Pediatric Somatic Symptom Disorder Masquerading as Tetany- A Case Report

INTRODUCTION

Somatic symptom disorder in children and adolescents refers to the presence of multiple recurrent physical complaints that cannot be fully explained by a medical condition, and are associated with significant distress and impairment in functioning.¹ In pediatrics, somatic symptoms are a common reason for outpatient visits. However, when investigations are repeatedly normal, and symptoms persist despite reassurance, a diagnosis of somatic symptom disorder or somatization disorder should be considered.² As per DSM-5, somatic symptom disorder replaces the older term, somatization disorder. We report such a case of somatic symptom disorder, which initially presented to us as a suspected focal seizure or suspected tetany.

CASE REPORT

A 11-year-8-month-old girl presented to us in casualty with complaints of headache and nausea since the morning. There is a history of travel by car to a temple, and during the return journey, the child had 3 episodes of vomiting. Immediately, they got medicine over the counter from a nearby pharmacy and also gave the child water mixed with ORS. Upon reaching home, there is a history of further 3 episodes of vomiting soon after drinking ORS. The child complains that after these episodes of vomiting at home, she developed cooling of her extremities, and also, she complains that both her upper arms got stretched and her hands turned into a posture of tonicity, which lasted for a few minutes. As soon as this episode of stretching and tonic posturing of both upper limbs occurred, the child was brought to the casualty. In the emergency room, the child again had an episode of stretching of the upper limbs followed by tonic contraction of the hand. There was no history of fever, loose stools, loss of consciousness, early morning headache, or double vision. On examination, she had tetany-like carpopedal spasm in both hands with cold peripheries. She was agitated and was also hyperventilating with a respiratory rate of around 40 per minute. Her heart rate was 84/minute, her temperature was 37° C. Her blood pressure was 110/70 mm Hg. Capillary blood glucose was 130 mg/dL. On general examination, there was no pallor, icterus, cyanosis, clubbing, or lymphadenopathy. Her systemic examination was normal. There were no signs of meningeal irritation. Neurocutaneous markers were absent. Examination of the external genitalia was normal. Fundus examination was normal. On further probing of the history, she was treated on an outpatient basis on multiple occasions for a wide variety of complaints, such as nausea, loss of appetite, palpitation, headache, vomiting, sneezing, etc., during the last 6 months, and each time her examination findings were normal. She has also undergone blood investigation on an outpatient basis (complete blood count), which was normal. She has undergone a Mantoux test from another hospital, which was reported as positive with 15 mm induration, and was advised by a peripheral clinician to start Isoniazid prophylaxis until confirmatory test results, which were refused by the parents. On detailed review of the Mantoux test, it turned out to be a false negative due to incorrect dosage administration. She consulted multiple doctors on multiple occasions, and there was a clear history of different symptoms and anxiety regarding different diseases noted each time.

She was a single child of non-consanguineous parents, born by emergency LSCS (Indication -non progression of labor/ Failed induction) with a birth weight of 2.9 kg. There is no history of NICU admission. She is developmentally normal, studying in the 7th standard with average scholastic performance. Her sleep pattern is normal. Bowel and bladder habits were normal. She has not attained menarche yet. She gave a history of her father giving her physical punishment whenever she failed to do her homework or got low grades in school. She was immunized as per the National Immunization Schedule till 10 years of age. Her anthropometry showed normal height with underweight and a Body Mass Index less than the 3rd centile (thinness).

She was started on intravenous fluids in view of multiple episodes of vomiting, and immediately her carpopedal spasm subsided. Initial venous blood gas done showed pH -7.5, pCO₂- 24, and HCO₃ of 22, suggestive of respiratory alkalosis, due to the hyperventilation. Repeat venous blood gas done after 6 hours was normal. Complete blood count done showed Hb -14.5 g%, TC -13500 cells/cu mm, Platelet count of 2.6 lakhs/cu mm. Serum electrolytes showed Calcium of 10.7 mg/dL, ionized calcium of 1.3 mmol/L, magnesium of 2.04 mg/dL, sodium of 142 mmol/L, potassium of 3.9 mmol/L, and chloride of 111 mmol/L. All the routine blood investigations turned out to be normal. Since her father's repeated concern was that she has a very poor appetite and has nausea while taking food, and also feels bloated soon after taking a small quantity of food, an ultrasound of the abdomen and pelvis was done, which was found to be normal. Further need for endoscopy explained, which her parents refused. The thyroid function test was normal. 25-hydroxy vitamin D level was also normal (30 ng/mL). She had recurrent episodes of similar spasms in both hands during the hospital stay, and each time the symptoms subsided with a placebo of normal saline flush. In order to rule out other organic causes like intracranial space-occupying lesions, the neurologist's opinion was obtained, and they advised doing MRI brain, MR venography, and MR angiography. These investigations also turned out to be normal.

Since her symptoms did not correlate clinically and subsided without any intervention, somatic symptom disorder was considered as a differential diagnosis. Psychiatry opinion was sought for the same, and they opined that based on the symptomatology pattern of the child, and after ruling out organic causes, as per DSM-5 criteria, somatic symptom disorder is of high probability in this child. They counseled both the child and the father and also advised on family psychoeducation. In the psychoeducation sessions, both parents were taught how psychological distress or anxiety amplifies bodily symptoms.

Parents were trained to stop their frequent checking on symptoms and to learn to reward the child when they are symptom-free, and to encourage normal daily routines. We discharged the child after the counseling sessions and advised regular follow-up. Soon after discharge, she was admitted to another hospital by her parents, where a lumbar puncture was performed, and cerebrospinal fluid analysis was done, which also turned out to be normal. They are now on regular follow-up with our Pediatric and Psychiatry department and regularly undergoing family psychoeducation sessions. The child is improving and is now able to overcome her fear and anxiety of different diseases, and her school absenteeism has reduced to a great extent. There are no further episodes observed following regular family psychoeducation.

DISCUSSION

Acute carpopedal spasm in children is typically brief, but it can be painful and sometimes severe. There can be involuntary cramping of fingers, toes, or ankles, pain, muscle weakness, numbness, or a tingling sensation. The differential diagnosis for carpopedal spasms in children includes hypocalcemia, hypomagnesemia, metabolic alkalosis, hypoparathyroidism, hypothyroidism, vitamin D deficiency, and increased intracranial hypertension due to various causes^3,4 [Table 1]. All these organic causes were ruled out in our patient methodically.

Hyperventilation during anxiety, stress, or panic attacks lowers the carbon dioxide level in the blood, termed as hypocapnia, which in turn causes respiratory alkalosis. In this alkaline environment, more calcium binds to blood proteins, reducing ionized calcium, which normally acts as a nerve stabilizer. This results in numbness, tingling, and carpopedal spasms. Ionized calcium levels were normal in our patient.

Somatic symptom disorder, earlier termed as Somatization disorder, is estimated to have a prevalence of 3-10% in pediatric outpatient and school settings.⁵ As per DSM-5⁶, the diagnostic criteria for Somatic symptom disorder include

Criterion A: Somatic symptoms: One or more somatic symptoms that are distressing or result in significant disruption in daily life.

Criterion B: Excessive thoughts, feelings, or behaviors: demonstrated by at least one of the following:

• Disproportionate, persistent thoughts regarding symptom severity.

• Persistently high anxiety about health.

• Excessive time/ energy devoted to health concerns.

Criterion C: Persistence: While individual symptoms may not be constant, the symptomatic state is persistent, typically lasting over 6 months.

The DSM-5 removed the requirement that symptoms be “medically unexplained”, allowing diagnosis regardless of underlying medical conditions.

This condition is more common in girls and in early adolescence (10 to 15 years of age). Etiology is usually multifactorial, including biological predisposition, psychological stressors like school/ peer/ family conflict, and social factors like attention to illness behavior.^7,8 The main challenge in these disorders is usually that the diagnosis requires exclusion of organic disease, but also avoidance of excessive investigation that can reinforce the “sick role”. Management of this disorder comprises a multidisciplinary approach, including reassurance, family psychoeducation, and cognitive behavioral therapy in some cases, and gradual return to normal activities.^9,10

Few studies have investigated integrated care for pediatric somatic symptoms.¹¹ It combines medical, psychological, and physical rehabilitation into one care plan. The team typically coordinates care using the following specific components, such as

• psychoeducation and medical reassurance,

• cognitive behavioral therapy,

• physical therapy and functional restoration,

• parental coaching,

• stepped care approach.¹²

While integrated somatic symptom management remains understudied in primary care, evidence suggests such approaches positively impact adolescent children in specialized outpatient and inpatient settings.^13,14

CONCLUSION

Pediatric somatic symptom disorders are often under-recognized and can lead to unnecessary hospitalizations, school absenteeism, and increased healthcare costs. Early recognition and appropriate management can significantly improve prognosis. This case report highlights the importance of considering somatic symptom disorder in the differential diagnosis of chronic unexplained physical symptoms in children, not supported by clinical examination, and thereby reducing the healthcare burden to a small extent.