Harminder S. Sandhu, MD
Resident Physician
Texas Rehab Hospital of Fort Worth
Fort Worth, Texas, United States
Kevin Mullins, MD
Attending Physician
University of California, Davis
Sacramento, California, United States
Jordan Eisner, MD
Resident Physician
University of California, San Diego
San Diego, California, United States
This case presents an 18-month-old boy who developed lower extremity segmental dystonia with complex regional pain syndrome type 1 (CRPS-1) following a focal injury to the foot (peripherally induced movement disorder or PIMD). To our knowledge, this case represents the youngest documented patient with both PIMD and CRPS-1, and the first pediatric case demonstrating significant motor recovery following segmental dystonia.
A fully vaccinated, 18-month-old boy with minor speech delay sustains a cut on dorsum of left foot. Within 3 days, he develops allodynia and at 10 days intermittent dystonia (left knee extension, left ankle eversion, and toe extension). Patient is admitted to the hospital, administered tetanus immunoglobulin and 7-days of oral metronidazole. MRI brain/spine, EEG, lumbar puncture, Invitae Dystonia Panel are unremarkable and patient is discharged home. Parents correlate episodes of dystonia with stress and improvement with musical play. Parents remove potential psychosocial stressors at home and begin intensive daily physical and behavioral therapy. Symptoms resolve after 4 weeks. Parents discontinue therapy and symptoms return again after 6 weeks. Intensive therapies are re-initiated and symptoms resolve again after 2 weeks. Parents develop long-term maintenance therapy plan, and at the time of this writing patient has remained symptom-free for 7 months.
Dystonia is the most common movement disorder in pediatrics, described as intermittent contractions/abnormal postures. Organic vs functional (psychogenic) dystonia is often debated and require vastly different treatment algorithms. Previously, the youngest case of functional dystonia was in a 2.5-year-old girl and symptoms resolved in 3 weeks with immediate psychosocial interventions. Our patient re-affirms the importance of trialing an aggressive therapy program as 1st-line treatment for patients with new functional dystonia diagnosis.
Dystonia from focal traumatic injury can occur. This case reinforces PIMD as a subset of functional dystonia and full motor recovery in segmental dystonia is possible with therapy.
