[Confusion as a presentation symptom of pseudomigraine with pleocytosis in a paediatric patient]

Transient headache and neurological deficits with cerebrospinal fluid lymphocytic pleocytosis (Handl) syndrome is a rare condition of unknown origin that is characterized by episodes of severe headache, transient neurological deficits that recur over less than 3 months, and lymphocytic pleocytosis in CSF. We report the case of a 14 year-old girl who presented with headache and vomiting that lasted 4 days, later combined with a clinical presentation of confusion, with a decrease in the level of consciousness, aphasia, peripheral facial paralysis, ataxia and fever for 24 hours. CSF analysis showed pleocytosis (110 cells/ml) and proteinorrachia (87 mg/dl). Electroencephalogram in the acute time showed generalized slowing, and later a focal slowing in the left hemisphere. She suffered 7 episodes of migraine (severe headache and vomiting) in the following two months, remaining asymptomatic thereafter. This is the first pediatric case published in the literature that presents with an agitated and/or confused state. This condition must be considered in the differential diagnosis of patients with headache and acute altered level of consciousness, in order to avoid prolonged treatments or unnecessary invasive testing.