Treatment of severe neuroleptic-induced tardive torticollis

Clinical Evolution of Tardive Cervical Dystonia from Antecollis to Retrocollis

Tardive dystonia occurs after exposure, over months to years, to antipsychotics and other drugs that block dopaminergic receptors. Anterocollis is a rare form of cervical dystonia which is usually disabling for the patient. Here, we present the case of a 61-year-old woman with Alzheimer's dementia diagnosed eight years ago who was previously medicated with antipsychotics. Two years before admission, she was medicated with olanzapine. She presented to the emergency room with a sustained flexion posture of the neck that was difficult to feed. She had a marked and fixed anterocollis and severe akathisia. After the administration of propofol to perform computerized tomography, the abnormal posture disappeared. Subsequently, she was started on biperiden without improvement. One week later, olanzapine was suspended, and she was progressively started on propranolol, trihexyphenidyl, and tetrabenazine. Cervical posture improved, but two weeks later, she presented with a left laterocollis, which allowed feeding, and improvement of akathisia. We present a case of tardive dystonia supported by the beginning of dystonia five months after olanzapine administration and improvement after its suspension. The coexistence of degenerative pathology is a risk factor for dystonia, which often persists despite the suspension of the causative agent. Therefore, non-pharmacological treatment and approach with antipsychotics with a better profile of extrapyramidal effects should be preferred in patients with dementia.

Exploring the role of botulinum toxin in critical care

INTRODUCTION

Botulinum neurotoxin (BoNT) is one of the most potent and extensively studied neurotoxins with clinical applications across several different medical specialties. This review article explores the latest evidence for therapeutic applications of BoNT in patients receiving critical management in an intensive care unit (ICU).

AREAS COVERED

The authors did a literature search in PubMed, Google Scholar, and Texas Medical Center Library database for studies describing the use of BoNT in a critical care setting. They extracted information on study design, patient selection, methodology, and results of relevant studies. Based on initial identification of 85 studies and after conducting screening, the authors identified 61 studies to be included in this review. In an ICU setting, BoNT has been used for several neurological and non-neurological indications. However, the supporting evidence is mostly limited to small observational studies.

EXPERT OPINION

The use of BoNT in this setting is largely underutilized due to paucity of well-designed clinical trials and financial barriers. Further research is needed to provide evidence for the safety and efficacy of BoNT and to optimize the dosing and injection techniques for various conditions encountered in this setting.

Neuroleptic-Induced Tardive Cervical Dystonia: Clinical Series of 20 Patients

Background:

Cervical dystonia (CD) may be classified according to the underlying cause into primary or secondary CD. Previous exposure to neuroleptics is one of the main causes of adult-onset secondary dystonia. There are few reports that characterize the clinical features of primary CD and secondary neuroleptic-induced CD. Herein our aim was to investigate a series of patients with neuroleptic induced tardive CD and to describe their clinical and demographic features.

Patients and Methods:

We retrospectively evaluated 20 patients with neuroleptic-induced tardive CD and compared clinical, demographic and therapeutic characteristics to another 77 patients with primary CD. All patients underwent Botulinum toxin type-A therapy.

Results:

We did not identify any relevant clinical and demographic characteristics in our group of patients that could be used to distinguish tardive and primary CD.

Conclusion:

Patients with tardive CD presented demographic characteristics and disease course similar to those with primary CD.

Clozapine and tardive movement disorders: a review

BACKGROUND

Tardive syndromes (TS) arise from long term exposure to dopamine receptor blocking agents. Clozapine has been considered to have low risk of causing new onset TS and is considered as a treatment option in patients with TS.

AIM

This review evaluates the usefulness of clozapine in patients with TS and occasional reports of clozapine causing TS.

METHODOLOGY

Electronic searches were carried out using the search engines of PUBMED, Science direct and Google Scholar databases. All reports describing use of clozapine in management of TS, monitoring of TS while on clozapine and onset of TS after initiation of clozapine were identified.

RESULTS

Fifteen trials and 28 case series/case reports describe the use of clozapine in TS. Most of these reports show that clozapine is useful in patients with TS, in the dose range of 200-300 mg/day and the beneficial effect is seen within 4-12 weeks of initiation. One case series and two case reports described clozapine withdrawal emergent dyskinesias suggesting a masking role of clozapine. One trial, three case series and two case reports describe beneficial effects of clozapine on long standing neurological syndromes. There is relatively less literature (2 trials and 15 case series/reports) describing the emergence of TS with clozapine.

CONCLUSION

Evidence of beneficial effects of clozapine in TS is greater than its role in causation/worsening of TS. Hence, clozapine should be considered in symptomatic patients who develop TS while receiving other antipsychotics. Further research on mechanism of TS and clozapine effect on TS is required.

Successful treatment of tardive lingual dystonia with botulinum toxin: case report and review of the literature

Tardive dyskinesia (TD) is a dreaded side effect of antipsychotic medication. Recommended treatments for TD may provide reliable improvement but can be, in turn, associated with additional adverse reactions. Recently, several reports have suggested that botulinum toxin A (BTX-A) injection in affected muscles may significantly improve TD. Here, we report a case of severe tongue protrusion dystonia secondary to an antipsychotic medication in a young man. Several approaches including clozapine, amisulpride, aripiprazole, ziprasidone, tiapride and clonazepam failed to improve the symptoms. Injection of 50 U of BTX-A (Dysport, Ipsen, Ettlingen, Germany) into each genioglossal muscle dramatically improved tongue protrusion within few days with a sustained effect. If reasonable precautions are taken, the application seems to be well tolerated with only minor side effects. A review of the literature that is part of this article adverts BTX-A injection as a potential beneficial approach of various kinds of TD.