This is a 17-year-old Haitian-American male with no prior psychiatric or medical history who was brought to the emergency department by his mother for waxing and waning altered mental status (AMS) over the preceding seven days. According to the family, he exhibited episodes of unresponsiveness, minimal verbal output, inappropriate smiling, and prolonged staring spells. Over the past several months, he had become increasingly socially withdrawn, particularly following a physical altercation with friends that resulted in dental trauma. One week prior to presentation, his sister noted that he had begun talking to himself with further decline in social engagement.

Upon initial evaluation in the emergency department, the patient was awake but minimally responsive, with a Glasgow Coma Scale (GCS) of 8. He was nonverbal, displayed inappropriate smiling, and had pinpoint pupils. Initial laboratory evaluation, including basic metabolic panel, liver function tests, complete blood count, urinalysis, and urine toxicology, was unremarkable (Tables 1-4). A non-contrast computed tomography (CT) of the brain showed no acute intracranial abnormalities (Figure 1). Notably, after administration of 2 mg of intravenous naloxone, the patient briefly became more interactive and admitted to recent oxycodone use, raising concern for potential opioid intoxication. He was admitted to the pediatric intensive care unit (PICU) for tachycardia, tachypnea, and respiratory monitoring for risk of apnea.

During his PICU stay, his mental status continued to fluctuate. Neurology was consulted, and an electroencephalogram (EEG) revealed generalized slowing consistent with encephalopathy. Magnetic resonance imaging (MRI) of the brain (Figure 1) and cerebrospinal fluid (CSF) studies, including autoimmune and infectious panels, were unremarkable (Tables 5-7). Psychiatry was consulted to evaluate for catatonia and psychosis. On exam, the patient met criteria for catatonia as per the DSM-5, with an initial Bush Francis Catatonia Rating Scale (BFCRS) score of 17. A lorazepam challenge resulted in rapid, temporary clinical improvement, with a reduction in BFCRS score to 8.

The patient was initiated on scheduled intravenous lorazepam and later transitioned to oral dosing. Risperidone was started due to concern for worsening psychotic features. Over several days, the patient demonstrated gradual improvement in responsiveness, interaction, and orientation. However, he continued to exhibit inappropriate affect, disorganized thought processes, and delusional statements (e.g., stating he was a vampire). His catatonic features waxed and waned, with regression noted after missed doses of lorazepam. Ultimately, the patient was diagnosed with first-episode psychosis with catatonia, likely within the spectrum of schizoaffective disorder or schizophrenia. His lorazepam was tapered off, and he was discharged on oral olanzapine with close outpatient psychiatric follow-up.

The patient had no documented psychiatric or medical history, nor prior hospitalizations. Family psychiatric history was noncontributory, though his sister noted that mental health was seldom discussed in the household, raising the possibility of unrecognized or unreported conditions. Although his mother denied concerns for substance use and his initial urine toxicology screen was negative for commonly screened substances, the patient reported that substances - specifically oxycodone, alcohol, and cannabis - were a significant problem in his life.

During follow-up visits in the first two to three months post-discharge, the patient exhibited selective mutism and inappropriate smiling. He appeared psychotic with internal preoccupations and a lack of eye contact. His mother reported his lack of communication with family members and poor sleep. The patient was subsequently started on trazodone for sleep and switched from olanzapine to risperidone, due to his lack of improvement in psychosis.

Over the following three months, the patient’s psychotic symptoms persisted despite a gradual uptitration of risperidone. As a result, risperidone was discontinued, and haloperidol was initiated. Despite dose escalation over the following four months, there continued to be minimal clinical improvement; the patient continued to exhibit active psychosis, including responding to internal stimuli, inappropriate smiling, and disorganized speech. Approximately nine months after discharge from the inpatient unit, he was diagnosed with schizophrenia. The patient was recommended to transition to clozapine due to treatment resistance; however, the patient and his mother declined, expressing concerns about the regular blood monitoring requirement. The full hospital course, events, and interventions are detailed in Table 8.