Objective: To describe a case of a young man diagnosed with Tourette Syndrome and Attention-Deficit Hyperactivity Disorder, where oculomotor tics were observed as the main clinical affection.

Background: Tourette Syndrome (TS) is a neurodevelopmental and neuropsychiatric disorder mainly characterized by motor and phonic tics. Children and adolescents are the most affected with a prevalence of 0.3-0.9% (1). Although the pathophysiology of TS is still unclear, it has been suggested that it is produced by the dysfunction of cortico-striato-pallido-thalamo-cortical networks (2), which in relation with superior colliculi, modulate voluntary saccadic movements (3). Most TS patients have at least one association with additional psychiatric comorbidities, especially with Attention Deficit Hyperactivity Disorder (ADHD) (1). These findings suggest that patients with TS+ADHD have abnormalities in prefrontal-striatal circuits, which explains excessive antisaccade errors.

Method: A 23-year-old Mexican man with a 16-year history of TS and ADHD. At the age of 7, started with involuntary stereotyped movements, exacerbated under psychological stress, and decreased by exercising or playing music. By age 11, abrupt neck movements, clearing of the throat, ocular supraversion and intense blinking. 6 years later, he was diagnosed and started treatment based on risperidone (1mL/day) with a clear improvement of oculomotor tics. However, after 1 year the patient abandoned the treatment because of side effects. Management was changed to paroxetine (10mg/day). At present, the patient reports amelioration of oculomotor tics and ADHD symptoms, without relevant side effects.

Results: Oculomotor tics were the main clinical features, managed with risperidone as initial treatment, yet because of the side effects, there was poor adherence to treatment. Paroxetine was established instead, with noticeable improvement of the movement disorders.

Conclusion: The association of TS+ADHD remains underestimated in clinical practice. This leads to a suboptimal diagnosis and treatment of these patients who present typical symptoms of TS, but also show oculomotor pathway impairments (uncontrolled saccadic involuntary movements) as the main clinical affection (4,5,6). Thus, it is essential to see TS as a multidimensional disease, where other comorbidities could not only be associated but may even mark the clinical course of the disease.

References: 1. Oluwabusi O., Parke S., Amrosini P. (2016). Tourette syndrome associated with attention deficit hyperactivity disorder: The impact of tics and psychopharmacological treatment options. World J Clin Pediatr, 5(1): 128–135. 2. Worbe, Y., Marrakchi-Kacem, L., Lecomte, S., Valabregue, R., Poupon, F., Guevara, P., Tucholka, A., Mangin, J. F., Vidailhet, M., Lehericy, S., Hartmann, A., & Poupon, C. (2015). Altered structural connectivity of cortico-striato-pallido-thalamic networks in Gilles de la Tourette syndrome. Brain, 138(2), 472–482. Jankovic, J. (2009). Treatment of hyperkinetic movement disorders. The Lancet Neurology, 8(9), 844–856. 3. Harting, J. K., & Updyke, B. V. (2006). Oculomotor-related pathways of the basal ganglia. Progress in Brain Research, 151(1993), 441–460. 4. Shaikh A., Finkelstein S., Schuchard R., Ross G., Juncos J. 2017. Fixational eye movements in Tourette syndrome. Neurol Sci. 2017 Nov;38(11):1977-1984. 5. Mostofsky S., Lasker A., Singer H. Denckla M., Zee D. 2001. Oculomotor Abnormalities in Boys With Tourette Syndrome With and Without ADHD. J Am Acad Child Adolesc Psychiatry, 40(12):1464-72. 6. Jeter C., Petel S., Morris J., Chuang A., Butler I., Sereno A. 2015. Oculomotor executive function abnormalities with increased tic severity in Tourette syndrome. Journal of Child Psychology and Psychiatry 56:2, pp 193–202.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/excessive-directional-antisaccade-errors-in-tourette-syndrome-with-attention-de%ef%ac%81cit-hyperactivity-disorder-a-case-report/