Delirium

Delirium is an alteration in consciousness that can be associated with hallucinations, disorientation, and delusions. Normal thought processes are altered, including judgment, and rational behavior may be lost. Causes are typically metabolic derangements, acute infections, or drug use.

Differential Diagnosis

• Acute systemic infection
  –May be viral or bacterial cause
  –Often associated with high fever
• Hypoglycemia, diabetic ketoacidosis
• Central nervous system infection
  –Meningitis, encephalitis, brain abscess

• Drugs
  –Alcohol: Acute intoxication
  –Amphetamines: Also tremors, dry mouth, tachycardia, hyperactivity
  –Hallucinogens (LSD, mescaline, PCB) also tremors, dilated pupils, nausea, and abdominal pain
  –Phencyclidine (a.k.a. Angel Dust) with atxia, nystagmus, hyperreflexia, and hypertension
  –Opiates: Also with pinpoint pupils
  –Antihistamines
  –Phenothiazines
  –Organic solvents
  –Salicylates
  –Glucocorticoids

• Head injury
• Rocky Mountain spotted fever (RMSF)
  –Delirium and hallucinations may precede rash; fever, headache, myalgias, chills
• Malaria
• Rabies
• Syphilis
  –Tertiary syphilis is rare in children
• Hyponatremia
• Uremia
• Migraine
• Hypoxia
• Heat stroke
• Hepatic failure
• Systemic lupus erythematosus
  –Delirium is due to cerebral vasculitis
• Pellagra
  –Due to niacin deficiency
  –Also with diarrhea, dermatitis, dementia
• Hartnup disease
  –Rash, ataxia, psychological disturbance
  –Symptoms may be intermittent
• Porphyria
  –Attacks of abnormal behavior do not begin until late adolescence

Workup and Diagnosis

• History
  –Duration of delirium
  –Exposure to excessive heat
  –Ingestion of drugs
  –Associated signs and symptoms (fever, diarrhea, vomiting, rashes, sweating)
  –Recent head trauma
  –Unusual or fad diets (diets that are mainly corn-based can lead to pellagra)

• Physical exam
  –Vital signs
  –Pupil size and reactivity
  –Nuchal ridgidity, Kernig and Brudzinski sign
  –Head exam for signs of trauma
  –Scaling rashes (pellagra), petechiae of palms and soles (RMSF), sun sensitivity scars (porphyria)
  –Ataxia, asterixis (flapping at wrists with uremia)
• Labs
  –All patients should have a glucose measurement
  –Strongly consider toxicology evaluation for all patients (typically do both blood and urine)
  –Serum electrolytes, BUN, creatinine
  –Liver testing (ALT, AST, bilirubin, PT/PTT)
  –Specific testing of enzyme levels (porphyries), urinary amino acids (Hartnup disease), niacin levels (pellagra)
  • Studies
    –Consider LP and head imaging (CT or MRI)

  Treatment

  • Correction of any metabolic derangements, including alterations of glucose and sodium
  • Drug ingestion
    –Discuss with poison control center
  • Infectious causes
    –Use of appropriate antibiotics based on likely organisms
  • Psychological disturbance
    –Antipsychotics if appropriate
  • Heat stroke
    –Aggressive rehydration
  • Hepatic failure
    –Supportive therapy
    –Lactulose may help to improve mental state/cognition
  • Hartnup
    –Supplemental nicotinamide
  • Pellagra
    –Supplemental niacin

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Concentration difficulty

• Back to symptom: Concentration difficulty: Introduction (review 307 causes)
• Next Book Extract About Concentration difficulty: DELIRIUM (Differential Diagnosis in Primary Care)
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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: DELIRIUM (Differential Diagnosis in Primary Care)

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