highlighting the importance of strict control of formula preparation for infants in hospital.
Case presentation
A 6-month-old girl child initially presented to her general practitioner with an abnormal breathing pattern and a history of several days of coryzal symptoms. An ambulance was called for her altered level of consciousness and she was found to have a Glasgow Coma Scale of 3 when the ambulance arrived. She was urgently transferred to her closest peripheral hospital.
The infant was previously well with no significant medical history. There was no history of fevers, trauma or drug ingestion. She was immunised, took no regular medication and was achieving appropriate developmental milestones. She had no significant family history of seizures or other medical illness.
She was initially treated with intranasal midazolam by paramedics for potential seizures, then on arrival to the emergency department was empirically covered with ceftriaxone and aciclovir for possible meningitis. She had a CT brain performed which was normal and was observed on the ward for 48 hours.
The patient continued to have an abnormal pattern of breathing throughout her peripheral hospital admission, so her progress was discussed with subspecialty teams at the closest tertiary children’s hospital with a plan for an elective transfer to conduct further investigation. She then however progressed to having longer episodes of profound unresponsiveness warranting...