Out of nowhere, a teenager threatens to want to hurt himself or his family. In psychiatry, the doctors present the 14-year-old with various diagnoses. It takes two whole years until they finally find the cause.
A teenager is suddenly confused, depressed and agitated. The situation escalates. Convinced of being the "son of the devil," he declares that he wants to do something to himself or his family. He is immediately admitted to the emergency department of a psychiatric hospital.
The doctors diagnose the boy as having a major depressive episode with psychotic symptoms. He is treated with aripiprazole and released a week later. At this time, while he is indeed no longer a danger to himself and others, the psychotic symptoms have not yet completely disappeared.
Is it Asperger syndrome?
The medical record reveals the evident fact that the 14-year-old had already gone through a depressive phase during year three at school. His parents' explanation for this was that their son was not challenged enough by his schooling and at the same time was teased by peers. The boy was considered very smart, but socially awkward. After switching to a school for gifted pupils and being treated for a year with sertraline 25mg, the symptoms resolved. The treating psychiatrist then also noted in the case file that Asperger syndrome could be a possible diagnosis.
Meanwhile, teachers and relatives describe him as being extremely popular and social. He has excellent grades, plays the lead role in a school theatre piece and is winning athletic competitions. The boy's family lives in a quiet suburb with a few pets, including several cats and a dog.
His pet wants to kill him
Weeks after the first hospital stay in October, his condition worsens again. School attendance becomes impossible due to the severity of psychotic symptoms. He develops obsessive thoughts, irrational fears and is emotionally unstable. The teen believes that he has superpowers, and is convinced that one of the family cats wants to kill him. Meanwhile, his mother quits her job in order to be able to solely take care of her son. In addition to paranoia, he soon also has auditory, visual and tactile hallucinations. But only when he refuses to leave the house is he sent to the clinic again. Only then does his actual odyssey begin.
The second hospital stay in December again lasts only a week. He thereafter develops non-specific physical symptoms, including severe fatigue, headache and chest pain, and shortness of breath. During the subsequent period, his parents take him to several psychiatrists. The diagnosis: schizophrenia. A few months pass without the boy getting better, despite drug therapy.
The parents present their son to various specialists, who perform numerous tests. But neither psychiatrists, endocrinologists nor neurologists know what is wrong with the teenager.
Strange stretch marks
In the following summer, he is again referred to a clinic. This time he spends a full eleven weeks there. Doctors try out a lot of medications to get his symptoms under control, including antipsychotics, mood stabilisers, antidepressants and benzodiazepines. The doctors there again carry out extensive testing – without results. The teenager is released with the diagnosis of schizophrenia and obsessive-compulsive disorder. Again, weeks pass by without any visible improvements.
Following his discharge, his parents notice abnormal skin lesions on their son. There are strange red stripes on his thighs and armpits – they are very reminiscent of stretch marks. But these at first are given no further attention. However, when one doctor takes a look at these stripes, he has a suspicion.
The cat it was
The doctor brings a dermatologist to the case. He confirms that the stripes are not just typical stretch marks. The position, orientation and colour of the stripes do not match a growth spurt or potential body weight fluctuations in the boy. This supports the doctor's suspicion. The boy could be suffering from Bartonellosis, a group of bacterial infectious diseases that are primarily transmitted from animals to humans. He also suspects which pathogen is responsible. The doctor remembers a detail from the medical record: On his first visit to the emergency room, the boy's arm had minor bites and scratches from the cats living in the house. They could consequently be dealing with the causative agent of cat scratch disease, Bartonella henselae.
Although results from detection method tests are not yet available, the doctor nevertheless starts antibiotic therapy – with success. Several weeks and one Jarisch-Herxheimer reaction later, it is clear that the boy is mentally better. Even the stripes on his skin are disappearing. Using a PCR analysis, the pathogen B. henselae is indeed able to be detected.
The doctors suspect that this pathogen triggered pediatric acute-onset neuropsychiatric syndrome (PANS) in the boy. Some cases seem to be the consequences of an infection involving streptococci or mycoplasma. These pathogens however were able to be excluded in the boy's case. This case offers, according to the doctors, the possibility of future investigations. Nonetheless, they say that the exact pathophysiological causes of PANS have not yet been fully elucidated.
Two years after the onset of his symptoms, the boy can finally go back to school. He is soon back at the mental and physical level as he was before his illness.
Source: Journal of Central Nervous System Disease
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