An acutely confused 15-year-old girl

Abstract

A 15-year-old girl was admitted to hospital in August, 1994, with an acute confusional state. She had been well until July, 1994, when she developed impairment of recent memory. The memory impairment became severe, and she gradually lost contact with reality. On the morning of August 22, she became acutely confused and was transferred to a psychiatric unit. On admission, she had a stiff facial expression, incoherent thoughts, and was dismissive; we could not communicate with her at all. On physical examination, a mass was palpated in the lower abdomen. Neurological examination was unremarkable. Her temperature was 37·4°C. Results of laboratory tests including blood counts, biochemical tests, and C-reactive protein were within the normal range. There were no evident endocrine or metabolic abnormalities. Tests for antinuclear antibodies were negative. Magnetic resonance imaging (MRI) of the brain was normal. Cerebrospinal fluid (CSF) was normal on two occasions. Anti-Yo, anti-Hu, and anti-Ri antibodies were all negative in both CSF and serum. However, electroencephalographic tracings on Aug 29 showed diffuse slow waves (figure, top). Abdominal MRI showed that the abdominal mass was a 15×10×7 cm multi-follicular tumour of the right ovary. Alphafetoprotein, CA125, and CA19-9 concentrations were not raised. To manage her confusion, we gave her chlorpromazine (maximum dose 150 mg daily), haloperidol (maximum dose 10 mg daily), and carbamazepine (maximum dose 600 mg daily); but she did not get better. She had a right salpingo-oophorectomy, with the consent of her parents, on Sept 29. On Aug 29, 1994 (top), and on Oct 31, 1994 (bottom).