Recurrent acute dystonic reaction and oculogyric crisis despite withdrawal of dopamine receptor blocking drugs

Drug-Induced Movement Disorders

Drug-induced movement disorders (DIMDs) are most commonly associated with typical and atypical antipsychotics. However, other drugs such as antidepressants, antihistamines, antiepileptics, antiarrhythmics, and gastrointestinal drugs can also cause abnormal involuntary movements. Different types of movement disorders can also occur because of adverse drug reactions. Therefore, the important key to diagnosing DIMDs is a causal relationship between potential offending drugs and the occurrence of abnormal movements. The pathophysiology of DIMDs is not clearly understood; however, many cases of DIMDs are thought to exert adverse mechanisms of action in the basal ganglia. The treatment of some DIMDs is quite challenging, and removing the offending drugs may not be possible in some conditions such as withdrawing antipsychotics in the patient with partially or uncontrollable neuropsychiatric conditions. Future research is needed to understand the mechanism of DIMDs and the development of drugs with better side-effect profiles. This article reviews the phenomenology, diagnostic criteria, pathophysiology, and management of DIMDs.

The clinical phenomenology and correlations of oculogyric tics

BACKGROUND

Oculogyric tics are identified in a substantial proportion of patients with Tourette syndrome (TS) and related tic-disorders. Nevertheless, studies assessing its frequency and clinical correlations are lacking.

MATERIALS AND METHODS

We reviewed video-recordings and clinical history of 201 patients with TS and chronic motor/phonic tic disorder, diagnosed according to DSM-5.

RESULTS

Oculogyric tics presented in 22.4% of our patients. Transient upward gaze was the most common phenomenology in patients with simple oculogyric tics; whereas eye-closure followed by upward and lateral deviations was the most commonly observed phenomenon in patients with combined oculogyric tics. Oculogyric tics have a median duration of 799 ms (range 299-34,500 ms). Patients with oculogyric tics were younger (P = 0.023) and had a higher frequency of cranial tics (P = 0.037) compared to those without oculogyric tics. No differences in tic severity, frequency of attention-deficit/hyperactivity disorder, obsessive-compulsive disorder or use of dopamine receptor antagonists were observed in patients with and without oculogyric tics.

CONCLUSIONS

Oculogyric tics are a common phenomenology in chronic tic disorders. They are more common in younger patients with TS and are markers of other cranial tics, but not of TS severity or comorbid neuropsychiatric syndromes.

Spotlight on Oculogyric Crisis: A Review

BACKGROUND

Oculogyric crisis (OGC) is a form of acute dystonia characterized by sustained dystonic, conjugate, and upward deviation of the eyes. It was initially reported in patients with postencephalitic parkinsonism. But later, other factors such as medications, movement disorders, metabolic disorders, and focal brain lesions were also found to be associated with OGC.

METHODS

The literature regarding OGC was searched via PubMed, Google Scholar, and through citations in relevant articles till December 2019, with keywords including OGC, oculogyric eye movements, tonic eye movement, neuroleptics and OGC, antipsychotics and OGC, and all combinations of these. Only original articles (abstract or full text) that were published in the English language were reviewed.

RESULTS

Hypodopaminergic state is implicated in the pathogenesis of OGC. Common risk factors are younger age, male sex, severe illness, high neuroleptic dose, parenteral administration of neuroleptics, high potency of neuroleptic drugs, abrupt discontinuation of anticholinergic medication, and family history of dystonia.

CONCLUSION

OGC is an acute dystonic reaction leading to tonic upward deviation of eyes. It is associated with various neurometabolic, neurodegenerative, and movement disorders and medications such as antipsychotics, antiemetics, antidepressants, antiepileptics, and antimalarials. OGC can adversely impact the compliance and prognosis of the primary illness. Hence, it needs to be managed at earlier stages with appropriate medication, primarily anticholinergics.

Clinical characteristics of acute drug-induced dystonia in pediatric patients

Objective

Dystonia is a movement disorder in which muscles contract uncontrollably. Acute drug-induced dystonia (DID) can be diagnosed through detailed history taking and physical examination. This study aimed to identify the clinical characteristics of DID in children, which could help emergency physicians diagnose these conditions more efficiently.

Methods

We reviewed medical records of children aged below 18 years diagnosed with drug-related dystonia after discharge from the emergency department over 10 years. We collected the patients’ age, sex, suspected causative drugs, initial diagnosis of the prescribing physician, duration of drug-taking, diagnostic evaluations, treatment methods, and prognosis.

Results

Seventy-nine patients were enrolled. The mean age was 11.3±4.9 years (range, 4.0 months to 18.0 years), and 41 patients (51.9%) were boys. The most common cause of DID was gastrointestinal medications in 45 patients (57.0%), followed by antipsychotics in 23 patients (29.1%). Eleven (24.4%) out of 45 patients with DID due to gastrointestinal medications had the initial diagnosis of upper respiratory infection, and seven (30.4%) out of 23 patients with DID due to antipsychotics had the initial diagnosis of non-psychotic diseases. Younger children received more diagnostic procedures and were more frequently admitted. A benzodiazepine (67.1%) was the most common single drug for treatment.

Conclusion

Physicians should not only acknowledge DID in order to reduce unnecessary workup and admission, but also know that antiemetics and antipsychotics are common causes of DID. Therefore, physicians should try to avoid multidrug prescriptions in children.

Common toxidromes in movement disorder neurology

BACKGROUND

Physicians can come across patients who are exposed to certain prescription drugs or toxins that can result in adverse effects and complications which have high rates of morbidity and mortality.

OBJECTIVE

To summarise the key clinical features and management of the common movement disorder toxidromes relevant to physicians (with an interest in neurology).

METHODS

We searched PUBMED from 1946 to 2016 for papers relating to movement toxidromes and their treatment. The findings from those studies were then summarised and are presented here.

RESULTS

The key features of 6 of the common movement disorder toxidromes and their treatment are tabulated and highlighted. The management of toxidromes with the highest mortality like neuroleptic malignant syndrome and serotonin syndrome are discussed in detail.

CONCLUSION

There are several toxidromes that have the potential to become a serious life-threatening emergency if there is a delay in recognition of key clinical features and instituting the appropriate treatment at the earliest is crucial.

Ocular and visual disorders in Parkinson's disease: Common but frequently overlooked

Patients with Parkinson's disease (PD) often compensate for their motor deficits by guiding their movements visually. A wide range of ocular and visual disorders threatens the patients' ability to benefit optimally from visual feedback. These disorders are common in patients with PD, yet they have received little attention in both research and clinical practice, leading to unnecessary - but possibly treatable - disability. Based on a literature search covering 50 years, we review the range of ocular and visual disorders in patients with PD, and classify these according to anatomical structures of the visual pathway. We discuss six common disorders in more detail: dry eyes; diplopia; glaucoma and glaucoma-like visual problems; impaired contrast and colour vision; visuospatial and visuoperceptual impairments; and visual hallucinations. In addition, we review the effects of PD-related pharmacological and surgical treatments on visual function, and we offer practical recommendations for clinical management. Greater awareness and early recognition of ocular and visual problems in PD might enable timely instalment of tailored treatments, leading to improved patient safety, greater independence, and better quality of life.

Incidence of Oculogyric Crisis and Long-Term Outcomes With Second-Generation Antipsychotics in a First-Episode Psychosis Program

Oculogyric crisis (OGC) is an often recurrent dystonic adverse effect of antipsychotic treatment characterized by a sustained fixed upward gaze lasting minutes to hours. The risk of OGC has not been established. We prospectively estimated the incidence rate of OGC in an early intervention service for psychosis and provided details regarding the antipsychotics implicated, clinical presentation, and long-term outcomes of OGC. The Nova Scotia Early Psychosis Program provides comprehensive, team-based care to youth and young adults with schizophrenia spectrum disorder. For 6 years (April 2008 to March 2014), 452 new patients were admitted to the program and participated in an individualized program of care. Eight patients (4 females; mean age, 19.8 years) developed recurrent episodes of OGC after 3 months to 2 years of treatment with 1 or more second-generation antipsychotics, yielding an incidence rate of 1.8% (95% confidence interval, 0.9%-3.4%). Risperidone or olanzapine (alone or in combination with a second antipsychotic) seemed causative in each case. Also implicated in the onset or recurrence of oculogyric episodes were ziprasidone, quetiapine, clozapine, aripiprazole, and the first-generation antipsychotic loxapine. Follow-up ranged between 2 and 7 years. Episodes stopped after switching antipsychotic treatment in 4 cases and after stopping antipsychotic treatment in 2 cases. In the other 2 cases, recurrences were ongoing at last follow-up 2 and 6 years after onset with antipsychotic treatment continuing. We observed a high rate of tardive-onset, recurrent, and potentially chronic ocular dystonias in patients with first-episode psychosis caused by the use of second-generation antipsychotics.

Drug-induced movement disorders

Movement disorders are frequently a result of prescription drugs or of illicit drug use. This article focuses on prescribed drugs but briefly mentions drugs of abuse. The main emphasis is on movement disorders caused by dopamine receptor-blocking agents. However, movement disorders caused by other drugs are also briefly discussed.

Commonly used gastrointestinal drugs

This chapter reviews the spectrum and mechanisms of neurologic adverse effects of commonly used gastrointestinal drugs including antiemetics, promotility drugs, laxatives, antimotility drugs, and drugs for acid-related disorders. The commonly used gastrointestinal drugs as a group are considered safe and are widely used. A range of neurologic complications are reported following use of various gastrointestinal drugs. Acute neurotoxicities, including transient akathisias, oculogyric crisis, delirium, seizures, and strokes, can develop after use of certain gastrointestinal medications, while disabling and pervasive tardive syndromes are described following long-term and often unsupervised use of phenothiazines, metoclopramide, and other drugs. In rare instances, some of the antiemetics can precipitate life-threatening extrapyramidal reactions, neuroleptic malignant syndrome, or serotonin syndrome. In contrast, concerns about the cardiovascular toxicity of drugs such as cisapride and tegaserod have been grave enough to lead to their withdrawal from many world markets. Awareness and recognition of the neurotoxicity of gastrointestinal drugs is essential to help weigh the benefit of their use against possible adverse effects, even if uncommon. Furthermore, as far as possible, drugs such as metoclopramide and others that can lead to tardive dyskinesias should be used for as short time as possible, with close clinical monitoring and patient education.

Parkinson's disease presenting with oculogyric crisis in the off period

We herein report the case of a 67-year-old Japanese man diagnosed with sporadic Parkinson's disease (PD) at 52 years of age who presented with oculogyric crisis (OGC) in the off period. Ordinarily, OGC is caused by postencephalitic parkinsonism or the chronic use of antidopaminergic medications. The OGC began at 65 years of age and was associated with the wearing-off of symptoms. The dominant OGC feature was tonic deviations in eye posture induced by looking upward with prominent retrocollis. The administration of control dopaminergic medications led to improvements in the wearing-off phenomenon and OGC. This observation confirms that sporadic PD can induce OGC in the off period.

A new tyrosine hydroxylase genotype associated with early-onset severe encephalopathy

We describe a boy affected by an early-onset severe encephalopathy (stagnation of psychomotor development, paroxysmal dystonic postures and movements of limbs, hypokinesia) due to tyrosine hydroxylase deficiency. High blood prolactin and low homovanillic acid in cerebrospinal fluid suggested the diagnosis. Genetic analysis revealed 3 new missense mutations on tyrosine hydroxylase gene: [c.752C>T(p.P251L) and c.887G>A(p.R296Q] harbored by the father and c.836G>T (p.C279F) of maternal origin. Bioinformatics tools have been helpful in predicting the pathogenic role of p.P251L and p.C279F substitutions, while a weak pathogenic effect was ascribed to p.R296Q.