![]() Sixteen months before this evaluation, the first of three episodes of severe vomiting requiring intravenous hydration occurred subsequent episodes occurred 6 months and 4 months before this evaluation, each preceded by fever and viral symptoms. She had a history of anxiety and depression she had no response to a trial of sertraline but did have a response to both escitalopram, begun 2 years before this evaluation, and 7 months of cognitive behavioral therapy. She adhered to a gluten-free diet and had been otherwise well. A diagnosis of celiac disease had been made at the age of 8 years, when she presented with abdominal pain and constipation elevated levels of tissue transglutaminase antibody (70 U per milliliter) and endomysial antibody (80 U per milliliter) were detected, and examination of a biopsy specimen of the duodenum showed changes consistent with celiac disease. The patient was born to a 39-year-old mother by cesarean section because of maternal preeclampsia, and her childhood development was normal. The ranges shown are obtained from the laboratories at the other hospital. †Reference values are affected by many variables, including the patient population and the laboratory methods used. She was referred to the outpatient gastroenterology, neurology, and psychiatry clinics of this hospital.Ĥ.5 Mo before Evaluation, Pediatrician’s OfficeĦ Wk after Evaluation, Pediatrician’s Office ![]() Approximately 4.5 months before this presentation, red-cell indexes and results of thyroid-function tests were normal, and testing for heterophile antibody was negative other test results are shown in Table 1. Her performance in school deteriorated, and she failed mathematics. ![]() She became increasingly isolated from her friends and lost interest in activities. She had frequent angry outbursts directed at her mother and sister, and acted out physically on occasion. ![]() The patient had celiac disease but had been otherwise well until approximately 8 months earlier, when she became increasingly irritable and reported daily stomachaches, tingling and pain in her arms and legs, dizziness, anorexia, and severe fatigue she also became increasingly somnolent, sleeping up to 13 hours per night. Pinsky (Psychiatry): A 12-year-old girl was seen in the outpatient psychiatry clinic of this hospital because of severe irritability, hypersomnia, and multiple somatic symptoms. ![]()
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