Medical Case Reports

Description

Limping is a common chief complaint in the pediatric Emergency Department (ED) and can be difficult to assess in pediatric patients, particularly if they have developmental delay. We present a case of a 5-year-old male with nonverbal autism who presented with a progressive limp, weakness, pain, and rash over the course of 1 month. A magnetic resonance imaging scan of the pelvis performed while the patient was sedated revealed multifocal osseous marrow signal abnormalities, ultimately consistent with vitamin C deficiency or scurvy. Scurvy can present with nonspecific limp, rash, and bony pain and should be considered in pediatric patients with developmental/ sensory delay who may restrict their diets. Emergency physicians should broaden their differential diagnoses to nutritional deficiencies such as scurvy in the evaluation of pediatric patients with limp. Autism spectrum disorder represents a set of developmental disorders characterized by lack of social interaction and verbal and nonverbal communication in the first 3 years of life. It is also associated with several comorbidities, including epilepsy, aggression, self-mutilating behavior, and obsessive-compulsive behavior. In some cases, Obsessive- Compulsive Disorder (OCD) develops. The Nucleus Accumbens (NAc) plays a key role in reward circuitry and is involved in the control of OCD and aggression. A 42-year-old woman with autism was offered NAc deep brain stimulation for her comorbidities of OCD and aggression. The NAc was targeted using standard stereotactic methods, and postoperative scans confirmed the position of the active electrode to be within the NAc. The patient experienced significant symptom relief. At 1- year follow-up, the Yale-Brown Obsessive Compulsive Scale score for OCD, excluding items 1–5 of the scale, improved from 19 to 5.

Psychotic Disorders

Hamilton depression scale and Hamilton anxiety scale scores similarly improved from 20 to 15 and from 30 to 18, respectively. Social communication questionnaire current version for autism score improved from 26 to 16. Subscores for reciprocal social interaction improved from 13 to 8; for communication improved from 5 to 4; and for restricted, repetitive, and stereotyped patterns of behavior improved from 6 to 3. This case report illustrated the role of the NAc in OCD and aggression in an autistic patient. We discussed the role of the NAc as a target to explain the outcome of this case. Risperidone is commonly prescribed by pediatricians for a variety of behavioral and psychological disorders. We report a boy with autism-spectrum disorder, who developed frequent penile erections after an increase in risperidone dosage for a month. The patient fully recovered 2 days after risperidone discontinuation. This report concerns the youngest case of psychotropic medication-induced sexual disorders, which illustrates the differences in presentation between children and adults. Moreover, this case can serve as evidence that discontinuation should be recommended for the management of drug-induced sexual disorders. Childhood narcolepsy is associated with various emotional, behavioural and cognitive dysfunctions as well as with psychiatric and neurodevelopmental disorders: Anxiety, depression, attention deficit hyperactivity disorder and psychosis. A relationship between these conditions is unclear-comorbidity or similar pathophysiological mechanisms can be suggested. This paper highlights the clinical challenges faced when assessing patients with stalking behaviors with psychotic disorders, suggesting the need for an accurate assessment of adult autism spectrum symptoms.

Therapeutic Challenges of Complex Neuropsychiatric

A 25-year-old man with a diagnosis of delusional disorder, erotomanic type, was hospitalized for acute psychotic symptoms occurred in the framework of a repeated stalking behavior towards his ex-girlfriend. When assessed for adult autism spectrum symptoms upon an accurate clinical evaluation, he reported elevated scores in the mentalizing deficit and social anxiety domains by means of the 14 item Ritvo Autism and Asperger Diagnostic Scale (RAADS-14). Authors discuss a possible role of adult (subthreshold) autism spectrum symptoms, generally disregarded in adult psychiatry, on the type of psychotic features and stalking behavior developed that may help for appropriate diagnosis and treatment. We describe a case study of comorbid Obsessive–Compulsive Disorder (OCD) in a nine-year-old boy with Duchenne Muscular Dystrophy (DMD). Patient history included persistent deficits in social communication and restrictive and repetitive patterns of behavior: A diagnosis of autism spectrum was formalized. Due to serious disruption on social functioning and negative development of the obsessive behavior we decided to start pharmacotherapy. Fluoxetine 5 mg/day was started and gradually increased to 20 mg/day. A significant positive effect was observed by both parents and teacher in daily functioning. Although parents reported a positive change in mood, formal behavior rating by them did not reveal a significant effect, reflecting the insensitivity of general behavior rating scales. However, neuropsychological testing revealed a significant effect. This case report highlights the diagnostic and therapeutic challenges of complex neuropsychiatric comorbidities in DMD. It is the first scientific report on fluoxetine effectiveness in this patient group. Further research is needed. We present a case report of a 14-year-old boy with ASD and vocal tics. Vocal tic frequency was nearly 2000 per day and 90 dB in volume. He presented to our laryngology clinic after multiple failed attempts of pharmacologic management of vocal fold botulinum toxin injection. After evaluation in our clinic, we recommended a lateralization (type IIB) thyroplasty. An autologous cartilage graft from the superior thyroid ala was used and held in place with a bioresorbable mesh. Using 4-0 prolene sutures, the mesh was secured in place. The operation was well tolerated with minimal signs of aspiration, and he was discharged to his home within 48 hours. Selective Mutism (SM) is a rare childhood psychiatric disorder (prevalence 0.47%–0.76%) characterized by the persistent failure to speak in specific contexts (such as at school or with playmates/strangers) where speech is typically expected, despite hearing and speaking in other contexts (with parents and other family members). It is diagnosed mostly in the childhood or early adolescence. Co-morbidity is a rule than an exception in children with SM. Some of the common co-morbid psychiatric conditions in children with SM are speech and language problems, depression, panic disorders, dissociative disorders, obsessive compulsive behavior and Autism Spectrum Disorder (ASD) like Asperger’s disorder/Atypical autism. When SM and ASD co-occur, the condition becomes more difficult to treat and requires intensive non-pharmacological therapies. Earlier, comorbid pervasive developmental disorder and SM were not diagnosed together (American Psychiatric Association, 2000). But currently DSM-5 had allowed for the same (American Psychiatric Association, 2013). SM is a treatable condition and if left untreated, then it can have a significant impact not only on the child’s normal growth and development as well as on his/her academic performance and future. In this case report, we report a case of 11 years old male child with ASD who developed SM and discuss the diagnostic challenges and management.