Acute Altered Mental Status in the Pediatric Emergency Department: A Case Report

Introduction: Acute alteration of consciousness and seizure-like episodes represent clinical presentations with a broad differential diagnosis in the pediatric age group, requiring urgent evaluation and management. Rapid identification of the etiology is of critical importance in determining mortality and neurological sequelae. This case report describes the diagnostic process and clinical course of a two-year-old patient who presented with suspected seizure, altered consciousness, and nuchal rigidity. Case: A two-year-old girl with no known prior medical history was brought to the pediatric emergency department following a brief episode of tonic contractions and gaze fixation. On admission, her Glasgow Coma Scale (GCS) score was 9, pupils were bilaterally mydriatic, and nuchal rigidity was present; physical examination for signs of meningeal irritation revealed a clinical picture consistent with meningitis. Cranial computed tomography showed no intracranial pathology. Cerebrospinal fluid (CSF) analysis was not consistent with infectious meningitis; however, given the clinical presentation and examination findings, empirical ceftriaxone and acyclovir therapy was initiated without delay. Subsequent advanced neuroimaging obtained during follow-up was also reported within normal limits. The patient’s level of consciousness fully recovered during the acute phase, and she was discharged without any neurological sequelae. Conclusion: In pediatric patients presenting with acute alteration of consciousness and signs of meningeal irritation, empirical antimicrobial and antiviral therapy should not be withheld until meningitis and encephalitis have been definitively excluded, even when imaging and CSF findings are within normal limits. Clinical judgment may take precedence over laboratory and imaging results. This case highlights the importance of transient encephalopathic presentations in the pediatric emergency differential diagnosis and underscores the decisive role of clinical suspicion in guiding treatment decisions despite negative investigative findings.