Case Presentation 2 By Kalen Gerulski Nur674 Winter 2023

Hi, my name is

Kalin

Goski and this is my second case presentation for this semester.

So, the patient I'm gonna be discussing,

came into the office where I was doing my pediatric clinical rotation

with the chief complaint of increased fatigue and new onset ticks.

So this was an eight

year old Caucasian female who presented to the office with her mother,

she did have autism, but she had effective communication

for her mother.

She was recently diagnosed with strep throat about two weeks prior to being seen

and she was seen at the outside the office at an urgent care.

They did test her there and she was positive and then they prescribed Zithromycin

for her strep infection.

I'm not sure why they prescribed the five day course of

azithromycin versus like amoxicillin or Cephalin.

And the mother didn't really know why either.

Um,

her symptoms of sore throat and fever seemed

to improve after three days post antibiotic therapy.

And then she returned to normal activities

about a week prior to the um

office visit.

Though the mother noticed that the girl had started doing

these frequent shutters and would seem unfazed by them afterwards.

They would happen randomly and abruptly.

Um she did have video proof of the erratic movements on

her phone and then showed them to us during the appointment.

One of the videos showed the girl sitting on the

couch playing her ipad and then she would randomly twitch,

moving her shoulders, arms and neck.

Um In another video,

she'd be walking and then her arms would jerk

upwards and back down almost like a dancing motion.

Those situations did not really seem to faze the girl in the slightest.

The mother also stated that she had been more emotional lately,

she'll cry and have tantrums over things that

typically she doesn't really get upset about.

Um But aside from these symptoms,

she's also been complaining of being just more tired after activity and

feeling like it's harder for her to move her arms and legs.

She does deny any falls or having a hard time walking despite that weakness.

Um She was negative for a cough, runny nose,

sore throat during her visit and she denies nausea or diarrhea.

She also denied any headaches or dizziness or vision changes.

So her review of systems was mostly negative.

A girl and the mother denied any shortness of breath,

chest pain or palpitations or painful urination.

She was positive for fatigue,

the ticks that involved her arms and legs and being more emotionally

labile dear.

During the interview process,

the girl had two of those episodes where she'd be walking or talking and smiling and

then would jerk her neck to the side and fill her arms up a little.

She didn't really seem to notice the movement and

kept talking as if nothing happened after the episodes

past medical history was pretty insignificant as well.

She didn't have any previous hospitalizations or injuries or surgeries.

She was diagnosed with autism in 2019, but according to her mother,

she seemed to be high functioning.

Um,

she does not take any home medications other than the over the

counter Tylenol and Ibuprofen as needed when she's got fevers or pain.

Um, and she stopped the

ayin a little over a week prior to the office visit today or that day

socially.

She lives at home with her parents has no siblings and attends public school.

She's in the second grade and enjoys going

to school and participating in school activities.

Her mother states that she gets along really well with her classmates and friends.

Um, as far as family history,

she had a paternal grandfather with diabetes and a maternal grandfather who had,

who was deceased, um, at 66 for lung cancer.

Her mother was uh bipolar and her father had a DH D.

Ok.

All right. So the physical exam, um, she wasn't presenting ill or malnourished.

She answered all the questions appropriately and was cooperative with the exam.

Her head eyes, ears and no were nose were all normal.

Her throat appeared mildly red but it did not appear swollen um,

she didn't complain about pain when we were doing the review of systems.

Uh, she did not have any Olympia

annoy.

Uh, let's see,

murmurs or a regular rhythm.

Her breath cells were clear and un labored and her gastro Testino exam was normal

when testing her muscle strength.

Um, she did have some moderate weakness and resistance with her arm,

push and poles and grip strength.

Bilaterally.

We, I rated this about a three on the strength. Uh three out of five on the strength.

Um Her leg strength was normal. That was a full five out of five symmetrically.

She was equal on both sides with movement and strength.

She did not have any speech problems or new cognitive impairments.

We did witness those rapid random and involuntary um neck head,

trunk and arm jerking twice during the exam process.

Her mother claimed that this happens about every 2-5 minutes at home

and while she was calm and cooperative during the um physical exam,

she did cry and fight during the lab draws and throat culture.

But it's hard to decipher if this was normal

reaction for her autism or eight year old child

or if it was maybe more of an overreaction due to her change in temperament,

but it was easy to calm her down.

All right.

So this is where I felt that things got a little bit tricky because of the patient

scenario.

Um It was apparent that it was apparent that she was experiencing

some sort of tick and it was most likely a neurological issue.

However, while the ticks weren't causing her to be physically compromised,

it was still critical to make sure that there wasn't

an issue that could end up being life threatening,

especially since these were a new onset,

um,

a thorough exam and history intake was critical to helping identify

and classify signs and symptoms that could aid in the diagnosis.

Um We also knew that she was recently infected with the strep a infection

and that could have led to further complications such as acute rheumatic fever,

which actually does have a symptom called synonyms

chorea.

It's a movement disorder that causes ticks.

Um because of this likelihood, we wanted to do like an acute rheumatic fever work up

and which consists of a throat culture for a send

out to see if the infection is still present.

Um maybe an EKG and an echo to assess the heart rhythm and function

and you know,

inflammatory markers to identify systemic inflammation like the C R P and er E E S R.

Uh We did not do an A S O tighter since we already knew that she

had a positive uh strep test two weeks ago when she was in the urgent care.

And aside from the rheumatic fever work up,

it was also important to get some basic baseline labs

um such as a CBC C MP for liver function

and renal function B 12 is that can sometimes lead

to tick symptoms if you have a B 12 deficiency

and T S H because it can, the ticks can occur with a hyperthyroidism.

So do the neurological component of this symptom.

Um It may be important sometimes to get an image study of the brain

MRI would be the best, but AC T may may be more cost efficient. In some cases,

we didn't end up doing it for this patient.

But it's something that we discussed if her symptoms were more

severe or had worsened or if her labs came back.

Abnormal.

All right. So

as for the differentials, um the top of the list was the Sydor,

which is a manifestation of rheumatic fever.

That is an autoimmune issue caused by the group.

A beta hemolytic streptococcal infection.

So,

this symptom occurs in about 40% of patients with the acute

rheumatic fever and results from portions of the brain being like

basically mis attacked by the antibodies that cross the cells of

the basal ganglia that control the motor function of the body.

Typically,

this does not present until about 6-8 weeks after the group a ST infection.

But it can occur sooner.

Females are more susceptible than males and childhood disease is more affected

in patients between the ages of eight and 18 years old.

With the peak age between 8 to 9 years old.

Synonym

crea can occur by itself but it most often

presents with other signs and symptoms of rheumatic fever.

So, therefore, it's important to assess the cardiac function

such as carditis, which can occur in up to 80% of patients with uh rheumatic fever

And involuntary movement, poor muscle tone,

muscular weakness and emotional disturbances.

Um

like the emotional ability,

labial um obsession, compulsion, hyperactivity, um psychosis,

these things are often present 70% of the time with this.

Um

snore

cases,

The duration of episodes can last for as long as 12 months,

but the main duration tends to be about 12-15 weeks.

Um

Also um referred to as ticks.

Um that we were seeing with this patient

could have resulted from other acquired diseases,

not necessarily the group strep group, a strep

um such as hyperthyroidism, systemic lupus encephalitis

prion disease, lyme disease, or

intraoral

um

hemorrhaging. Certain drugs can also cause this acquired correa.

But for this patient, she wasn't on any known medications that could have taken

that she could have taken that would have caused these symptoms

regardless of this specifically um the synonym synonym

Korea or just another form required Korea.

The important key action was to

decipher characteristics of involved body systems.

So for example, a positive strep culture and cardiac involvement will need

the syn

crea

is more likely while the absence of these symptoms

may lead to another autoimmune vascular or metabolic diagnosis.

And of course, when we think of ticks, we often think of tourettes tot

syndrome syndrome is a neurological disorder that causes the motor and vocal ticks

with the onset sometimes being most of the time being in childhood.

Um, the tick characteristics are pre mandatory,

meaning like that you'll feel uh the sensation of wanting to

do the tick movement and then you get relief after that.

Um

This patient could have had a new development of Tourette's,

but it seemed more important to rule out the correa caused by

the strep infection since we knew that she had had it previously.

Um, and, you know,

was only treated with the Zithro

aid and not something that was more maybe susceptible to or that

was making the group based threat more susceptible to the therapy.

Huntington

Huntington disease is, um, least likely,

but the Korea is a key feature of the disease as well.

The age of onset ranges from childhood to eight years old. Um,

to 18 y, I'm sorry, 80 years old, I don't know why I said 18 but 80 years old,

it's most common in adulthood.

However, and when it does happen in childhood,

it's known as juvenile Huntington disease.

Um, this is genetically inherited.

So obviously, you, you know,

you're gonna need to get the genetic testing

and clinical symptoms for the diagnostic criteria for the

Huntington's disease.

All right.

So, um,

basing the plan of care on the fact that we have not

yet had concrete evidence of the cause of ticks and increased fatigue,

but we're gonna proceed with tests and therapy that would hopefully aim to

treat the cause of the disease while

also limiting potential life threatening complications.

So believing that her recent problems were stemming from her strep a infection.

Um so that syre,

it seemed more evident that her diagnosis was that unfortunately,

this disease is self-limiting.

So treatment was aimed more at symptom relief more than anything else.

So we wanted to go back to um if she was undertreated with the Azimi,

then she would need a more efficient antibiotic for the infection

such as amoxicillin. So we prescribed 500 mg twice a day for 10 days. With that,

this would of course be followed up by a throat culture um to ensure

er well in the office that day to ensure that she did not have.

Um

I'm sorry that she did have an infection.

Um But we wanted to get the antibiotics started, started right away. Just in case

in severe cases of Korea, the patients may benefit from an anti

convulsant therapy.

Ric acid

is the first line of treatment option for mild cases of S C.

Um This patient,

we didn't prescribe that because her symptoms

were not really interfering with her ampulla

ambulation dressing or

daily self-care activities. So,

you know, with that, we just decided to hold off.

And then in more severe cases, the patients may be prescribed low dose,

high potency, do dopamine agonists or immunomodulators like Cortico

corticosteroid therapy.

Um We also wanted to do an EKG just to make sure there wasn't any like um abnormal

um rhythm with the card if there was carditis

and then, you know,

an echo would probably be something that we want to look

at just to make sure there wasn't anything like uh in

carditis.

Well, this was an office screening tool.

Um We did consider if it came back abnormal that we would go ahead and order the echo.

Um And then we also did some labs while she was in there.

We did the E S R C R P CBC C MP and the T S H levels.

And most importantly,

we did refer to the pediatric neurologist because of the complication of this case.

Um

So then we also wanted to see her in two weeks um to assess her response to

the antibiotics and the status of her condition

since she probably wouldn't get into the neurologist.

Um right away

and her mother was educated to take her to the

emergency department if symptoms appeared to worsen or um or she

was affecting her breathing or level of consciousness at all.

So here is my billing codes for the uh

procedure. Obviously, we have the offices at the culture testing lab draw EKG.

And then my journal article would be linked

like

um anyways, I really hope that you

uh got a lot out of this information for the synonym

Korea or at least with this case presentation patient presentation.

Um It was very interesting to see, but thank you so much for listening.

Case Presentation 2 By Kalen Gerulski Nur674 Winter 2023

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