Comment On: Dance-like Movements in Obsessive Compulsive Disorder.

Sir,

We were fascinated to read the article by Bavle A, Kumar K, and Sharath V about dance-like movements in obsessive-compulsive disorder (OCD) which was recently published in the Indian J Psychol Med.[1] It made for a very interesting read. We are, however, intrigued by some points and would like to put forth following comments.

In the above-mentioned article, authors presented a case of 23-year-old Bodo homemaker from Assam, India, who presented with a 2 years history of abnormal movements. The movements were described as symmetrical, dance-like, voluntary, and mainly involving upper limbs. Some of the movements were described to have a resemblance to Bagurumba, a folk dance of the Bodo community. She was also described to have obsessions of contamination, washing, and counting compulsions with other repetitive behavior. The patient was diagnosed with OCD, and the dance-like movements were attributed to being an unusual and rare presentation of OCD.

While it was mentioned that the patient was extensively investigated, it was not clear if rheumatic fever/rheumatic heart disease (RF/RHD) and associated Sydenham's chorea (SC) were ruled out. According to the 2015 revised Jones criteria, RF is diagnosed if 1 required criteria and 2 major criteria are met or 1 required, 1 major, and 2 minor criteria are fulfilled.[2] A workup for ruling out RF would include antistreptolysin O titer/throat culture/anti-hyaluronidase, electrocardiogram, echocardiogram, and levels of acute phase reactants (erythrocyte sedimentation rate, C-reactive protein).

SC is a neurological disorder which is one of the major Jones diagnostic criteria for RF. It could be latent, occurring up to 6 months after streptococcal infection and could be the only presenting symptom of RF. SC, also referred to as Saint Vitus Dance, is characterized by rapid, jerking, uncoordinated movements of hands, feet, and face. These are similar to the movements described for the patient in the report.

Epidemiologically, RF/RHD is still common in India with an overall prevalence of 1.5–2/1000 in all age groups suggesting that there are about 2.5 million patients in the country.[3] SC is seen to be more common in young females especially below 18 years of age. Adult onset of the disorder, although comparatively rarer, is associated with exacerbation of chorea following childhood SC.

Moreover, multiple studies, both recent and past found patients with SC, both pediatric and adults to have an elevated frequency of OCD.[45] All these reasons warrant ruling out RF associated SC before considering rarer presentations.

In conclusion, we suggest that along with conversion disorder it is important to keep RF associated SC in the differential diagnosis for a young, Indian female patient who presents with an abnormal movement disorder. We suggest that the authors include all the relevant diagnostic workup to rule out RF. This will help rule out a common mimic of the dance-like movements described in the report.

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