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Description
A 10-year-old boy presented to us with a history of sudden onset of abnormal movements from the last 8 days. On examination, he had no problems except some abnormal movements of the lips, hands and feet (see video 1).
Abnormal movements in a young boy.
Discussion
This patient had no family history of movement disorder. He never had seizures or intellectual impairment. His blood examination showed normal complete blood count and erythrocyte sedimentation rate along with a normal antistreptolysin O titre.
Movement disorder in this 10-year-old boy (video 1) is characterised by rapid uncoordinated, jerking movements mainly in face, hands and feet, which is also quasi-purposive as you can see him trying to hide the problem by putting his right hand into his pockets.
We sent this video to a US-based neurolistserv frequented by neurologists globally for an opinion and the responses are as below.
Message from: Hussein H Abdel-Dayem
These involuntary movements appear to be of chorea (mainly proximal, non-repetitive, non-purposeless and rapid).
Dr Hussein Abdel-Dayem, MD, Professor of Child Neurology, Faculty of Medicine, Alex University, Egypt.
Message from: Jorge A Romero
He has chorea, and some mild dystonic features.
You did not give much clinical information. Is there a family history of movement disorder? Are there seizures? Intellectual impairment? Any other symptoms that preceded the onset of the neurologic signs?
In a 10-year-old with new onset of this movement disorder, I would be concerned about Sydenham's chorea, particularly with the relatively rapid onset.
Jorge A Romero, MD, Baylor University Medical Center, 3600 Gaston Avenue Suite 901, Dallas, Texas 75246, USA.
In rheumatic chorea or Sydenham's chorea (SC), the abnormal movements may merge imperceptibly into purposeful or semi-purposeful acts, sometimes making the chorea hard to identify.
Chorea may also be seen with Huntington's disease and as a complication of medication (levodopa, anticonvulsants, antipsychotics). Our patient did not have a history of medication intake before his symptoms started. He was unlikely to be affected by Huntington's disease because of the absence of the same in the family history and it did not occur in adulthood as is usually the case.
The patient was also suspected of SC due to the commonality of this particular aetiology in our part of the world.1 SC usually develops in those aged 3–13 years and is believed to result from a preceding streptococcal infection. The patient may have no history of rheumatic fever and a preceding streptococcal infection cannot always be documented. Infections can be subclinical and often precede the development of neurologic symptoms by age 1–6 months. At least 25% of patients with SC fail to have serologic evidence of prior infection.2
Acknowledgments
To all those who cared for this patient.
Footnotes
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Competing interests None.
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Patient consent Obtained.