What is the diagnosis and management for an 11-year-old male with abdominal pain, vomiting, mesenteric lymphadenitis, and unexplained scratch marks, who claims the scratch marks are caused by an evil spirit?

Diagnosis: Factitious Disorder Imposed on Self (Self-Inflicted Injury with Delusional Attribution)

This 11-year-old male presenting with chronic abdominal pain, vomiting, mesenteric lymphadenitis, and self-inflicted scratch marks attributed to "evil spirits" most likely has a psychiatric disorder involving self-harm with either delusional thinking or culturally-influenced explanatory models, requiring immediate psychiatric intervention while continuing medical monitoring.

Clinical Reasoning and Differential Diagnosis

Medical Evaluation Completed

• The surgical team appropriately evaluated and managed the mesenteric lymphadenitis, which is a common self-limiting condition in children that typically presents with abdominal pain and vomiting 1, 2
• Mesenteric lymphadenopathy in children most frequently occurs with acute infections (respiratory or gastrointestinal), with primary mesenteric lymphadenitis diagnosed in approximately 21% of cases 1
• The 6-month duration of symptoms is atypical for acute nonspecific mesenteric lymphadenitis, which typically resolves within 2-4 weeks, suggesting either recurrent episodes or an alternative underlying process 2

Psychiatric Red Flags Requiring Immediate Attention

• Self-inflicted injury with delusional attribution: The "insidious appearance" of scratch marks that the child attributes to an "evil spirit" represents either:

  • Factitious disorder imposed on self (deliberate self-harm with external attribution)
  • Psychotic disorder with somatic delusions
  • Severe dissociative disorder with self-harm during dissociative episodes
  • Cultural belief system requiring sensitive exploration

• The combination of chronic somatic complaints (abdominal pain, vomiting) with self-harm and unusual explanatory models suggests significant psychiatric pathology that requires urgent evaluation 3

Critical Differential Considerations

Psychiatric Diagnoses to Evaluate:

• Primary consideration: Factitious disorder or somatic symptom disorder with self-injurious behavior
• Psychotic disorder (childhood-onset schizophrenia, brief psychotic disorder)
• Severe anxiety or trauma-related disorder with dissociation
• Depression with psychotic features
• Obsessive-compulsive disorder with religious/magical thinking

Medical conditions that can present with psychiatric symptoms and abdominal pain:

• While rare, Fabry disease can present in children with unexplained gastrointestinal disturbances (diarrhea, vomiting, nausea, abdominal pain) and should be considered if other unexplained symptoms persist 4
• Cyclic vomiting syndrome, though the 6-month continuous pattern is atypical 4

Management Algorithm

Step 1: Immediate Psychiatric Safety Assessment

• Assess for suicidal ideation, homicidal ideation, and acute psychosis requiring inpatient psychiatric hospitalization
• Evaluate the severity and frequency of self-harm behavior
• Determine if the child has insight into the self-inflicted nature of the injuries or truly believes in the "evil spirit" explanation
• Screen for command hallucinations or other psychotic symptoms

Step 2: Comprehensive Psychiatric Evaluation

• Conduct detailed mental status examination focusing on:

  • Thought content (delusions, obsessions, preoccupations)
  • Perceptual disturbances (hallucinations)
  • Cognitive function and reality testing
  • Mood and affect assessment

• Obtain collateral history from parents/caregivers regarding:

  • Timing and circumstances of scratch mark appearance
  • Whether injuries occur when child is alone or observed
  • Any witnessed self-harm behavior
  • Family psychiatric history
  • Recent stressors, trauma, or abuse
  • Cultural and religious beliefs about spirits/supernatural entities

• Screen for abuse and neglect: Self-harm and somatic complaints can be manifestations of ongoing abuse 3

Step 3: Targeted Medical Workup (If Not Already Completed)

• Review all prior laboratory investigations for mesenteric lymphadenitis
• If inflammatory markers were elevated, ensure appropriate infectious workup was completed (viral serologies, parasitic evaluation) 1
• Consider α-galactosidase A enzyme level if other unexplained symptoms suggest Fabry disease (heat/cold intolerance, chronic pain unresponsive to analgesics) 4
• Rule out neurological causes if any focal neurological signs present

Step 4: Psychiatric Treatment Initiation

For Psychotic Features:

• If true delusions or hallucinations are present, initiate antipsychotic medication in consultation with child psychiatry
• Consider inpatient psychiatric admission for medication initiation and safety monitoring

For Factitious Disorder/Self-Harm Without Psychosis:

• Individual psychotherapy (cognitive-behavioral therapy or dialectical behavior therapy)
• Family therapy to address family dynamics and parental response to illness behavior
• Avoid reinforcing illness behavior through excessive medical attention 3
• Establish clear behavioral plan with parents to respond consistently to self-harm

For Somatic Symptom Disorder:

• Explain brain-gut connection and validate that symptoms are real 3
• Implement scheduled medical follow-up (not as-needed) to reduce anxiety-driven healthcare seeking
• Consider trial of prednisone 1 mg/kg (max 40 mg daily) for 5 days if mesenteric lymphadenitis symptoms are severe and persistent 5

Step 5: Cultural Sensitivity and Family Engagement

• Explore cultural context of "evil spirit" attribution without dismissing family beliefs
• Engage cultural liaison or religious leader if family's belief system is central to their understanding
• Frame psychiatric treatment in culturally acceptable terms
• Address any stigma around mental health treatment

Step 6: Ongoing Monitoring and Coordination

• Establish clear communication between pediatrics and psychiatry teams
• Schedule regular follow-up to monitor both medical and psychiatric symptoms
• Monitor for escalation of self-harm or emergence of new psychiatric symptoms
• Reassess diagnosis if symptoms evolve or new information emerges

Critical Pitfalls to Avoid

• Do not dismiss the scratch marks as "attention-seeking" without thorough psychiatric evaluation—this represents significant psychopathology requiring treatment
• Do not perform repeated invasive medical testing for the abdominal symptoms once mesenteric lymphadenitis has been diagnosed and other serious pathology excluded, as this reinforces illness behavior 3
• Do not allow chronic school avoidance due to abdominal symptoms, as this perpetuates dysfunction 3
• Do not ignore child protection concerns—self-harm and somatic symptoms can indicate abuse 3
• Do not assume cultural beliefs are pathological—distinguish between culturally normative explanatory models and true delusions requiring treatment

Prognosis and Follow-Up

• Mesenteric lymphadenitis typically resolves within 2-4 weeks with supportive care 2
• Psychiatric prognosis depends on underlying diagnosis and treatment engagement
• Close follow-up within 1 week of psychiatric referral is essential to ensure treatment initiation and safety
• If psychotic disorder is confirmed, early intervention improves long-term outcomes