Differentials
Provisional tic disorder
SIGNS / SYMPTOMS
Motor and/or vocal tics for <1 year.
INVESTIGATIONS
Diagnosis is based on history and physical exam.
Persistent (chronic) motor or vocal tic disorder
SIGNS / SYMPTOMS
Either only motor or only vocal tics for >1 year.
INVESTIGATIONS
Diagnosis is based on history and physical exam.
Stereotypies
SIGNS / SYMPTOMS
Can be seen in normal children but often in children with pervasive developmental disorders. Common ones include head banging, body rocking, and repetitive finger movements.
INVESTIGATIONS
Diagnosis is based on history and physical exam.
Akathisia
SIGNS / SYMPTOMS
An abnormal state of excessive restlessness accompanied by feeling the need to move about, with relief gained after moving. Often seen in the context of dopamine receptor-blocking agent exposure, both acutely and chronically.
INVESTIGATIONS
Diagnosis is based on history and physical exam.
Compulsions and obsessions (including OCD)
SIGNS / SYMPTOMS
Although compulsions are also usually associated with feelings of inner anxiety, they are characterized by ritualistic behaviors (checking, touching, arranging, etc.) and the need to repeat them in the same manner. Obsessions are closely linked and are defined as recurrent, often undesired, intrusive thoughts.
INVESTIGATIONS
Diagnosis is based on history and physical exam.
Pediatric autoimmune neuropsychiatric disorders associated with streptococcus (PANDAS)
SIGNS / SYMPTOMS
By definition, abrupt or explosive onset or exacerbation of tics and/or OCD in prepubertal children in temporal association with laboratory evidence of a streptococcal infection.
Pediatric acute-onset neuropsychiatric syndrome (PANS)
SIGNS / SYMPTOMS
A syndrome with primary diagnostic criteria of acute-onset OCD, with secondary features of anxiety, emotional lability, irritability, aggression, behavioral regression, deterioration in school performance, sensory or motor abnormalities, and somatic signs and symptoms such as loss of handwriting skills or frequent urination.
INVESTIGATIONS
Positive throat culture.
Positive antistreptolysin O antibodies (peak at 3 to 6 weeks) and antiDNAase B antibodies (peak at 6 to 8 weeks).[61][62]
CBC with differential, comprehensive metabolic panel, ESR, and CRP.
Urinalysis to exclude urinary tract infection.
ANA may be positive.
Consideration of other infectious etiologies with Lyme disease and Mycoplasma infection serology.[57]
Myoclonus
SIGNS / SYMPTOMS
Involuntary brief, jerk-like movement. Can be irregular and is not preceded by the urge to perform the movement.
INVESTIGATIONS
Diagnosis is usually based on history and physical exam.
Wilson disease
SIGNS / SYMPTOMS
Kaiser-Fleischer rings, parkinsonism, slow high-amplitude proximal tremor.
INVESTIGATIONS
Increased serum copper levels and low serum ceruloplasmin levels.
MRI with symmetric T2 hyperintensities in the bilateral basal ganglia and mesencephalon with sparing of the red nuclei.
Huntington disease
SIGNS / SYMPTOMS
Involuntary choreic movements not associated with an urge to move. By definition, these movements should be random and not stereotyped.
INVESTIGATIONS
Positive genetic testing for Huntington disease.
Sydenham chorea
SIGNS / SYMPTOMS
Develops weeks to months after streptococcus infection, characterized by chorea and truncal movements.
INVESTIGATIONS
Diagnosis is usually based on history and physical exam.
Allergic rhinitis
SIGNS / SYMPTOMS
May present with sniffing, eye blinking, and throat clearing.
INVESTIGATIONS
Skin testing may reveal causative allergen. Response to a therapeutic trial of antihistamine or intranasal corticosteroid.
Conjunctivitis
SIGNS / SYMPTOMS
May present with eye blinking.
INVESTIGATIONS
Positive adenovirus immunoassay in adenovirus infection.
Positive culture for bacterial or viral infection.
Cough-variant asthma
SIGNS / SYMPTOMS
Chronic cough following exposure to allergens or upper respiratory infection.
INVESTIGATIONS
Physical exam; response to bronchodilators or corticosteroids.
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