Question

“Kyle” is a 6-year-old boy with a history of mild developmental delay who presented with one month of disorganized behavior, hallucinations, and developmental regression. At 3 months old, he began tracking objects his parents were unable to see. At 7 months old, he began visually fixating on unseen objects and would “open his eyes widely, become very excited, flap his arms, and tense his legs,” according to his mother. He did not begin walking until 20 months old and was referred to early intervention for gross motor delay. At age 3, he began talking to someone his parents could not see, leading them to believe he had an imaginary friend. While learning to read at age 5, he would say, “Stop mom! The words are talking back!” This possibly suggests an experience of auditory hallucinations. In kindergarten, he was held back due to poor attention but remained socially interactive without grossly abnormal behavior. Then, one month prior to admission, he developed frank hallucinations and severe social withdrawal. He frequently whispered to himself nonsensically and was so internally preoccupied that he often was unable to follow commands. The patient's family history was notable for 1) schizophrenia in a maternal cousin, two paternal cousins, and his paternal great grandmother; 2) bipolar disorder in two paternal cousins; and 3) autism in a paternal cousin and a paternal great aunt. His pediatrician performed a preliminary workup, including routine laboratory examination and a CT of the head, which were normal. The pediatrician referred the patient for admission to our hospital.
On initial evaluation, the child appeared thin and younger than his stated age. His mother stated that he had been eating only intermittently, resulting in significant weight loss and failure to thrive (body mass index=14.5, weight <10th percentile; height <3rd percentile). His behavior was notable for stereotyped pursing of his lips, repetitive blinking, and poor eye contact. The child was mumbling to himself, and upon questioning, his speech was impoverished and disorganized. His affect was flat and intermittently guarded. He endorsed visual hallucinations of “people in [his] eyes” who were “following [him] everywhere,” named “Shavonni, James, and Jack,” who appeared “black with yellow teeth and green eyes.” The child's mother endorsed that he had a history of paranoid delusions that people were chasing him or taking away his food. He expressed passive suicidal ideation, saying, He did not exhibit self-injurious or violent behavior.

summarize this

Answer 1

6-year-old boy with mild developmental delay and early abnormal visual behaviors who presented with one month of marked disorganization, hallucinations, and developmental regression.

Key points
- Developmental history: mild global delay (walked at 20 months); early atypical visual behaviors beginning in infancy (from 3–7 months: tracking/fixating on unseen objects, excitable/stereotyped movements); talked to unseen people from age 3; held back in kindergarten for attention problems but remained social until recent decline.
- Present illness: over the past month developed frank visual hallucinations and severe social withdrawal, whispering to himself, impoverished/disorganized speech, inability to follow commands, and passive suicidal ideation without self‑injury or violence.
- Mental status/exam: thin, appearing younger than stated age; failure to thrive (BMI 14.5; weight <10th percentile; height <3rd percentile); stereotypies (lip pursing, repetitive blinking), poor eye contact, flat/guarded affect; describes visual hallucinations of named figures and endorses paranoid delusions (people chasing him/taking his food).
- Family history: schizophrenia (maternal and paternal cousins, paternal great-grandmother), bipolar disorder (paternal cousins), and autism (paternal relatives).
- Workup: routine labs and head CT performed by pediatrician were normal.

Overall: a young child with longstanding developmental abnormalities who has acutely regressed and developed florid psychotic symptoms with associated poor weight gain and failure to thrive; initial basic medical workup was unrevealing.