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Pitton Rissardo J, Murtaza Vora N, Danaf N, Ramesh S, Shariff S, Fornari Caprara AL. Pisa Syndrome Secondary to Drugs: A Scope Review. Geriatrics (Basel) 2024; 9:100. [PMID: 39195130 DOI: 10.3390/geriatrics9040100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 07/16/2024] [Accepted: 07/25/2024] [Indexed: 08/29/2024] Open
Abstract
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.
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Affiliation(s)
| | - Nilofar Murtaza Vora
- Medicine Department, Terna Speciality Hospital and Research Centre, Navi Mumbai 400706, India
| | - Naseeb Danaf
- Medicine Department, Lebanese University, Hadath RGHC+4PR, Lebanon
| | - Saivignesh Ramesh
- Medicine Department, Terna Speciality Hospital and Research Centre, Navi Mumbai 400706, India
| | - Sanobar Shariff
- Faculty of General Medicine, Yerevan State Medical University, Yerevan 0025, Armenia
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Ueda A, Komatsu K, Takahashi M. [Abnormal posture of the trunk related to donepezil hydrochloride: report of 2 cases]. Rinsho Shinkeigaku 2023; 63:85-91. [PMID: 36725013 DOI: 10.5692/clinicalneurol.cn-001792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Akihiro Ueda
- Department of Neurology, Kitano Hospital, Tazuke Kofukai Medical Research Institute
| | - Kenichi Komatsu
- Department of Neurology, Kitano Hospital, Tazuke Kofukai Medical Research Institute
| | - Makio Takahashi
- Department of Neurology, Kitano Hospital, Tazuke Kofukai Medical Research Institute
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Clozapine-Associated Pisa Syndrome: A Case Report of an Acute Reaction in a Bipolar Patient. Clin Neuropharmacol 2021; 44:222-224. [PMID: 34654016 DOI: 10.1097/wnf.0000000000000485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Abstract
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.
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Mimura Y, Kurose S, Takata T, Tabuchi H, Mimura M, Funayama M. Pisa syndrome induced by switching of a choline-esterase inhibitor treatment from donepezil to galantamine: a case report. BMC Neurol 2020; 20:183. [PMID: 32404068 PMCID: PMC7218485 DOI: 10.1186/s12883-020-01769-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 05/06/2020] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Yu Mimura
- Department of Neuropsychiatry, Japanese Red Cross Ashikaga Hospital, 49-1 Yobe, Ashikaga, Tochigi, Japan. .,Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, Japan.
| | - Shin Kurose
- Department of Neuropsychiatry, Japanese Red Cross Ashikaga Hospital, 49-1 Yobe, Ashikaga, Tochigi, Japan.,Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, Japan
| | - Taketo Takata
- Department of Neuropsychiatry, Japanese Red Cross Ashikaga Hospital, 49-1 Yobe, Ashikaga, Tochigi, Japan
| | - Hajime Tabuchi
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, Japan
| | - Michitaka Funayama
- Department of Neuropsychiatry, Japanese Red Cross Ashikaga Hospital, 49-1 Yobe, Ashikaga, Tochigi, Japan
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Tinazzi M, Geroin C, Gandolfi M, Smania N, Tamburin S, Morgante F, Fasano A. Pisa syndrome in Parkinson's disease: An integrated approach from pathophysiology to management. Mov Disord 2016; 31:1785-1795. [PMID: 27779784 DOI: 10.1002/mds.26829] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 09/09/2016] [Accepted: 09/11/2016] [Indexed: 12/26/2022] Open
Abstract
Pisa syndrome was first described in 1972 in patients treated with neuroleptics. Since 2003, when it was first reported in patients with Parkinson's disease (PD), Pisa syndrome has progressively drawn the attention of clinicians and researchers. Although emerging evidence has partially clarified its prevalence and pathophysiology, the current debate revolves around diagnostic criteria and assessment and the effectiveness of pharmacological, surgical, and rehabilitative approaches. Contrary to initial thought, Pisa syndrome is common among PD patients, with an estimated prevalence of 8.8% according to a large survey. Furthermore, it is associated with the following specific patient features: more severe motor phenotype, ongoing combined pharmacological treatment with levodopa and dopamine agonists, gait disorders, and such comorbidities as osteoporosis and arthrosis. The present literature on treatment outcomes is scant, and the uneven effectiveness of specific treatments has produced conflicting results. This might be because of the limited knowledge of Pisa syndrome pathophysiology and its variable clinical presentation, which further complicates designing randomized clinical trials on this condition. However, because some forms of Pisa syndrome are potentially reversible, there is growing consensus on the importance of its early recognition and the importance of pharmacological adjustment and rehabilitation. © 2016 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Michele Tinazzi
- Neurology Unit, Movement Disorders Division, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Christian Geroin
- Neuromotor and Cognitive Rehabilitation Research Center (CRRNC), Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Marialuisa Gandolfi
- Neuromotor and Cognitive Rehabilitation Research Center (CRRNC), Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy.,Neurorehabilitation Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Nicola Smania
- Neuromotor and Cognitive Rehabilitation Research Center (CRRNC), Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy.,Neurorehabilitation Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Stefano Tamburin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Francesca Morgante
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Alfonso Fasano
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, UHN, Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, Toronto, Ontario, Canada
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Deng M, Huang L, Ning B, Wang N, Zhang Q, Zhu C, Fang Y. β-asarone improves learning and memory and reduces Acetyl Cholinesterase and Beta-amyloid 42 levels in APP/PS1 transgenic mice by regulating Beclin-1-dependent autophagy. Brain Res 2016; 1652:188-194. [PMID: 27737765 DOI: 10.1016/j.brainres.2016.10.008] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 10/07/2016] [Accepted: 10/09/2016] [Indexed: 12/11/2022]
Abstract
Alzheimer's disease (AD) is the most common neurodegenerative disorder in the elderly, and studies have suggested that β-asarone has pharmacological effects on beta-amyloid (Aβ) injected in the rat hippocampus. However, the effect of β-asarone on autophagy in the APP/PS1 transgenic mouse is unreported. APP/PS1 transgenic mice were randomly divided into six groups (n=10/group): an untreated group, an Aricept-treated group, a 3-MA-treated group, a rapamycin-treated group, an LY294002-treated group, a β-asarone-treated group. The control group consisted of wild-type C57BL/6 mice. All treatments were administered to the mice for 30 days. Spatial learning and memory were assessed by water maze, passive avoidance, and step-down tests. AChE and Aβ42 levels in the hippocampus were determined by ELISA. p-Akt, p-mTOR, and LC3B expression were detected by flow cytometry. The expression of p-Akt, p-mTOR, Beclin-1, and p62 proteins was assessed by western blot. Changes in autophagy were viewed using a transmission electron microscope. APP and Beclin-1 mRNA levels were measured by Real-Time PCR. The learning and memory of APP/PS1 transgenic mice were improved significantly after β-asarone treatment compared with the untreated group. In addition, β-asarone treatment reduced AChE and Aβ42 levels, increased p-mTOR and p62 expression, decreased p-Akt, Beclin-1, and LC3B expression, decreased the number of autophagosomes and reduced APP mRNA and Beclin-1 mRNA levels compared with the untreated group. That is, β-asarone treatment can improve the learning and memory abilities of APP/PS1 transgenic mouse by inhibiting Beclin-1-dependent autophagy via the PI3K/Akt/mTOR pathway.
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Affiliation(s)
- Minzhen Deng
- Guangdong Provincial Hospital of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou 510120, PR China; Guangzhou University of Chinese Medicine, Guangzhou 510006, PR China
| | - Liping Huang
- Hainan Medical University, Haikou 571199, PR China; Lingnan Normal University, Zhanjiang 524048, PR China
| | - Baile Ning
- Guangzhou University of Chinese Medicine, Guangzhou 510006, PR China
| | - Nanbu Wang
- Guangzhou University of Chinese Medicine, Guangzhou 510006, PR China
| | - Qinxin Zhang
- Guangzhou University of Chinese Medicine, Guangzhou 510006, PR China
| | - Caixia Zhu
- Guangzhou University of Chinese Medicine, Guangzhou 510006, PR China
| | - Yongqi Fang
- Guangzhou University of Chinese Medicine, Guangzhou 510006, PR China; The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510405, PR China.
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Barone P, Santangelo G, Amboni M, Pellecchia MT, Vitale C. Pisa syndrome in Parkinson's disease and parkinsonism: clinical features, pathophysiology, and treatment. Lancet Neurol 2016; 15:1063-74. [PMID: 27571158 DOI: 10.1016/s1474-4422(16)30173-9] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 06/26/2016] [Accepted: 06/27/2016] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Paolo Barone
- Neurodegenerative Diseases Centre, Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Gabriella Santangelo
- Department of Psychology, Second University of Naples, Caserta, Italy; IDC-Hermitage-Capodimonte, Naples, Italy
| | - Marianna Amboni
- Neurodegenerative Diseases Centre, Department of Medicine and Surgery, University of Salerno, Salerno, Italy; IDC-Hermitage-Capodimonte, Naples, Italy
| | - Maria Teresa Pellecchia
- Neurodegenerative Diseases Centre, Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Carmine Vitale
- IDC-Hermitage-Capodimonte, Naples, Italy; Department of Motor Sciences and Wellness, University Parthenope, Naples, Italy.
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Chung J, Choi SI, Kim J. Experience of media presentations for the alleviation of agitation and emotional distress among dementia patients in a long-term nursing facility. DEMENTIA 2016; 15:1021-33. [DOI: 10.1177/1471301214550660] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although the cause and the cure for dementia remain unknown, it is clear that environmental factors can offer relief of cognitive impairment and encourage emotional stability. The purpose was to explore dementia patients’ experiences of a media presentation including images of nature. Combining a qualitative approach with quantitative data analysis, the project exposed 23 participants to slide show presentations of fascinating natural scenes over 4 weeks. The patients’ feelings and experiences of the media presentations were investigated using semistructured interviews and daily chart reviews in which weekly behavioral changes. The experience of natural scenes in dementia patients’ everyday atmosphere became a new and positive aspect of life at the long-term nursing facility, although the quantitative data did not significantly change during the project. This treatment could provide dementia patients with a nurturing relationship, making nature a supportive part of their everyday experience.
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Affiliation(s)
| | | | - Jun Kim
- Department of Health Education & Recreation, College of Education & Human Services, Southern Illinois University Carbondale, USA
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Diaz MCB, Rosales RL. 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. Medicine (Baltimore) 2015; 94:e1364. [PMID: 26313774 PMCID: PMC4602930 DOI: 10.1097/md.0000000000001364] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Maria Cristina B Diaz
- From the Department of Neurology and Psychiatry, University of Santo Tomas Hospital, Espana, Manila, Philippines
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Faridhosseini F, Omidi-Kashani F, Baradaran A. Pisa Syndrome Associated With Clozapine: A Rare Case Report and Literature Review. Spine Deform 2015; 3:386-389. [PMID: 27927486 DOI: 10.1016/j.jspd.2015.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 02/04/2015] [Accepted: 02/15/2015] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Farhad Faridhosseini
- Psychiatric and Behavioral Sciences Research Center, Ibn Sina Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Farzad Omidi-Kashani
- Orthopedic Research Center, Orthopedic Department, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Aslan Baradaran
- Orthopedic Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
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Zannas AS, Okuno Y, Doraiswamy PM. Cholinesterase inhibitors and Pisa syndrome: a pharmacovigilance study. Pharmacotherapy 2013; 34:272-8. [PMID: 24127392 DOI: 10.1002/phar.1359] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- Anthony S Zannas
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
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Pisa syndrome in a patient with progressive supranuclear palsy. J Clin Neurosci 2012; 19:922-3. [DOI: 10.1016/j.jocn.2012.01.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Accepted: 01/23/2012] [Indexed: 11/16/2022]
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