[Alon]

Mind, not matter

At the girl's second hospitalization, opinion coalesces that her illness is not rheumatologic, and she is admitted under the neurology service. Investigation reveals total anesthesia below L5, although the balance of the sensory and motor exam is inconsistent with that finding and does not fit any neurologic distribution. Although some features suggest a psychosomatic disorder, chronic inflammatory neuropathy cannot be excluded.1,2

The patient does not appear in distress or concerned during the investigation, and again seems content and calm. She is easily suggestible. Once provided with stepwise recommendations for regaining her health, and sensation and mobility in her extremities, she improves in a short time and is discharged after six days, having made a full recovery.3

The neurology and psychiatry services' conclusion is that her parents' separation has been a significant stressor for the girl—especially because she has a close relationship with her father.4 Notably, approximately one year before the patient exhibited symptoms, her maternal uncle was paralyzed from the neck down in a car crash and is in a wheelchair. How much, you are left to wonder, might this event have unconsciously influenced her symptom "selection"?

Things are set right again

Your patient does well, without relapse, after psychological counseling and pediatric follow-up. At the beginning of a new school year, she is eager to return to the classroom.

This case illustrates the need to suspect a conversion disorder in children when the neurologic or somatic outline is difficult to clarify and all instrumental and clinical laboratory tests do not support a precise pathologic pattern or disease entity. Further exploration of behavioral or emotional problems and other stressors can be the missing key to the diagnosis.
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DR. ESTEP is an assistant professor of pediatrics at Texas Tech University Health Science Center