Drug-induced Pisa syndrome associated with aripiprazole during clozapine treatment

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.

Add-on Cariprazine in Patients with Long-term Clozapine Treatment and Treatment Resistant Schizophrenia: Two Cases of Psychotic Deterioration and Pisa Syndrome

An increasing number of studies deal with medical options for treatment resistant schizophrenia. If no remission can be achieved with clozapine, a combination of antipsychotics can be considered. The combination of clozapine and cariprazine is rarely studied. Cariprazine is a partial agonist on dopamine D₂ and D₃ receptors and a pharmaceutically rational add-on to clozapine. Stimulating D₃ receptors has been linked to improved cognition and mood, with negligible extrapyramidal side effects. We present two patients with long-term treatment resistant schizophrenia receiving cariprazine and clozapine. Whereas psychotic symptoms worsened, the patients developed extrapyramidal side effects with a Pisa syndrome. The syndrome remitted after discontinuation of cariprazine. Possible explanations by pharmacodynamic interactions and drug specific receptor profiles are discussed.

Clozapine-Associated Pisa Syndrome: A Case Report of an Acute Reaction in a Bipolar Patient

OBJECTIVES

The aims of the study were to describe the case of a 73-year-old woman with bipolar disorder who developed Pisa syndrome (PS) after starting clozapine and to present a review of this particular type of dystonia.

METHODS

After a brief introduction to the PS, we conduct a detailed description of the case and review, after a search on the PubMed database, the known risk factors, drugs associated with the onset of this syndrome, and the management of PS.

RESULTS

Pisa syndrome is a rare type of dystonia first described in 1972 as an adverse effect of neuroleptic agents. Clozapine is known for its small potential for inducing extrapyramidal symptoms, and it is often preferred as an alternative when extrapyramidal symptoms develop over the course of treatment with other agents. Many drugs have been associated with this kind of dystonia; however, we only found 5 previous reports of clozapine-induced PS. Tardive syndromes secondary to antipsychotic medication are better treated with the reduction or interruption of the causative agent, which was effective in this case.

CONCLUSIONS

The occurrence of clozapine-associated PS is rare and should be reported to further understand this phenomenon as well as the underlying risk factors.

Quetiapine Relieved Pisa Syndrome in Patient With Parkinson Disease

The aim of the study was to report quetiapine-relieved Pisa syndrome in a patient with Parkinson disease and to discuss the pathogenesis and treatment of Pisa syndrome.

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.

Management of aripiprazole-induced tardive Pisa syndrome: a case report and literature review

Pisa syndrome (PS) is characterized by an abnormally sustained posture with flexion of the body and head to one side and slight axial rotation of the trunk. PS has been related to the use of neuroleptics and is clinically classified as either an acute or a tardive dystonia. This is the first report describing a case of late-onset PS, occurring in a young patient treated with aripiprazole for 2 years. To establish optimal treatment management, we reviewed the literature on aripiprazole-induced PS and tardive dystonia. In light of current knowledge, we proposed a multistep algorithm to aid in the clinical management of this condition.

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.