Decreased Speech and Jerky Eye Movements in a 'Clumsy' Toddler

Vikramjit Kanwar, MBBS, MBA; Shyam Srinivasan, MBBS, DM


September 02, 2021

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 28-month-old girl has recently become irritable and "clingy" with difficulty sleeping and occasional high-pitched crying. Her mother reports that her speech has decreased and she is clumsier. The girl also complains of "ouchy" and points to her navel but is not constipated.

She is an only child born by normal vaginal delivery at full term, and she has met the normal developmental milestones until recently. Her immunizations are up to date. Her symptoms started a month ago when her grandmother relocated to a different state. Her pediatrician suspected that her symptoms resulted from the anxiety of losing contact with "nana" and reassured her mother that she should "watch and wait." However, the child grew increasingly unsteady when she walked, to the point of losing her balance and falling over, and her eyes developed intermittent chaotic and jerky movements. The mother was alarmed and contacted the pediatrician, who directed her to the emergency department.

The mother and child live in an older part of Philadelphia. The only significant illness recorded for the child is an episode of iron deficiency anemia at the age of 12 months when the child was drinking four bottles of cow's milk a day, eating dirt, and chewing on the doorframe. Laboratory testing confirmed she had microcytic hypochromic anemia and a profoundly low ferritin level that resolved with dietary counseling and a therapeutic course of ferrous sulfate. She has had the usual childhood coughs, colds, and mild viral illnesses, including a "strep throat" infection, but she has not had any such illnesses during the previous 2 months. She has no history of weight loss, fever, headache, rashes, joint swelling, pallor, or bruising.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.