Metabolic Workup for 10-Year-Old with Anxiety and Visual Hallucinations
In a 10-year-old presenting with anxiety and visual hallucinations, perform a comprehensive metabolic panel, complete blood count, toxicology screen (including over-the-counter medications), and urinalysis to exclude organic causes before attributing symptoms to primary psychiatric etiology. 1, 2
Initial Laboratory Assessment
The metabolic workup should include:
- Complete blood count (CBC) to assess for infection, anemia, or hematologic abnormalities 1
- Comprehensive metabolic panel including glucose, electrolytes, renal function, and liver function to identify metabolic derangements 1
- Toxicology screen with specific attention to sympathomimetic agents (pseudoephedrine, other decongestants), as these are common culprits in pediatric hallucinations 2
- Urinalysis to screen for infection or metabolic abnormalities 1
Critical Medication and Exposure History
Obtain detailed medication history including all over-the-counter medications, particularly nasal decongestants containing pseudoephedrine, which can cause visual hallucinations in children even at inappropriately high therapeutic doses. 2 This is a frequently missed organic cause in pediatric patients presenting with hallucinations.
Additional exposures to evaluate:
- Anticholinergic medications 1
- Steroids 1
- Benzodiazepines if co-administered with macrolide antibiotics 3
Neuroimaging Considerations
Brain MRI is the preferred imaging modality if organic pathology is suspected, particularly to exclude intracranial processes such as CNS malignancy, encephalitis, or structural abnormalities 1, 2. The American College of Radiology recommends neuroimaging to distinguish between primary psychiatric causes and secondary neurological disorders 4.
Ophthalmologic Assessment
While less common in this age group, formal ophthalmological examination should be considered if vision impairment is present, as visual pathway pathology can contribute to hallucinations even when other conditions are present 1, 5.
Additional Testing Based on Clinical Suspicion
- Electroencephalogram (EEG) if temporal lobe epilepsy is suspected 1, 2
- Lumbar puncture if encephalitis or CNS infection cannot be excluded clinically 1
Key Diagnostic Distinction
Assess the patient's insight into the unreality of the hallucinations. 4 Preserved insight (recognizing hallucinations are not real) suggests benign causes like Charles Bonnet Syndrome or anxiety-related visual hallucinations, whereas lack of insight may indicate primary psychotic disorder or mania requiring different management 4.
Anxiety-Related Visual Hallucinations in Children
Visual, tactile, and phobic hallucinations (VTPH) represent an important differential diagnosis in this age group, characterized by:
- Preschool to young school-age children 6
- Tactile and visual (not auditory) hallucinations 6
- Symptoms presenting at night 6
- Anxiety-based but short-lived duration 6
- When organic causes are excluded, psychiatric consultation is more appropriate than extensive additional testing 6
Common Pitfall
Do not reflexively order extensive neuroimaging or invasive procedures without first completing basic metabolic screening and obtaining thorough medication/exposure history. 6 In pediatric patients, toxicologic causes and anxiety-related hallucinations are more common than previously recognized, and unnecessary testing causes emotional distress and increased costs 6.