Visual diagnosis: 6-month-old boy with strange body movements.

1. Osman Farooq, MD* 2. Ayesha Kirmani, MBBS† 3. Nitin Agarwal, MD* 4. Hema Purushotham, MD* 5. Amit Kandel, MD‡ 1. *Department of Pediatric Neurology, University of Buffalo, The State University of New York, Buffalo, NY. 2. †Liaqat University of Medical and Health Sciences, Jamshoro, Pakistan. 3. ‡Department of Neurology, University of Buffalo, The State University of New York, Buffalo, NY. * Abbreviations: ACTH: : adrenocorticotropin hormone ECMO: : extracorporeal membrane oxygenation ED: : emergency department EEG: : electroencephalography A 6-month-old boy with a history of seizures presents to the emergency department (ED) with new “strange body movements.” His mother first noticed this behavior 2 weeks ago, when his arms and legs would be held in a flexed position, lasting 1 to 2 seconds at a time (Figure 1). She said that these did not look like his typical seizures, and he remained alert and responsive during the episodes. After first witnessing these episodes 2 weeks ago, she did not notice them again until 1 week before presentation, at which time they began occurring every other day, increasing in frequency to 3 times per day, at times with full body flexing. Figure 1. Click here to view the video. On physical examination, his vital signs are within normal limits. He is smiling and playful. On motor examination, spontaneous movements of all extremities are seen but are slightly decreased on the left compared with the right. Bilateral fisting is noted, with increased tone in the left upper and lower extremities. Axial tone is mildly decreased for age. His history was notable for a cardiorespiratory arrest at 1 month of age secondary to respiratory syncytial virus bronchiolitis. At that time, he was resuscitated for 30 minutes, then given extracorporeal membrane oxygenation (ECMO). While receiving ECMO, he was noted to have episodes of left eyelid and arm twitching along with lip smacking. Electroencephalography (EEG) revealed status epilepticus. His seizures were pharmacologically controlled with phenobarbital and fosphenytoin. The patient was weaned off ECMO after 7 days. Subsequent EEGs revealed nonspecific abnormalities but no seizure activity. Magnetic resonance imaging, performed 12 days after the …