Rare Presentation of Genital Tics in a Pediatric Patient with Neurodevelopmental Comorbidities: A Case Report

Introduction

Tics are characterized by abrupt, rapid, recurrent, nonrhythmic movements or vocalizations, classified as simple or complex. ¹ Predominantly, motor tics involve craniofacial and upper limb regions, whereas phonic tics include nasal sounds, throat clearing, or guttural noises; however, genital tics represent an infrequent and underrecognized entity prone to diagnostic oversight. ² Herein, we delineate the clinical trajectory of a 9-year-old girl exhibiting a multifaceted profile of developmental impairments, behavioral dysregulations, and genital tics, underscoring diagnostic pitfalls and the imperative for an integrative management paradigm in pediatric neuropsychiatric disorders. Her perinatal history of complications, protracted milestone attainment, and progressive behavioral manifestations suggests a multifactorial pathogenesis typical of such presentations. Initial misreading of self-regulatory behaviors compounded diagnostic complexity, reinforcing the necessity for holistic appraisal transcending overt symptomatology.

Case Presentation

The patient, a 9-year-old female in third grade residing in New Tehri, Tehri Garhwal, Uttarakhand, India, was delivered at term via lower-segment cesarean section to an elderly primiparous mother. The perinatal course was marked by meconium aspiration syndrome, requiring neonatal intensive care unit admission. Subsequent developmental trajectory revealed lags in social interaction, expressive language, and gross motor domains, with preserved fine motor progression.

Verbal responsiveness was absent initially, with name recognition emerging at age 3 years. Communicative modalities relied on gestural cues, progressing to 4–5 lexical items by age 3 and rudimentary sentences by age 4. Early childhood was characterized by hyperkinetic behavior and sustained attentional deficits impacting academic and domestic tasks. Independence in activities of daily living, such as oral hygiene and toileting, was achieved only at 8.5 years, necessitating ongoing oversight.

Stereotyped facial gestures commenced circa age 3, accompanied by autoerotic genital manipulation culminating in facial erythema. These were first documented by personnel at the local Anganwadi preschool, attended from age 2.5, and relayed to guardians. Behavioral interventions proved inefficacious in suppression.

Scholastic advancement, notably upon entering second grade at age 7, was hindered by escalating attentional lapses and academic decline. Prolonged lavatory sojourns involving genital manipulation prompted classroom segregation, exacerbating educational hurdles. Symptom exacerbation occurred during screen-based activities at home.

Initial dermatological consultation yielded a prescription for topical clotrimazole, yet persistence prompted psychiatric referral. Psychiatric intake encompassed a comprehensive anamnesis and examination. Routine hematologic, hepatic, renal, thyroid, and glycemic assays were unremarkable. Cerebral magnetic resonance imaging was recommended to exclude organic etiologies. Provisional diagnosis of Persistent (Chronic) Motor or Vocal Tic Disorder (DSM-5: 307.22/ICD-11: F95.1) ³ was posited, predicated on stereotyped genital friction and intermittent grimacing. She did not report any pre-morbid symptoms. Pharmacologic intervention was instituted (Table 1), with parental endorsement of symptomatic alleviation post-initiation.

OPEN IN VIEWER

Table 1.

Summarizes the Patient’s Pre-treatment Status and the Improvements Observed at 15-day and 30-day Follow-up Visits, Based on Parental Reports and Yale Global Tic Severity Scale (YGTSS) Findings.

Feature/Metric	Pre-treatment (Baseline)	Post-treatment (15 & 30-day Follow-ups)
Tic symptoms observed	Repetitive facial movements, vocalizations, self-stimulatory genital rubbing, hand movements, leg/foot/toe movements, sniffing	Current criteria: No motor or phonic tics reported.
YGTSS (current tics)	Not formally assessed at baseline, but symptoms were present and problematic.	Motor Tics: 0 Phonic Tics: 0
YGTSS (worst ever tics)	This reflects the historical severity and types of tics prior to treatment.	Motor Tics: Hand movements (2), Leg/foot/toe movements (2) Phonic Tics: Sniffing (1)
YGTSS impairment score	High (reflected by “Worst Ever” score of 40)	40 (This score remains constant as it reflects the worst historical impairment, not current. The improvement is seen in “Current Tics” criteria)
Baseline YGTSS score (motor tic)	18	Not applicable (this reflects the pre-treatment baseline; improvement seen in “Current Tics” post-treatment)
Associated behaviors	Heightened motor activity, persistent difficulty maintaining focus, academic deterioration, and delayed ADLs.	Parents reported “noticeable improvement” and “maintaining well” on the current regimen, suggesting improvement in these associated concerns as well.
Medication status	No specific tic medication. Initially received topical clotrimazole powder from dermatology.	Initiated & Continued: 1. Tab. Risperidone 0.5 mg per day 2. Tab. Clonidine 100 mcg (¼ tablet BD) 3. Tab. Ginkgo Biloba 120 mg per day
Parental report	Concerns leading to psychiatric referral.	“Noticeable improvement in her symptoms” (after 15 days) and “maintaining well on the current treatment regimen, with no significant concerns noted” (after 30 days)

Table 1 delineates baseline characteristics and therapeutic responses at 15- and 30-day intervals, informed by caregiver narratives and Yale Global Tic Severity Scale (YGTSS) metrics. Follow-up evaluations at 15 and 30 days incorporated YGTSS administration, revealing the absence of motor or phonic tics per current criteria. Continuation of pharmacotherapy was advised, with reassessment scheduled in two months.

Discussion

This vignette exemplifies the diagnostic intricacies inherent in pediatric neuropsychiatry, wherein atypical tic phenotypes intersect with developmental and behavioral comorbidities. The patient’s evolution—from perinatal hypoxia to pervasive delays and genital tics—necessitates a nuanced, multidimensional diagnostic lens.

Symptomatic onset at age 3, featuring facial stereotypies, vocal emissions, and genital autoerotism, was initially misattributed dermatologically, deferring psychiatric engagement. This underscores the exigency of contextualizing ostensibly self-regulatory conduct within neurodevelopmental frameworks, rather than silos of specialization. Although scarce, genital tics are documented and may mimic autoerotism or maltreatment.^1,2 Differentiation hinges on involuntariness, stereotypy, and partial suppressibility, elusive in juveniles.

Perinatal meconium aspiration and ensuing delays in sociolinguistic and motor spheres intimate neurovulnerability. Hypoxic-ischemic insults predispose to tic disorders and attention-deficit/hyperactivity disorder (ADHD).^4,5 Concomitant hyperkinesia, inattention, and scholastic regression align with ADHD comorbidity prevalent in tic syndromes. ⁵ Aggravation in early schooling corroborates this nexus.

YGTSS deployment at intervals facilitated objective quantification of tic burden and therapeutic efficacy. Post-intervention null scores for current tics denote robust remission, while a historical impairment score of 20 attests to prior functional encumbrance. This bifurcated metric affords a longitudinal vista of interventional impact.

The therapeutic triad—risperidone, clonidine, and ginkgo biloba—merits scrutiny. Risperidone, via dopaminergic antagonism, is efficacious in tic suppression, notably in Tourette syndrome. ⁶ Clonidine, an α2-agonist, mitigates tics and ADHD features synergistically. ⁷ Ginkgo biloba, albeit with equivocal evidence in tics, may augment cognition adjunctively. Caregiver-reported enhancements validate regimen suitability. Neuroimaging referral prudently obviates structural anomalies; though idiopathic in preponderance, tics may herald neoplasms, vasculopathies, or encephalitides. ⁸ Sustained remission at 30 days portends favorable prognosis, informing protracted surveillance.

In summation, this case elucidates the interwoven neurodevelopmental tapestry underpinning atypical pediatric tics, mandating prompt identification, interdisciplinary synergy, holistic interventions, and familial empowerment. It imparts pedagogical value, enjoining vigilance for deviant tic expressions amid intricate neuroprofiles.