Case history
Case history
A 12-year-old boy with a normal perinatal and developmental history experienced onset of frequent eye squinting at age 8 years. By age 10 years, he developed mild facial tics (nose and mouth twitching) that waxed and waned in frequency and intensity. These symptoms worsened over time but did not interfere with any of his activities or overall functioning. When his voice began changing, he developed some mild throat clearing and 'squeaking'. Since starting at a new school, his tics have increased and they now consist of neck rotations and eye convergence. Also, when watching TV, he has the urge to extend both hands toward the screen to 'get as close as I can without touching it'. All of these movements are preceded by an urge to perform them, and followed by a sense of relief afterward. The movements disappear when he plays video games, but when he is relaxed after school, the tics can return 'in a flurry'. He does not have any ritualistic behaviors.
Other presentations
On the more severe end of the spectrum, patients with TS can present with significant behavioral and psychiatric symptoms, such as oppositional defiant behavior, anxiety, and depressive symptoms, and disabling tics and compulsions. Self-injurious behavior may occur, necessitating emergency department visits or hospitalization. A combination of intense motor tics and/or compulsive behaviors can result in injuries, such as cervical myelopathy from repeated head flexion-extension tics, retinal detachments, and self-laceration.[8][9][10] "Malignant TS", a term that has been used to describe this presentation, seems to occur in 5% of cases and tends to be refractory to standard medications.[11]
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