Reversible Pisa syndrome (pleurothotonus) due to the cholinesterase inhibitor galantamine: case report

Pisa Syndrome Secondary to Drugs: A Scope Review

BACKGROUND

Pisa syndrome, also known as pleurothotonus, is a neurological condition characterized by more than ten degrees of constant lateral curvature of the spine when upright. In this way, the present manuscript aims to systematically review Pisa syndrome secondary to drugs.

METHODS

Two reviewers identified and assessed relevant reports in six databases without language restriction between January 1990 and June 2024.

RESULTS

The prevalence of Pisa syndrome varied from 0.037 to 9.3%. We found 109 articles containing 191 cases of drug-induced Pisa syndrome reported in the literature. The mean and median ages were 59.70 (SD = 19.02) and 67 (range = 12-98 years). The most prevalent sex was female, 56.91% (107/188). The most frequent medications associated with Pisa syndrome were acetylcholinesterase inhibitors in 87 individuals. Of 112 individuals in which the onset time from the medication to the movement disorder occurrence was reported, 59 took place within a month. In this way, a return to baseline was observed in 45.50% of the cases, and partial recovery was observed in 14.28%.

CONCLUSION

We proposed new diagnostic criteria for Pisa syndrome based on previous findings in the literature. Moreover, multiple mechanisms are probably involved in balance control and the development of lateral trunk flexions.

[Abnormal posture of the trunk related to donepezil hydrochloride: report of 2 cases]

Patient 1, an 80-year-old woman with Alzheimer's disease, had been taking donepezil 5 mg for 2 years. Donepezil was increased to 10 mg, and 2 months later, the patient developed dropped head syndrome. MRI and needle EMG abnormality of the neck extensor muscles suggested focal myopathy, but the symptom disappeared within 2 months by discontinuing donepezil. Patient 2, a 78-year-old man with Lewy body dementia, had been taking levodopa and pramipexole (PPX). One month after tapering levodopa, donepezil 3 mg was introduced, and Pisa syndrome (bending of the trunk to the right anterior direction) developed 10 days later. Donepezil and PPX were discontinued and levodopa was increased. Within 5 months, his posture had almost recovered. Cholinesterase inhibitors can induce abnormal posture of the trunk, and clinicians should be aware of this uncommon but important side effect.

Tauopathy and Movement Disorders-Unveiling the Chameleons and Mimics

The spectrum of tauopathy encompasses heterogenous group of neurodegenerative disorders characterized by neural or glial deposition of pathological protein tau. Clinically they can present as cognitive syndromes, movement disorders, motor neuron disease, or mixed. The heterogeneity in clinical presentation, genetic background, and underlying pathology make it difficult to classify and clinically approach tauopathy. In the literature, tauopathies are thus mostly highlighted from pathological perspective. From clinical standpoint, cognitive syndromes are often been focussed while reviewing tauopathies. However, the spectrum of tauopathy has also evolved significantly in the domain of movement disorders and has transgressed beyond the domain of primary tauopathies. Secondary tauopathies from neuroinflammation or autoimmune insults and some other "novel" tauopathies are increasingly being reported in the current literature, while some of them are geographically isolated. Because of the overlapping clinical phenotypes, it often becomes difficult for the clinician to diagnose them clinically and have to wait for the pathological confirmation by autopsy. However, each of these tauopathies has some clinical and radiological signatures those can help in clinical diagnosis and targeted genetic testing. In this review, we have exposed the heterogeneity of tauopathy from a movement disorder perspective and have provided a clinical approach to diagnose them ante mortem before confirmatory autopsy. Additionally, phenotypic variability of these disorders (chameleons) and the look-alikes (mimics) have been discussed with potential clinical pointers for each of them. The review provides a framework within which new and as yet undiscovered entities can be classified in the future.

Pisa syndrome induced by switching of a choline-esterase inhibitor treatment from donepezil to galantamine: a case report

Background

Pisa syndrome (PS) is characterized by an abnormally sustained posture, with flexion of the body and head to one side and slight rotation of the trunk. Although PS most commonly arises as an adverse effect of antipsychotic drugs, choline-esterase inhibitors (ChEIs) are also sometimes known to induce PS. Despite the fact that the precise mechanism remains unclear, cholinergic-dopaminergic imbalance has been considered as a possible pathophysiologic mechanism underlying the genesis of PS.

Case presentation

We hereby report the case of a 60-year-old woman with Alzheimer’s disease who presented with the signs of PS after her treatment was switched to galantamine, a type of ChEI, even though she had received donepezil, another type of ChEI, for 5 years without any complications. To the best of our knowledge, this is the first report of PS associated with treatment switch from one to another type of ChEI. Galantamine, but not other ChEIs, can enhance striatal dopamine release through allosteric modulation of the nicotinic acetylcholine receptor, and has weaker muscarinic effects than donepezil. Therefore, we propose two novel hypotheses to explain the development of PS, as follows; galantamine, which enhances dopamine release, can induce imbalance of dopamine levels in the striatum of patients with dementia, resulting in PS, and the weaker muscarinic effects of the drug could be one of the factors predisposing to the development of PS.

Conclusion

The present case suggests that treatment with galantamine is associated with a higher risk of development of PS than that with other ChEIs, such as donepezil, despite the pharmacological profile of galantamine as a dopamine modulator. Also, this report provides novel insight into another plausible mechanism underlying the development of PS, besides cholinergic-dopaminergic imbalance, namely, dopamine imbalance in the striatum with muscarinic-nicotinic imbalance.

Clozapine Effective in Olanzapine-Induced Pisa Syndrome

Objective:

To report a case of olanzapine-induced Pisa syndrome that improved after treatment with clozapine.

Case Summary:

A 22-year-old male with paranoid schizophrenia presented with insidious onset tonic truncal flexion with axial rotation and difficulty in walking after exposure to olanzapine in doses up to 15 mg/day for 9 months. An objective causality assessment suggested that Pisa syndrome was probably related to olanzapine. There was improvement in his symptoms after 6 weeks of treatment with clozapine in doses gradually titrated to 350 mg/day.

Discussion:

Pisa syndrome is a type of dystonia that has been associated with both typical and atypical antipsychotics. Both acute and insidious onset cases have been described in the literature, which have different course and treatment response. Clozapine was found to be effective in reducing the severity of olanzapine-induced Pisa syndrome.

Conclusion:

Clozapine may be a useful treatment option for Pisa syndrome that has been caused by olanzapine.

Pisa syndrome in Parkinson's disease and parkinsonism: clinical features, pathophysiology, and treatment

Pisa syndrome is defined as a reversible lateral bending of the trunk with a tendency to lean to one side. It is a frequent and often disabling complication of Parkinson's disease, and has also been described in several atypical forms of parkinsonism and in neurodegenerative and psychiatric disorders after drug exposure and surgical procedures. Although no consistent diagnostic criteria for Pisa syndrome are available, most investigations have adopted an arbitrary cutoff of at least 10° of lateral flexion for the diagnosis of the syndrome. Pathophysiological mechanisms underlying Pisa syndrome have not been fully explained. One hypothesis emphasises central mechanisms, whereby Pisa syndrome is thought to be caused by alterations in sensory-motor integration pathways; by contrast, a peripheral hypothesis emphasises the role of anatomical changes in the musculoskeletal system. Furthermore, several drugs are reported to induce Pisa syndrome, including antiparkinsonian drugs. As Pisa syndrome might be reversible, clinicians need to be able to recognise this condition early to enable prompt management. Nevertheless, further research is needed to determine optimum treatment strategies.

A Case Report on Dyskinesia Following Rivastigmine Patch 13.3 mg/24 hours for Alzheimer's Disease: Perspective in the Movement Disorders Spectrum Following Use of Cholinesterase Inhibitors

Current reports on movement disorder adverse effects of acetylcholinesterase inhibitors only include extrapyramidal symptoms and myoclonus.Here is a case of an 81-year-old female Filipino with dementia who presented with first-onset generalized choreiform movements.The etiology of the clinical finding of dyskinesia was investigated through laboratories, neuroimaging, and electroencephalogram, all of which yielded negative results. Review of her medications included the rivastigmine (Exelon) patch, which had just been increased to 13.3 mg/24-hour-dose 3 months prior. With all other possible causes excluded, a trial discontinuation of rivastigmine, showed decreased frequency of the dyskinesia 48 hours after, with complete resolution after 6 days, and no recurrence since then.This case thus presents a probable association or causality between the choreiform movement and rivastigmine at 13.3 mg/24-hour-dose patch because of clear temporal proximity, lack of alternative explanations, and a reversal of the dyskinesia upon medicament discontinuation.

Pisa Syndrome Associated With Clozapine: A Rare Case Report and Literature Review

STUDY DESIGN

Case report.

INTRODUCTION

Pisa syndrome (pleurothotonus) is a rare neurologic syndrome, often considered as a consequence of long-term treatment with neuroleptic drugs, defined as more than 10 degrees tonic lateral flexion in upright spine without any significant associated vertebral rotation resembled the leaning tower of Pisa. Unfamiliarity of many neuro- and orthopedic surgeons with this syndrome can lead to unnecessary diagnostic and therapeutic interventions.

CASE REPORT

A 33-year-old woman, who has been treated as a schizophrenic patient for 16 years, was referred to our spine clinic with signs of trunk shift. She was consuming valproic acid 500 mg twice a day and clozapine 100 mg three times daily, as an unchanged regimen for the past 2 years. Few months after treatment with clozapine, her parents noticed that the patient progressively leaned to one side. Physical and imaging examinations revealed a severe left truncal shift associated with right cervical tilt. Drug regimen was changed and clozapine dosage reduced to 200 mg daily, and bipyridine 2 mg daily was added to the therapeutic regimen. By 1 month, the deformity gradually disappeared and normal body posture was restored. At the last follow-up visit, 28 months later, normal body posture was observed to be maintained, and no evidence of spinal deformity was noted.

CONCLUSIONS

Spine deformity surgeons visiting patients with abnormal postures of the trunk need to ask the patient about medications they are receiving and should be aware of their neuropsychiatric complications. Even drugs with the minimum risk of dystonia, such as clozapine, may cause dystonic disorders like Pisa syndrome.

Cholinesterase inhibitors and Pisa syndrome: a pharmacovigilance study

STUDY OBJECTIVES

Case reports suggest a relationship between cholinesterase inhibitors (ChEIs) and Pisa syndrome (PS), also known as pleurothotonus, a form of dystonia, but this relationship has not been systematically examined. Our objective was to estimate the adjusted reporting ratios of PS with donepezil, rivastigmine, and galantamine in the United States Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) database.

DESIGN

Retrospective analysis of adverse event reports in the FAERS database.

PATIENTS

Patients with drug-related adverse events in the FAERS database.

MEASUREMENTS AND MAIN RESULTS

The Gamma Poisson Shrinker algorithm was used to estimate the empirical Bayes geometric mean (EBGM) along with the lower and upper 90% confidence interval (CI) limits (EB05 and EB95, respectively), as measures of the adjusted reporting ratio of PS in patients taking ChEIs. EB05 > 2.0 was used as the cutoff for significance for the signals. The EBGM (EB05) was 37.9 (30) for all ChEIs, 25.6 (17.6) for donepezil, 76.4 (50.3) for galantamine, and 33.7 (21.2) for rivastigmine. All adverse event signals were strongly significant based on the a priori set EB05 cutoff. The female:male ratio in the reported cases was 2:1. No significant signals were found between ChEIs and other dystonias. About half of the ChEI users were also taking concomitant antipsychotics.

CONCLUSION

Although FAERS data cannot establish causality due to reporting biases, our findings support a potential dopaminergic-cholinergic imbalance as an underlying mechanism for PS and may help increase clinician awareness, early identification, and treatment of ChEI-related dystonias.

Acute dystonic reaction with rivastigmine

Dystonic reactions are adverse extrapyramidal side effects and are common to antipsychotics, antiemetics, and a variety of other drugs. Rivastigmine, an anticholinesterase of carbamate variety, is well tolerated. A case of acute dystonic reaction with rivastigmine patch is being reported.

Pisa syndrome in Parkinson's disease: clinical, electromyographic, and radiological characterization

Abnormal postures of the trunk are a typical feature of Parkinson's disease (PD). These include Pisa syndrome (PS), a tonic lateral flexion of the trunk associated with slight rotation along the sagittal plane. In this study we describe clinical, electromyographic (EMG), and radiological features of PS in a group of 20 PD patients. All patients with trunk deviation underwent EMG and radiological (RX and CT scan) investigation. Clinical characteristics of patients with PS were compared with a control group of PD patients without trunk deviation. PD patients with PS showed a significantly higher score of disease asymmetry compared with the control group. In the majority of patients with PS, trunk bending was contralateral to the side of symptom onset. EMG showed abnormal tonic hyperactivity on the side of the deviation in the paravertebral thoracic muscles and in the abdominal oblique muscles. CT of the lumbar paraspinal muscles showed muscular atrophy more marked on the side of the deviation, with a craniocaudal gradient. PS may represent a complication of advanced PD in a subgroup of patients who show more marked asymmetry of disease and who have detectable hyperactivity of the dorsal paravertebral muscles on the less affected side. This postural abnormality deserves attention and proper early treatment to prevent comorbidities and pain.

Botulinum toxin treatment of lateral axial dystonia in parkinsonism

Lateral axial dystonia (LAD) has been described in patients with Parkinson's disease (PD), but treatment might be more controversial than treatment of LAD in other neurological conditions. Our study was designed as a blinded cross-over with botulinum toxin (BTX) and placebo in order to investigate the efficacy of BTX in PD LAD. Nine patients with LAD who failed to experience benefit from oral medications were randomly assigned to 2 groups, 4 patients received BTX and 5 placebo as a first treatment, and were switched-over to BTX or placebo in the following treatment session, performed 3 months after the first session. Each patient was evaluated at baseline, 2 and 4 weeks after injection and after 3 months follow-up with the Trunk Dystonia Disability Scale (TDDS), a Visual Analogue Scale (VAS) and a goniometric measurement of the lateral displacement. Patients were videotaped at each visit. None of the patients of the placebo group experienced benefit from treatment. BTX treatment was effective in 6 patients. One patient reported subjective benefit, with improvement of VAS score and mild improvement of TDDS score, but with no improvement of flexion degree. Two patients did not report any benefit. Four patients opted to continue to receive BTX treatment for 2 years after the cross-over study. Our study shows that BTX could be considered a possible treatment for LAD in parkinsonism.

Pisa syndrome without neuroleptic exposure in a patient with Parkinson's disease: Case report

We report on a patient affected by Parkinson's disease who developed over a period of a few weeks a tonic deviation of her head, neck, and trunk fitting the typical description of Pisa syndrome (PS). This patient was under stable levodopa and pramipexole treatment and had never been exposed to any psychotropic or antiemetic drugs before or at the time she developed the postural abnormality. Because dopamine transporter imaging revealed bilateral and symmetrical reduction of striatal uptake, we suggest that PS is not primarily related to side differences in dopaminergic denervation or drug exposure.