Hallucinations at Seven: When the Diagnosis Isn't the Answer

Document Type

Conference Proceeding - Restricted Access

Publication Date

5-8-2026

Abstract

New-onset hallucinations and psychosis in children are uncommon and prompt concern for serious neurologic or infectious etiologies, including autoimmune encephalitis, CNS infection, seizure disorders, or structural brain abnormalities. Autoimmune encephalitis may present with prominent psychiatric symptoms, often necessitating early recognition and treatment. However, differentiating inflammatory encephalopathies from primary psychiatric or stress-related conditions can be challenging, particularly when systemic symptoms such as fever or sensory complaints are present. This diagnostic overlap may lead to extensive evaluations and uncertainty regarding treatment approaches. We present a pediatric case highlighting these challenges.

A previously healthy 7-year-old female presented with subacute visual hallucinations over several months, with acute worsening characterized by auditory command hallucinations instructing self-harm, anxiety, paranoia, personality changes, intermittent bilateral lower extremity paresthesias, and a brief febrile episode (Tmax 38.5°C). Family history was notable for anxiety and severe mental illness. Given concern for autoimmune or infectious encephalitis, extensive evaluation was pursued. Brain MRI demonstrated incidental pineal and arachnoid cysts without evidence of inflammation or elevated intracranial pressure. Lumbar puncture revealed normal cell counts, glucose, and protein. EEG showed mild, nonspecific generalized slowing without epileptiform activity. MRI of the spine was unremarkable, and neurologic examination remained non-focal throughout hospitalization.

This case highlights the limitations of existing diagnostic frameworks in explaining atypical pediatric psychosis in the absence of objective neurologic findings. Although extensive evaluation did not support autoimmune or infectious encephalitis, the psychiatric diagnoses of adjustment disorder and anxiety did not fully account for the severity or phenomenology of the patient's hallucinations. Rather than offering resolution, the diagnosis marked the limits of our current understanding.

Comments

2026 Research Day Corewell Health West, Grand Rapids, MI, May 8, 2026. Abstract 2145

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