Rethinking a Case of Paediatric Agitation Through a Different Mindset

Paediatric emergency departments are increasingly reporting a significant rise in visits for neuropsychiatric concerns. Although not always severe, these presentations often involve acute episodes of agitation, anxiety, behavioural dysregulation, self-injurious behaviour, or suicidal ideation that require prompt assessment and intervention. Many children and adolescents presenting with these symptoms have predisposing conditions such as autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), or other behavioural disorders and their episodes are frequently exacerbated by external factors [1-3]. It is important to emphasise, however, that in psychiatry a diagnosis is fundamentally one of exclusion: organic causes must always be considered and ruled out, as timely recognition and treatment of an underlying medical condition can result in complete recovery. An 11-year-old female, previously healthy and without relevant past medical history, presented to the Paediatric Emergency Department with acute abdominal pain, marked hyperventilation with polypnea and increased respiratory effort. According to parental report, the patient had experienced two isolated episodes of non-bloody vomiting the previous evening. Oral intake of food and fluids had been preserved. The medical history revealed a 4-month period of psychological distress following the death of her paternal grandmother, with whom she had a close emotional bond. Since that event, she had been undergoing private psychological counselling for anxiety symptoms and had been advised to participate in a residential summer camp programme. On the morning of admission, she was evaluated by her primary care paediatrician for agitation. A behavioural origin was initially considered, and the patient received diazepam, but her symptoms did not improve. Over the preceding 2 months, the patient had experienced an unintentional weight loss of approximately 4–5 kg, initially attributed to the emotional stress. In the weeks leading up to presentation, her parents had also observed polydipsia, polyuria and two episodes of nocturia. At the initial evaluation, the patient was alert but demonstrated mildly slowed responsiveness. She was afebrile, with noted pallor. The patient was polypneic, with a markedly elevated respiratory rate of 50 breaths per minute, characterised by deep, laboured breathing respiration. Cardiovascular examination revealed tachycardia with 150 bpm and hypertension 150/100 mmHg. Abdominal examination elicited generalised deep tenderness, which limited completion of the POCUS assessment. Neurological examination revealed reduced responsiveness alternating with periods of wakefulness. For this reason, a capillary blood test for glucose and ketones was performed, which revealed hyperglycaemia and hyperketonaemia. Initial venous blood gas point of care investigations demonstrated severe hyperglycaemia (plasma glucose: 623 mg/dL), significant ketonemia (6.9 mmol/L) and pronounced metabolic acidosis (venous blood gas: pH 6.92, HCO3− 3.2 mmol/L, base excess −28 mmol/L). Serum sodium was reduced (128 mmol/L), and lactate was elevated (3.96 mmol/L). The combination of clinical presentation and biochemical profile was diagnostic for severe diabetic ketoacidosis (DKA) secondary to new-onset type 1 diabetes mellitus. This case highlights the critical importance of considering organic etiologies in the differential diagnosis of paediatric patients presenting with acute neuropsychiatric symptoms [4]. Although the patient's recent bereavement and ongoing psychological counselling could have supported a presumptive psychiatric diagnosis, careful clinical assessment and laboratory testing revealed a life-threatening metabolic emergency. A key clinical element was the presence of marked polypnea, initially interpretable as anxiety or panic-related hyperventilation, but in reality a compensatory respiratory pattern known as ‘Kussmaul breathing’ secondary to severe metabolic acidosis. Another important, and often overlooked, bedside finding is the fruity, acetone-like odour of the breath, which can further support suspicion of DKA. In paediatric emergency settings, the rising prevalence of psychiatric presentations must not overshadow the need for thorough somatic evaluation. Psychiatric symptoms such as agitation, anxiety, or altered responsiveness may in fact represent the initial clinical expression of underlying causes. Failure to recognise these conditions in a timely manner can delay life-saving interventions. For this reason, maintaining an open mindset and a systematic diagnostic approach is essential, serving as a reminder not to be influenced by a child's medical history when current symptoms point toward a different diagnosis. In this case, rapid bedside blood glucose measurement could have promptly guided the diagnosis. The main diagnostic bias stemmed from the patient's history of anxiety and recent family loss, which initially oriented the clinical reasoning toward a neuropsychiatric origin despite the presence of symptoms more typical of DKA. For this reason, every episode of unexplained polypnea in children should prompt consideration of a broad spectrum of differential diagnoses presented in Table 1. Polypnea associated with abdominal pain may suggest acute appendicitis, with the suspicion being particularly strong in younger children. Moreover, the rapid progression of the disease can result in complications such as a bronchoperitoneal fistula [5]. Although rare, pulmonary embolism can be fatal if not recognised and may present with polypnea and agitation. In this case, the presence of risk factors for hypercoagulability or corrected congenital heart disease should be carefully considered [6]. Among the potential causes of polypnea and agitation, myocarditis is especially insidious. A recent history of flu-like symptoms or the presence of an infant with a pale, greyish complexion should be emphasised as an index of suspicion [7]. Altered responsiveness, with or without polypnea, should prompt consideration of toxicological causes or the onset of an underlying metabolic disorder. A normal oxygen saturation does not exclude carbon monoxide exposure, whose manifestations may range from irritability to seizures depending on levels of exposure [8]. Hyperammonemia may help raise suspicion of an underlying metabolic disease. In adolescents, the unthinkable must be considered: polypnea with agitation should prompt evaluation for toxic inhalant exposure, with focused questions on recreational inhalants, vaping and stimulants [9, 10]. Finally, when polypnea is combined with a fruity, acetone-like odour, DKA must be strongly considered as a possible initial manifestation of type 1 diabetes. This case demonstrates that avoiding premature closure on a psychiatric diagnosis requires a systematic and comprehensive approach. In children and especially adolescents presenting with agitation, anxiety, hyperventilation, or altered consciousness, organic causes must be excluded before considering a primary psychological disorder. Every acute psychiatric presentation in the ED therefore demands careful differential diagnosis to identify and promptly treat reversible conditions. The authors have nothing to report. As this was an individual case, where the patient's guardian provided consent, no hospital board ethical approval was required. The authors declare that the research presented in this manuscript adheres to the ethical principles outlined by the IRCSS Burlo Garofolo Ethics Committee. All procedures involving human participants were conducted in accordance with the ethical standards of the IRCSS Burlo Garofolo, and the Declaration of Helsinki (1964), as revised in 2013. Verbal consent was taken from the patient's guardian and documented in the medical file. No identifiable patient characteristics were reported. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.