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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 2  |  Issue : 1  |  Page : 55-57

Childhood-onset schizophrenia: A diagnostic challenge


1 Department of Psychiatry, BJGMC and Sassoon General Hospital, Pune, Maharashtra, India
2 Department of Psychiatry, D.Y Patil Hospital, Nerul, Maharashtra, India

Date of Web Publication8-May-2018

Correspondence Address:
Swaroop Sudhir Bhatankar
Saket Complex, A/8 604 Veer Sawarkar Marg Maziwada, Thane West, Thane - 400 601, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_33_17

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  Abstract 


Childhood-onset schizophrenia is characterized by onset before the age of 13 years. These symptoms overlap with other disorders of childhood onset (e.g., autism spectrum disorder and attention-deficit hyperactivity disorder) and hence can present as a diagnostic challenge. A 7-year-old boy presented with hyperactive behavior, inattention, and repetitive stereotypic hand movements, muttering and gesticulating to self for the 1½-year duration that developed after an episode of high-grade fever which was not associated with any focal neurological deficit. He was treated with antipsychotics, mood stabilizers, and stimulants on an outpatient basis and subsequently admitted for diagnostic evaluation due to persistent symptoms. We would like to discuss this case due to its complexity and the challenge we faced while treating this child. It is important to evaluate the cause of psychosis in a child as many disorders of childhood onset can present with psychotic symptoms.

Keywords: Attention deficit hyperactivity disorder, autism spectrum disorder, childhood-onset schizophrenia


How to cite this article:
Khar PB, Bhatankar SS, Santre MS, Pawar AV. Childhood-onset schizophrenia: A diagnostic challenge. Ann Indian Psychiatry 2018;2:55-7

How to cite this URL:
Khar PB, Bhatankar SS, Santre MS, Pawar AV. Childhood-onset schizophrenia: A diagnostic challenge. Ann Indian Psychiatry [serial online] 2018 [cited 2018 Aug 14];2:55-7. Available from: http://www.anip.co.in/text.asp?2018/2/1/55/232042




  Introduction Top


Childhood-onset schizophrenia (COS) is characterized by onset before 13 years of age and has prevalence of approximately 1 in 40,000.[1] This is a severe form of the illness with insidious onset and poor outcome. The symptoms overlap with other disorders of childhood onset (e.g., autism spectrum disorder and attention-deficit hyperactivity disorder) and hence can present as a diagnostic challenge.[2] We present an interesting case of a 7-year-old boy which proved to be diagnostic challenge for us.


  Case Report Top


Master XYZ, a 7-year-old boy hailing from a rural area was brought by his grandmother with complaints of hyperactive behavior, inattention, repetitive stereotypic hand movements, muttering and smiling to self for 1½ year which had increased for the past 2½ months. The onset was preceded by high-grade fever which lasted for 2–3 days. The child started having visual hallucinations in the form of seeing snakes and cartoon characters and expressed fearfulness and clinging behavior towards his mother during fever. These behavioral changes disappeared when the fever subsided. There was no focal neurological deficit, rash, loss of consciousness, or seizure episode during or after febrile episode. Details of the treatment taken for fever could not be verified due to unavailability of documents. The child attended school after fever episode and was back to his daily routine. A week later, he again started having visual hallucinations in the form of seeing snakes behind the school compound and became fearful. Although he would attend the school, he was observed by teachers to be inattentive during class, lost in his own world and would make some repetitive hand movements as if enacting something and recite dialogues of his favorite cartoon characters in Hindi. He would not sit in one place and started constantly moving around. Gradually at home, he was withdrawn and stopped playing with his brother and his friends in the neighborhood. He even failed to acknowledge, the presence of his mother even if she would repeatedly call out to him. Majority of his time would be spent moving around in circles, making repetitive hand movements, and humming the tunes of his favorite cartoon programs. These symptoms lasted for 2½ months after which he was brought to our outpatient department (OPD) for evaluation. The differentials considered were childhood psychosis, childhood disintegrative disorder, and subclinical seizure with associated behavioral problems. As the child had no focal neurological deficit, loss of consciousness, rigidity or seizure episode, encephalitis was ruled out. Electroencephalogram was done which was within normal limits and the child was started on Syrup Risperidone 0.5 mg (1 ml = 1 mg) once a day gradually increased to 2 mg per day. However, due to the minimal clinical improvement, drug was cross titrated to tablet Olanzapine 5 mg/day. In view of persistent mannerisms, hyperactivity, inattention, and academic decline tablet Valproate 200 mg and tablet Methylphenidate 5 mg was added. Although there was over 50% improvement clinically, there was a decrease in the appetite. Methylphenidate is known to cause decrease in appetite, hence, it was cross titrated with tablet Atomoxetine 10 mg. Over a period of 3 months, the patient had monthly follow-ups, during which there was more than 80% improvement clinically. After that patient was loss to follow-up. After 9 months from the last visit, the child presented to the OPD with worsening of symptoms in the form of pacing around, stereotypic hand movements, making odd hissing, grunting sounds, inattention, muttering, smiling to self, school refusal, and verbalizing cartoon dialogues. Hence, he was admitted for diagnostic evaluation and further management. On inquiry, it was found that parents had stopped medications, as they thought the child was cured. However, in the last 3 months, he had worsened due to which they reported to our OPD. On mental status examination, he was a well-dressed boy, intermittently getting up from the chair and moving in circles, moving his trunk back and forth, making hissing and grunting sound intermittently, making repetitive hand movements, at times appearing to be enacting something and reciting cartoon dialogues of “Doraemon and Chota Bheem.” He could not maintain eye contact and it was difficult to establish rapport with him. His attention was neither aroused nor sustained. He would only answer his name and that too after repeated questioning; hence, further formal mental status examination was deferred. Three main differential diagnoses were considered. First was Attention Deficit Hyperactivity disorder with Autism Spectrum Disorder. A score of 80 on application of Indian Scale for Assessment of Autism was obtained, suggestive of mild autism. A score of 71 on Vineland Social Maturity Scoring scale was suggestive of Borderline level of social maturity. However, the child had developed his language milestones at appropriate age with sudden onset of symptoms; hence, autism spectrum disorder was ruled out. The second differential considered was Pediatric Autoimmune Neuropsychiatric disorders associated with β-Hemolytic Streptococcal Infection (PANDAS). This was due to raised Anti-Streptolysin O (ASO) titer of 406 IU (Above 200 IU is considered positive).[3],[4] A pediatric opinion was taken after which a throat swab culture and magnetic resonance imaging (MRI) brain were advised. There was no history of waxing/waning course of illness, consequently PANDAS was also ruled out. In the past, the child had a history of fever with rash around 2 years of age; hence, a third differential diagnosis of subacute sclerosing panencephalitis (SSPE) as a complication of measles was taken into consideration as SSPE symptoms can manifest 6–15 years after initial infection.[4],[5] But since cerebrospinal fluid-IgG for measles was within the normal range, SSPE was ruled out. During the stay in the ward, there was persistence of psychotic symptoms in the form of muttering to self, verbalizing cartoon dialogues, inattention, and preoccupation with a cartoon theme. This time on admission it was revealed that there was a family history of schizophrenia in maternal grandfather; hence, the diagnosis was revised to COS. The child was started on tablet Clozapine 25 mg/day which was gradually titrated upward to 75 mg/day.[6] His interactions with parents gradually improved over a period of 1 month; there was a significant decrease in his self-absorbed and hallucinatory behavior and was discharged after a month of admission. He was able to attend school as well and follow instructions. He continues to follow-up regularly at our OPD. There are residual symptoms in form of occasional muttering, gesticulating to self and withdrawn behavior and we wish to monitor him for further improvement.


  Discussion Top


Diagnosis of psychosis in a child often poses a diagnostic challenge as the presenting symptoms overlap with the other disorders of childhood onset (autism spectrum disorder and attention-deficit hyperactivity disorder).[1],[2] A detailed history and neurological examination, pertinent laboratory and imaging tests are important to rule out the various alternative differential diagnoses since they may also present with psychotic symptoms. COS occurs in children <13 years of age and is chronic and debilitating.[1] Diagnostic statistical manual of mental disorders, Fifth Edition cautions that although the essential features of schizophrenia are same in childhood, it is harder to diagnose.[2] Children may experience less elaborate delusions and hallucinations. Visual hallucinations are more common in COS as in our case and should be distinguished from normal fantasy play.[2] There could be a drop-in performance at school and lack of motivation. Symptoms such as disorganized speech and behavior which are seen in schizophrenia also occur in many disorders of childhood onset (e.g., autism spectrum disorder and attention deficit hyperactivity disorder. At this point, we would like to mention about PANDAS. These are poststreptococcal neurological sequelae which have varied manifestations. It is necessary to establish a temporal association between occurrences of the infection and the symptoms to establish element of causality.[3] The diagnostic criteria are presence of obsessive-compulsive disorder and/or a tic disorder, pediatric onset of symptoms (age of 3 years to puberty), episodic course of symptom severity, association with group A Beta-hemolytic streptococcal infection (a positive throat culture for strep or history of scarlet fever), association with neurological abnormalities in the form of physical hyperactivity, or unusual, jerky movements and very abrupt onset or worsening of symptoms.[3],[4] The readers are requested to note that PANDAS can manifest even months following an initial infection; hence, a throat swab culture may not always be positive. Merely raised ASO titer could have misdirected us to falsely label this as a case of PANDAS.[3],[4] In this case, following the raised ASO titer, an MRI brain was done. MRI brain did not reveal any increase in the volume of the basal ganglia and neuroinflammatory changes as seen in PANDAS.[7] A normal MRI brain along with the absence of waxing-waning course of illness, seen in PANDAS, led to exclusion of PANDAS as a diagnosis. Many times, medication-free observations may be necessary to arrive at diagnosis, especially where the manifestations are complex and difficult to attribute to a single cause.[2] An early and accurate diagnosis of COS has significant effect on a long-term sequelae.[1]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We would like to thank Dr. Ivan Netto, Dr. Smita Panase.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gochman P, Miller R, Rapoport JL. Childhood-Onset Schizophrenia: The Challenge of Diagnosis. Current Psychiatry Reports. Bethesda; 2011. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3289250/. [Last accessed on 28 Nov 2017].  Back to cited text no. 1
    
2.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington (VA): American Psychiatric Association; 2013.  Back to cited text no. 2
    
3.
Swedo SE, Leonard HL, Garvey M, Mittleman B, Allen AJ, Perlmutter S, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: Clinical description of the first 50 cases. Am J Psychiatry 1998;155:264-71.  Back to cited text no. 3
    
4.
Maini B, Bathla M, Dhanjal GS, Sharma PD. Pediatric autoimmune neuropsychiatric disorders after streptococcus infection. Indian J Psychiatry 2012;54:375-7.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Garg RK, Malhotra HS, Rizvi I, Kumar N, Jain A. An unusual case of acute encephalitic syndrome: Is it acute measles encephalitis or subacute sclerosing panencephalitis? Neurol India 2017;65:1333-44.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Mattai AK, Hill JL, Lenroot RK. Treatment of early-onset schizophrenia. Curr Opin Psychiatry 2010;23:304-10.  Back to cited text no. 6
    
7.
Giedd JN, Rapoport JL, Kruesi MJ, Parker C, Schapiro MB, Allen AJ, et al. Sydenham's chorea: Magnetic resonance imaging of the basal ganglia. Neurology 1995;45:2199-202.  Back to cited text no. 7
    




 

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