we report the case of a 16-year - old male who was diagnosed with schizoaffective disorder a year prior to his neurological consultation . neurological examination showed evidence of mild lower extremity spasticity with ataxia and dysarthria .
children presenting with symptoms suggestive of a mood disorder , decline in cognition or psychosis deserve a detailed neurological examination and appropriate imaging if indicated , before starting them on antidepressant or neuroleptic medication .
most young adults with psychosis have a nonorganic etiology for their symptoms , with schizophrenia and bipolar affective disorders accounting for the majority of cases .
however , in 5 - 10% of cases there is an organic basis that might include stroke , inborn errors of metabolism or demyelinating lesions . recognition of these conditions is often possible by eliciting relevant historical facts and pertinent neurological signs .
it is vital to be able to recognize these entities early in the disease process to initiate appropriate treatment options and offer counseling regarding prognosis .
we present the case of a teenager who was diagnosed as having a schizoaffective disorder but noted to have unusual physical findings .
this led to imaging studies and a final diagnosis of multiple sclerosis ( ms ) .
a 16-year - old caucasian adolescent with a history of emotional lability for a period of 12 months presented to the neurology clinic for an evaluation .
he had bouts of intense sadness characterized by withdrawal from routine activities , inability to attend school and suicidal thoughts .
these episodes were interspersed with periods of aggressive outbursts , depersonalization and incoherent thinking during which time he experienced auditory hallucinations .
the patient also did not wish to participate in soccer - a game he had previously been passionate about .
he was evaluated by a psychiatrist about 6 months after the onset of his symptoms .
the patient was referred to the child neurology clinic by his pediatrician for a neurological 
he felt unsteady on his legs for a period of 2 days and never felt comfortable returning to the game .
he also noted that walking up and down stairs was strenuous now with myalgia in his calves .
he mentioned that he had to take special education classes for the past few months and in fact was attending summer school to make up for a recent decline in grades .
there was no history of loss of vision , diplopia , dysphagia , bladder / bowel disturbances , fatigue or sensory symptoms .
he was not enthusiastic to answer questions pertaining to his health and replied in monosyllables while avoiding eye contact .
, there was mild spasticity of his lower extremities demonstrable only by stiffness at both ankles .
he had difficulty reading from a grade - level book and displayed poor comprehension of the content .
results of the wechsler intelligence scale for children - fourth edition ( wisc - iv ) and gordon diagnostic system for executive functioning are presented in table 1 and table 2 , respectively . on a self - report behavioral measure , utilizing the youth self report questionnaire , the patient showed a number of internalizing problems ( anxiety , depression and thought problems ) . in view of the constellation of symptoms suggestive of a disorder involving cognition and mood , and physical findings indicative of an upper motor neuron disease process , magnetic resonance imaging ( mri ) of the brain was ordered .
imaging revealed several t2-fluid - attenuated inversion recovery ( flair ) hyperintense signals in the white matter adjacent to the ventricles ( fig .
following administration of contrast material , some of the areas showed enhancement suggestive of an active demyelinating disease process .
subsequently , mri of the spine was obtained , which also showed lesions suggestive of demyelination in the thoracic spine ( fig .
a comprehensive workup was initiated starting with spinal fluid analysis which yielded a white blood cell count of 1 cell / mm , red blood cell count of 9 cells / mm , protein level was 69 mg / dl , glucose level was 54 mg / dl , 9 oligoclonal bands were detected compared to 0 oligoclonal bands in the serum , and igg index was 0.93 with a normative value of less than 0.85 .
serum testing for antinuclear antibodies , antibodies against double - stranded dna , lupus anticoagulant , angiotensin - converting enzyme , vitamin b12 levels and thyroid antibodies were negative .
a diagnosis of ms was made by applying the mcdonald criteria that utilize findings on mri and clinical symptomatology .
the patient was started on glatiramer acetate at a dose of 20 mg per day .
he tolerated it well and has not had any clinical relapses , psychiatric or otherwise , since therapy was commenced .
he has also been weaned off his psychotropic medications with no further exacerbation of his schizoaffective disorder .
onset in childhood occurs in 2.7 - 10% of all diagnosed cases , with most patients being female .
a higher proportion of african - american and hispanic patients have childhood onset of their disease .
similar to ms in adults , common clinical features at the time of initial presentation in childhood include motor weakness , sensory disturbances and symptoms suggestive of cerebellar disease ( ataxia , dysarthria ) .
psychiatric symptoms as the initial clinical feature are a rare phenomenon and are believed to occur in less than 2% of patients .
nonetheless , it has been noted in one study of patients diagnosed with ms that 25% had a depressive period prior to the diagnosis , as opposed to 17% in a control group .
hence , it may be that disorders of mood and personality may be fairly frequent even at the time of initial diagnosis , though they may not trigger a comprehensive neurological workup .
extrapolation of adult ms literature suggests that neuropsychiatric symptoms of ms can be grouped into 2 categories : cognitive and mood . amongst the latter ,
individuals with ms have a 50% lifetime prevalence of depression , with suicide rates that are higher compared to the general population .
pseudobulbar affect is more common in those with chronic ms with significant cognitive impairment and hence is unlikely to occur in childhood .
there is evidence to suggest that patients with high lesion load in the temporal lobes , especially the left temporal lobe , are more likely to have psychiatric features . inflammatory cytokines , which mediate disease pathology in ms , especially interferon - alpha and interleukin-1 , are known to have an effect on the serotonin and noradrenergic systems of the central nervous system and can mediate behavior and mood .
furthermore , decrease of inflammatory cells and cytokines by use of immune - modulating agents has been shown to positively affect psychiatric symptomatology .
other potential etiologies can include adverse effects of medication such as steroids and immune modulators , or it may be that ms and mood disorders share a common genetic link .
recent studies have highlighted deficits in attention , executive function and working memory in the pediatric age group , even in the absence of significant physical impairment .
such cognitive loss may be a consequence of disease affecting the maturation process of the white matter pathways in the frontal lobe .
children diagnosed with ms require objective tests of cognition at regular intervals , as cognitive dysfunction may exhibit a linear decline , in parallel with their neurological impairment .
however , mri techniques have revolutionized the clinicians ' approach to this disorder in the pediatric age group , adding a high degree of specificity and sensitivity and allowing for earlier diagnosis . the mcdonald criteria and kidmus mri criteria are 2 such well - validated measures to arrive at a conclusive diagnosis .
an organic basis for psychiatric disorders in childhood is often overlooked for extended periods of time , as a detailed neurological examination may not be performed by the clinician .
adults with ms whose initial clinical symptoms were purely psychiatric in nature have been reported . to our knowledge
this is the first case to be reported in the literature on an individual less than 18 years of age . in conclusion
, children presenting with disorders of mood and affect deserve a thorough neurological examination before commencing them on psychotropic medications .
performing routine imaging in the form of mri or computerized tomography in patients with psychosis and mood variability , but with no pertinent historical findings and nonlocalizing examination , is unlikely to be helpful .
treatment options include use of atypical antipsychotics such as olanzapine or ziprasidone , in addition to immune - modulating therapy directed towards the underlying disease process .
last but not least , other diseases may present with psychiatric disturbances in early adulthood including inborn errors of metabolism such as urea cycle disorders , porphyria , adrenoleukodystrophy , niemann - pick type c , wilson disease , low grade gliomas of the left temporal lobe and localization - related epilepsy .
 objectiveto report an unusual presenting manifestation of multiple sclerosis in a teenager.case reportwe report the case of a 16-year - old male who was diagnosed with schizoaffective disorder a year prior to his neurological consultation . 
 neurological examination showed evidence of mild lower extremity spasticity with ataxia and dysarthria . 
 imaging revealed lesions suggestive of multiple sclerosis.conclusionan organic basis for psychiatric disorders is often overlooked . 
 children presenting with symptoms suggestive of a mood disorder , decline in cognition or psychosis deserve a detailed neurological examination and appropriate imaging if indicated , before starting them on antidepressant or neuroleptic medication . 
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