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LETTER TO THE EDITOR |
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| Year : 2013 | Volume
: 16
| Issue : 2 | Page : 292-293 |
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Demyelination presenting as tics in a healthy child
Rashid Saleem, Gururaj Setty, Pooja Harijan, Nahin Hussain
Department of Pediatric Neurology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, United Kingdom
| Date of Web Publication | 24-May-2013 |
Correspondence Address:
Rashid Saleem
Department of Pediatric Neurology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, LE1 5WW
United Kingdom
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0972-2327.112503
How to cite this article:
Saleem R, Setty G, Harijan P, Hussain N. Demyelination presenting as tics in a healthy child. Ann Indian Acad Neurol 2013;16:292-3 |
Sir,
Post-infectious demyelination is not uncommon in children and can present with myriad of symptoms depending on the topographical localization. We would like to report a case of acute-onset facial motor tics as a presenting feature secondary to demyelination.
An 11-year-old healthy boy presented to us with a short history of fever, headache and sore throat. He was treated with five days of oral antibiotics for probable throat infection. His inflammatory markers and Antistreptolysin O titer were normal, and throat swab was sterile. He represented five weeks later with acute-onset facial motor tics worsening for last one month. In addition, he complained of mild headaches. There was no history suggestive of Obsessive Compulsive Disorder (OCD) or Attention Deficit Hyperactivity Disorder (ADHD). His neurodevelopment was age-appropriate, and there was no evidence of developmental regression.
On examination he was well in himself and apyrexial. He had very florid orofacial simple motor tics in the form of 'tongue protrusion' and 'eye blinking'. His neurological examination was unremarkable. His full blood count, electrolytes, C-reactive protein, liver function tests, Antistreptolysin O titer, Anti DNAse B, thyroid functions, copper, ceruloplasmin, auto-antibodies, throat culture and cardiac echocardiogram were normal. Magnetic resonance imaging (MRI) brain showed high signal lesions in the cerebellar peduncle and pons on T2-weighted image [Figure 1] with normal T1-weighted and diffusion-weighted (DW) images suggestive of demyelination. There was no post-gadolinium enhancement. Cerebrospinal fluid was normal. Polymerase chain reaction for herpes and other viruses was negative. | Figure 1: T2W MRI brain showing an area of demyelination at the junction of right middle cerebellar peduncle and pons
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He was treated with intravenous methylprednisolone and almost became symptom-free by the end of five days.
A tic is a sudden, rapid, recurrent, non-rhythmic, stereotyped motor movement or vocalization. [1] Depending upon the complexity, tics can be categorized into simple and complex types. Clinically, tics can manifest as motor or phonic presentations. A motor tic can be tonic, clonic or dystonic. Using the Diagnostic and Statistical Manual of Mental Disorders, 4 th Edition Text Revision (DSM-IV-TR) criterion tics can be categorized into Transient Tic Disorder, Chronic Tic Disorder, Tourette syndrome and Tic disorder not otherwise specified. [2] Our case had simple motor orofacial tics of dystonic form, and qualified at presentation for the DSM-IV-TR category of Transient Tic Disorder. Absence of vocal tics and co-morbidities such as ADHD and OCD and the duration of tics less than one year ruled out Tourette syndrome in our case at the time of presentation. [2] The acquired causes of tics include autoimmune, toxic, degenerative and vascular etiologies. [3] Acquired demyelination in children can present in several ways. Usual clinical features include encephalopathy, motor, sensory, brain-stem or ocular symptoms. [4] Extrapyramidal movement disorders have hardly been reported, [5] and there is only one published case report of phonic tics as a manifestation of Multiple Sclerosis in a 34-year-old lady, and motor tics have never been reported as a presenting feature. [6] While Acute Demyelinating Encephalomyelitis (ADEM) can present with tics, our case did not have encephalopathic features and the typical MRI findings seen in ADEM. [7] Our case highlights a very rare manifestation of demyelination, and underscores the importance of neuroimaging in the evaluation of acute-onset movement disorders including tics in children.
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| 2. | American Psychiatric Association. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4 th ed. Text Revision. Washington, DC: American Psychiatric Association; 2000.
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| 3. | Hyde TM, Aaronson BA, Randolph C, Rickler KC, Weinberger DR. Relationship of birth weight to the phenotypic expression of Gilles de la Tourette's syndrome in monozygotic twins. Neurology 1992;42:652-8.
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| 4. | Mikaeloff Y, Caridadea G, Hussonb B, Suissac S, Tardieu M. Acute disseminated encephalomyelitis cohort study: Prognostic factors for relapse. Eur J Paediatr Neurol 2007;11:90-5.
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| 5. | Maramattom BV, Sarada C. Clinical features and outcome of acute disseminated encephalomyelitis (ADEM): An outlook from South India. Ann Indian Acad Neurol 2006;9:20-4.
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| 6. | Lana-Peixoto MA, Teixeira AL. Simple phonic tic in multiple sclerosis. Mult Scler 2002;8:510-1.
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| 7. | Callen DJ, Shroff MM, Branson HM, Li DK, Lotze T, Stephens D, et al. Role of MRI in the differentiation of ADEM from MS in children. Neurology 2009;72:968-73.
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