A 12-y-old child presented with an insidious onset of involuntary facial movements for the past two weeks. The child appeared alert and oriented with brief, stereotyped, repetitive, and involuntary movements localised to the orbicularis oris and periorbital muscles of the face (Supplementary Video S1 and Fig. 1). These movements were not always suppressible and occurred at irregular frequencies. These movements were not present during sleep and were triggered by anxiety. No history of fever, sore throat, or joint pain was noted. Investigations revealed raised ASLO titres (350 IU/ml) and normal CRP, ESR, ECG and echocardiogram.

Involuntary facial movements in the child

Facial chorea and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS) and simple motor tics were the differential diagnoses considered. But isolated involvement of facial muscles, lack of other signs of chorea (pronator sign, dysarthria, hypotonia, milkmaid’s grip, emotional or behavioral changes) and normal ECG & echocardiogram argued against rheumatic chorea [1]. Insidious onset of abnormal movements without abrupt emotional or behavioral changes makes the possibility of PANDAS less likely [2]. Simple motor tics are common in this age group, involving the facial muscle groups without other neuropsychiatric manifestations [3]. Elevated ASLO titres may reflect endemic subclinical streptococcal exposure, a common finding in pediatric populations. A six-month follow-up evaluation revealed a decline in ASLO titres to 150 IU/ml and resolution of the facial movements. No pharmacological or behavioral interventions were required, as the tics resolved spontaneously.