A 12-year-old male child, at the age of 7 years, was misdiagnosed as mitral valve stenosis based on abnormal rhythmic clicking sounds during chest auscultation. He was extensively evaluated by primary care physician. His echocardiography and antistreptolysin-O titer were within normal limits. Subsequently, he was found to have clicks associated with left shoulder movements, and he was referred to a neurologist. There was no prior trauma. These movements remitted spontaneously after 2 years of onset. Then, around 1½ years later, it appeared again. This time, he was evaluated at our center. His scapular movements were rhythmic elevation with a clicking sound consistent with focal contractions of his left levator scapulae, left rhomboids major and minor [Video 1]. There was no distractability or variability in the movements. Needle electromyography (EMG) revealed dystonic contraction of left levator scapulae. He was given 30 units of botulinum neurotoxin in the left levator scapulae under EMG guidance. These movements completely resolved [Video 2] and had not recurred at 3 years of follow-up. His magnetic resonance imaging brain and cervical spine was normal. There were no stigmata of Wilson's disease.
There are only a handful of cases of shoulder dyskinesias described in literature.,,,, This patient had needle EMG suggestive of dystonia. He did not have any imaging abnormality. The origin of these movements could be due to central or peripheral mechanisms or could have been functional. The fact that his movements disappeared spontaneously and reappeared after 2 years was suggestive of functional movement disorder. The movements disappeared after injection of botulinum toxin and had not recurred for the past 2 years. However, there was no distractability or variability, suggesting idiopathic focal dystonia. This case highlights the importance of clinical examination.
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