824 - Methylphenidate-Induced Dyskinesia in a Pediatric Patient with Brain Injury

Methylphenidate-induced orofacial and truncal dyskinesia in a pediatric patient with a hypoxic-ischemic brain injury (HIBI) during inpatient rehabilitation (IPR).

Case Description: A 4-year-old male with a history of hypoplastic left heart syndrome s/p orthotopic heart transplant, HIBI, and subdural hemorrhage received methylphenidate for neurorehabilitation in IPR. After the patient exhibited improved attention and focus with administration of methylphenidate 2.5mg BID (7 am and noon), his dose was increased to 5mg BID. Afterwards, the patient began exhibiting orofacial and truncal dyskinesias characterized by tongue thrusting followed by cervical rotation to the right.  These worsened in the mornings (later determined after his first dose of methylphenidate) and improved in the evenings. The repetitive movements hindered his progression in speech, occupational, and physical therapy. Workup ruled out possible seizure activity. Dyskinesias improved after decreasing his dose back to 2.5mg BID, then resolved once the medication was discontinued.

Discussions:

This case demonstrates a rare but potential side effect of methylphenidate to consider that may influence management in pediatric brain injury rehabilitation. Methylphenidate, a neurostimulant that enhances dopamine and norepinephrine by blocking reuptake, has been used to address impairments in concentration, sustained attention, processing speed, and executive function following brain injury in pediatric patients. Available case reports describe dyskinetic reactions from methylphenidate in pediatric patients with ADHD, autism, concurrent valproic acid use, or accidental ingestion. There are no reported cases in medical literature of dyskinetic movements occurring after methylphenidate use in pediatric patients with history of HIBI. Further investigation is warranted to better understand the neurobiological mechanisms underlying this reaction.

Conclusions:

This case underscores a rare adverse effect associated with methylphenidate use in the pediatric brain injury population. While the medication remains a valuable therapeutic option for improving attention, processing speed, and executive functioning in children with brain injury, clinicians should be mindful of the possibility of dyskinetic reactions.