Acute paroxysmal dystonia induced by fluoxetine

Clinical Features and Treatment in the Spectrum of Paroxysmal Dyskinesias: An Observational Study in South-West Castilla y Leon, Spain

BACKGROUND

Paroxysmal dyskinesias (PxD) are a group of heterogeneous disorders characterized by intermittent episodes of involuntary movements. PxD include paroxysmal kinesigenic (PKD), nonkinesigenic (PNK), and exercise-induced (PED) varieties.

OBJECTIVES

To define the phenotype of primary and secondary PxD forms.

METHODS

Twenty-two patients with PxD (9 men/13 women) were evaluated in two hospitals in south-west Castilla y Leon, Spain. Clinical features of the episodes, causes, family history, and response to treatment were collected.

RESULTS

Thirteen participants with primary PxD (6 men/7 women) and 9 with secondary PxD (3 men/6 women) were recruited. Nine patients belong to three nonrelated families (2 had PKD and 1 had PED). Mean age at onset in primary PKD cases was 10 years (range 5-23 years), earlier than in PNKD (24 years) and PED (20 years). Most primary PKD cases experienced daily episodes of duration <1 minute, which are more frequent and shorter attacks than in PNKD (1-2 per month, 5 minutes) and PED (1 per day, 15 minutes). The location of the involuntary movements varied widely; isolated dystonia was more common than mixed chorea and dystonia. All PKD patients who received antiepileptic treatment significantly improved. Levodopa and ketogenic diet proved to be effective in two patients with PED. Secondary forms presented a later mean age of onset (51 years). Six cases had PNKD, 1 had PKD, 1 both PNKD and PKD, and 1 had PED. Causes comprised vascular lesions, encephalitis, multiple sclerosis, peripheral trauma, endocrinopathies, and drugs such as selective serotonin reuptake inhibitors (SSRIs).

CONCLUSION

The knowledge of the clinical features and spectrum of causes related to PxD is crucial to avoid delays in diagnosis and treatment, or even a nonorganic disorder diagnosis.

Acute Cervical Dystonia Induced by Clebopride

Antidopaminergic drugs are known to induce extrapyramidal symptoms. Clebopride, a dopamine antagonist, also can produce parkinsonism, tardive dyskinesia, tardive dystonia, hemifacial dystonia, or oculogyric crisis; however, acute dystonic reaction caused by clebopride has not been reported in adults. We report two young men who experienced acute cervical dystonia within a few days of taking clebopride. The patients recovered after discontinuation of the drug. Physicians prescribing clebopride should be aware of the adverse effects of this drug.

Extrapyramidal Reactions Associated with Serotonergic Antidepressants

OBJECTIVE

Extrapyramidal reactions (EPRs) associated with serotonergic antidepressant treatments have been reported since 1958. These reactions can be distressing for patients and complicate treatment. Our objective was to complete a follow-up review of published EPR cases reported for serotonergic antidepressants.

DATA SOURCES

Published cases between January 1998 and May 2015 were collected through a medical literature search. Citation reference lists were also searched manually.

STUDY SELECTION AND DATA EXTRACTION

Identified cases were reviewed for patient age, gender, psychiatric diagnosis, dosage, time to reaction onset, concurrent medications, and EPR description. Cases were excluded when there was not a clear description, if descriptions were not consistent with accepted definitions, or if the written English was poor. We included cases of akathisia, dystonia, dyskinesia, parkinsonism, or mixed EPRs. Authors scored each case using the Naranjo adverse drug reaction probability scale.

DATA SYNTHESIS

We identified 86 published reports involving 91 patients; selective serotonin reuptake inhibitors were implicated in 80.2% of cases. All EPR types were reported: 17 akathisia cases, 18 dyskinesia cases, 27 dystonia cases, 19 parkinsonism cases, and 10 mixed EPR cases. EPRs typically occurred within 30 days of either treatment initiation or dose increase. Age, gender, antidepressant dosing, or concurrent antipsychotic treatment did not appear to broadly contribute to EPR risk. Naranjo scores ranged from 2 to 8.

CONCLUSIONS

Case reports associating serotonergic antidepressants with EPRs continue to be published. Practitioners are advised that monitoring for such is important. Rigorous research efforts are needed to better understand the clinical risk factors for these adverse drug reactions.

Drug-induced hyperkinetic movement disorders by nonneuroleptic agents

Hyperkinetic movement disorders are characterized by excess movement, and include chorea, akathesia, asterixis, dystonia, tremor, myoclonus, and tics. A wide variety of pharmacologic agents may induce or exacerbate these disorders. Neuroleptic-induced tardive dyskinesia and levodopa-induced hyperkinesia are the most common causes of medication-induced chorea. However, several nonneuroleptic agents, including antidepressants and antiepileptic medications, may also worsen hyperkinetic movement disorders. Over-the-counter medications, such as analgesics and antiheartburn medications, have also occasionally been implicated as causing hyperkinetic movement disorders. Most information regarding drug-induced hyperkinetic disorders comes from case reports and anecdotes, rather than controlled clinical trials. Further research with larger controlled trials needs to verify many of these findings.

Acute dystonia after initial doses of ziprasidone: a case report

We present the case of an 18-year-old man, who was admitted with an obsessive compulsive disorder (OCD) since 17 years old. He had symmetry and contamination obsessions and cleaning compulsions, and had been treated with fluoxetine 40 mg/day for 2 months. The patient was not taking additional psychotropic medication. We made ziprasidone augmentation to the treatment. First day, ziprasidone 40 mg bid was applied. Four hours after the evening dose, the patient complained about distress. He demonstrated a notable torticollis and dystonic posture to his left side. Intramuscular biperiden lactate (5 mg) was given, and dystonic symptoms resolved within 30 min. Ziprasidone is a new atypical antipsychotic with reported low potential for extrapyramidal side effects. To our knowledge, acute dystonic reaction with initial doses of ziprasidone in adult has not been reported yet. This case report describes a male patient with OCD developed acute dystonia shortly after initial doses (80 mg/day) of ziprasidone and discusses precautions in antipsychotic use.

Movement Disorders Possibly Induced by Traditional Chinese Herbs

The authors describe the neurological presentation and CT/MRI findings in 4 patients exposed to overdoses of decoctions of two different Chinese herbs. Case 1, a 15-year-old boy, ingested herba serissae along with the safe-dosage Salvia miltiorrhiza for treating a left renal stone. Sophora subprostrata root (SSR) was primarily used for treating three other diseases: viral B hepatitis in case 2, a 9-year-old boy; infection of the throat and a low fever in case 3, a 11-year-old girl, and a minor facial infection in case 4, a 12-year-old boy. All patients showed complex neurological manifestations primarily including convulsions, mental changes and dystonia syndromes. Their CT and/or MRI revealed abnormal density lesions in the striatum and globus pallidus bilaterally. They excluded the possibility of Wilson's disease in each of the 4 patients and suggested that overdosage of SSR and herba serissae could cause intoxications of the central nervous system, particularly damage to the basal ganglia. Chemically, coumarin (case 1) and matrine and oxymatrine (cases 2-4) in the two medicinal herbs are suggested to be possibly responsible for the morbidity.