Dystonia is a hyperkinetic movement disorder described as contraction of both agonist and antagonist muscles simultaneously, causing twisting and repetitive movements or abnormal postures. It can be confused with other abnormal movement disorders such as parkinsonism, tremor, chorea, myoclonus, tics, and stereotypies; mistaken for tonic seizures; or coexist with other features as part of a complex movement disorder. The earlier the age of onset, the more generalized and severe the condition tends to be.
The first priority in the evaluation of an infant with dystonia is to establish whether the patient has a condition needing urgent intervention. Several metabolic disorders fall into this category, so clinical biochemical tests may need to be done as part of the initial testing even if other genetic testing is being considered. See Urgent considerations.
Molecular genetic testing is important and clinically useful in infantile dystonia due to its high yield of genetic diagnoses and medically actionable information. Next-generation sequencing tests such as gene panels and exome sequencing reveal the diagnosis in up to 60% of patients with infantile-onset dystonias. However, thorough clinical evaluation beyond the dystonia itself is crucial to achieve this diagnostic rate. Phenotypic features from the history, family history, and physical exam help narrow the differential diagnosis, allow selection of the most appropriate genetic tests, and improve the interpretation of genetic testing results.
Dystonic movements are patterned and sustained. They repeatedly involve the same muscle groups. The urge to perform the dystonic movements is absent, and there is no relief after the dystonic movements are executed. Dystonia usually gets worse with fatigue and emotional stress and it gets better with sleep and relaxation. Photographs and video footage of affected infants are helpful in delineating the dystonic movements. Periodic follow-up is often a prerequisite to making an accurate diagnosis.
Types of infantile dystonia
Clinical characteristics (axis 1), which include age at onset, body distribution, temporal pattern, and associated features
Etiology (axis 2), which includes nervous system pathology and inheritance.
Information from the history and physical examination allows an initial classification and differential diagnosis to be made. The presence and absence of motor features and other signs and symptoms can narrow the differential diagnosis by indicating a particular dystonia syndrome and by directing the diagnostic evaluation toward groups of disorders associated with different clinical patterns, such as:
Isolated dystonia (dystonia alone or dystonia with tremor)
Combined dystonia (dystonia with other movement disorders)
Complex dystonia (dystonia with other symptoms).
The clinical evaluation may also indicate whether the condition is neurodegenerative or suggest an acquired or inherited etiology.
Further investigations may be required including neuroimaging, evaluation for associated neurodevelopmental or systemic abnormalities, therapeutic trial of levodopa, or biochemical (including diagnostic lumbar puncture) and genetic tests.
Several pseudodystonias need to be considered in the differential diagnosis; these conditions involve dystonia-mimicking abnormal movements, but their etiologies differ from those of dystonias.
The rapid identification of several conditions is important to prevent irreversible injury or death:
Drug-induced acquired dystonia
Pseudodystonia due to cervical instability
Multiple neurometabolic disorders, such as glutaric aciduria type I
Acute bilirubin encephalopathy.
Dopa-responsive dystonia (Segawa syndrome, dystonia-parkinsonism with diurnal fluctuation) needs to be considered in any infant or child with unknown diagnosis and normal magnetic resonance imaging. It is usually misdiagnosed as spastic diplegic or quadriplegic cerebral palsy, intractable epilepsy, or hereditary spastic paraplegia.
- Transient idiopathic dystonia of infancy
- Benign paroxysmal torticollis of infancy
- Congenital torticollis
- Primary paroxysmal kinesigenic dyskinesia (PKD)
- Drug-related dystonia
- Dyskinetic cerebral palsy
- Post-traumatic dystonia
- Nonfatal drowning
- Primary stereotypies
- Secondary stereotypies
- Secondary infantile torticollis (SIT)
- Primary paroxysmal nonkinesigenic dyskinesia (PNKD)
- Alternating hemiplegia of childhood (AHC)
- DYT-TOR1A (primary torsion dystonia)
- Dopa-responsive dystonia (Segawa syndrome, dystonia-parkinsonism with diurnal fluctuation)
- Paroxysmal exercise-induced dyskinesia glucose transporter 1 (GLUT1)
- Dopamine transporter deficiency syndrome (DYT/PARK-SLC6A3, infantile parkinsonism-dystonia)
- Glutaric aciduria type I (glutaryl-CoA dehydrogenase [GCDH] deficiency)
- Methylmalonic acidemia
- Lesch-Nyhan syndrome
- Infantile GM2 gangliosidosis (Tay-Sachs and Sandhoff disease)
- Mitochondrial encephalomyopathies
- Biotin-thiamine-responsive basal ganglia disease (DYT-SLC19A3)
- Dopamine-serotonin vesicular transport disease
- Acquired paroxysmal kinesigenic dyskinesia (PKD)
- Acquired paroxysmal nonkinesigenic dyskinesia (PNKD)
- Neurodegeneration with brain iron accumulation (NBIA), including pantothenate kinase-associated neurodegeneration (PKAN)
- Leukodystrophies/hypomyelinating disorders
- Aicardi-Goutieres syndrome (AGS)
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