Clinical Practice and Cases in Emergency Medicine

Introduction: Altered mental status presentations are commonplace in the emergency department (ED), but not all are due to psychiatric etiologies, even if the patient has had a previous psychiatric diagnosis. It is critical to evaluate for organic causes of a patient’s altered presentation. This case highlights the necessity of a broad workup to correctly diagnose an altered patient.

Case Report: A 23-year-old Haitian male with a past medical history of bipolar 1 disorder, seizure disorder, and developmental delay presented to a critical access ED for altered mental status. The patient was given 300 milligrams of ketamine for delirious hyperactivity and agitation by emergency medical services in the field. On physical examination, the patient was in acute respiratory distress, hypoxic, not tolerating secretions, tachycardic, lethargic, and was subsequently intubated for airway protection. Computed tomography (CT) of the brain without contrast was obtained and revealed findings consistent with Fahr disease.

Conclusion: Fahr disease is a rare neurodegenerative condition that causes accumulation of calcium deposits in the basal ganglia as demonstrated on CT. Phenotypes can be variable, including
symptoms such as parkinsonism, chorea, dystonia, cognitive impairment, and ataxia. This case illustrates the importance of a broad differential diagnosis and emergent medical interventions for emergency physicians practicing in critical access facilities.