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Pediatric Oncall Journal

A 13 years old boy with tremors, poor scholastic performance and visual hallucinations.

A 13 years old boy with tremors, poor scholastic performance and visual hallucinations.

Dr Ira Shah.
Medical Sciences Department, Pediatric Oncall, Mumbai, India.

Dr Ira Shah, Medical Sciences Department, Pediatric Oncall, 1, B Saguna, 271, B St. Francis Road, Vile Parle {W}, Mumbai 400056.
Clinical Problem
A 13 years old born of non-consanguineous marriage presented with progressive tremors with change in behaviour and poor scholastic performance since 1 month. In addition he had repeated 10-15 episodes/day of falls with loss of consciousness for a second. He also had visual hallucinations, diplopia and slurred speech. He had history of dog scratch at 8 years of age (Dog was domestic and survived for several years). He also had exanthematous rash at 1½ years of age (Details not remembered). His birth history, immunization and milestones were normal. On examination, his vitals and general examination was normal. On CNS examination, he had coarse tremors, rigidity, cerebellar signs in form Rhomberg’s sign, dysdiadokinesis and slurred speech. Reflexes and sensory system was normal. There was no cranial nerve involvement. Other systems were normal. He was investigation for the same:
 CSF – Normal
 EEG – Abnormal periodic discharges
 MRI – Normal
 Hemogram, Renal function tests, Liver function tests – Normal
 Fundus and slit examination – Normal. No KF ring.

He was treated with syndopa but had no relief.

A neurological opinion was suggestive of schizophrenia.

Is the diagnosis of schizophrenia correct? Please give reason
Dr Ira Shah:

The diagnosis of schizophrenia is not correct as the child had visual hallucinations. Visual hallucinations are always organic in etiology. In schizophrenia, the common hallucinations are auditory and persecutive. Thus, this child had an organic cause to his symptoms.

Other organic etiologies that should be ruled out in this child are:
 Subacute sclerosing panencephalitis (SSPE) especially since the child had an exanthema at 1½ years of age and now has poor scholastic performance with absence seizures.
 Juvenile Parkinson’s disease especially since the child had tremors and rigidity. However there was no mask like facies or rolling movements of fingers and no improvement with Syndopa.
 Halloverden spatz disorder in view of extrapyramidal signs. However again the MRI is normal.
 Wilson’s disease in view of again extrapyramidal signs. But slit lamp examination did not show any KF ring.
 Heavy metal encephalopathy.

The child’s CSF Measles IgG antibody was positive and repeat EEG showed burst suppression pattern. His urine for heavy metals (Arsenic and Lead) was negative. Thus the child was diagnosed to have SSPE (Subacute sclerosing panencephalitis).
Compliance with ethical standards
Funding:  None  
Conflict of Interest:  None
Cite this article as:
Shah I. A 13 years old boy with tremors, poor scholastic performance and visual hallucinations. Pediatr Oncall J. 2006;3: 58.
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