Diagnosing tetraplegic functional neurologic symptom disorder (conversion disorder) in the emergency room: A case report

Abstract

INTRODUCTION: Functional neurologic symptom disorder (conversion disorder) is a psychiatric condition manifested by neurologic symptoms incongruent to neurological pathophysiology. Symptoms are common in neurologic and psychiatric settings, affecting up to 20% of patients. When patients present outside of these settings, diagnosis is difficult. PURPOSE: To educate providers on the clinical presentation, diagnosis, risk factors, and management of tetraplegic conversion disorder in the emergency room setting. CASE PRESENTATION: A 47-year-old female presented to the emergency department after a transient shock-like sensation in her body, chest pain, and acute-onset tetraplegia. Examination revealed flaccid-like muscle paralysis of each extremity despite normal sensation, normal deep-tendon reflexes, and signs suggestive of psychogenic weakness. Other body systems were normal. Chest pain was controlled with nitroglycerin. Comprehensive metabolic panel, complete blood count, and troponin were normal. Head and neck computed tomography was unremarkable. The patient was transferred for magnetic resonance imaging and neuro-intensivist assessment. Evidence of neurological disease was never found, confirming the diagnosis of conversion disorder. Once informed, the patient rapidly regained complete mobility. DISCUSSION: Diagnosis was difficult, requiring an in-depth assessment. Due to the presentation -- spinal cord ischemia, inflammatory disease, and traumatic injury needed exclusion using appropriate history, physical examination, and testing. Upon literature review, seven reports of tetraplegic conversion disorder were discovered. CONCLUSION: Clinicians should consider a conversion disorder diagnosis throughout the assessment of a neurologic complaint, especially when the evaluation discovers incompatibility to neuropathological disease. Exclusion of non-psychogenic causes of neurologic symptoms is the foundation for the conversion disorder diagnosis.