Delayed onset of oculogyric crisis and torticollis with intramuscular haloperidol

Haloperidol-Induced Laryngeal Dystonia: A Case Report on an Antipsychotic-Associated Airway Emergency

Acute dystonia is a neurological condition characterized by involuntary muscle contractions that can affect various parts of the body. It is commonly triggered by the use of antipsychotic medications, especially within the first few days after administration. Respiratory acute laryngeal dystonia, a particularly severe form of this condition and a very subtype of laryngeal dystonia, can lead to respiratory distress and airway obstruction if not promptly treated. This case report describes a 23-year-old male who developed acute laryngeal dystonia within 24 hours of receiving haloperidol for agitation. The patient presented with hoarseness, difficulty swallowing, and progressive respiratory distress, eventually requiring emergent intubation due to airway compromise. This case underscores the need for healthcare providers to recognize and promptly manage rare but potentially life-threatening side effects of antipsychotic medications. Particular attention must be directed toward patients with risk factors for developing extrapyramidal reactions. Early intervention is crucial to prevent progression to airway obstruction and respiratory failure.

Seeing beyond the norm: Unveiling ocular complications with atypical antipsychotics

Psychotropic medications, particularly antipsychotics, are known to elicit various adverse effects, with ocular complications being underreported yet significant. This case series presents three instances where atypical antipsychotics, namely Risperidone, Cariprazine, and Olanzapine, led to ocular dystonias and nystagmus. These adverse effects occurred at relatively low doses, highlighting the need for vigilant monitoring even with second-generation antipsychotics. Case descriptions delineate patients experiencing acute dystonic reactions and nystagmus following initiation or dose adjustment of atypical antipsychotics, leading to upward deviation of the eyes, involuntary movements, and nystagmus. Prompt recognition and management were crucial, with cessation of the offending medication resulting in symptom remission and subsequent stabilization with alternative treatments. Factors contributing to these adverse effects, such as dopamine receptor blockade and individual susceptibility, are explored, emphasizing the importance of comprehensive evaluation and open patient-physician communication. The present case series underscores the necessity of vigilant monitoring for ocular adverse effects, even with atypical antipsychotics, given their potential to induce acute dystonias and nystagmus. The presented cases advocate for heightened awareness among clinicians to promptly recognize and manage such rare complications, ensuring optimal patient care and treatment outcomes.

A case of delayed-onset multiple oculogyric crisis and torticollis episodes after low dose intramuscular haloperidol in a non-neuroleptic drug overdose setting

This report documents a rare case of delayed-onset multiple acute dystonias after treatment with low dose intramuscular (IM) haloperidol lactate injection in a setting of non-neuroleptic drug overdose. The drug–drug interactions between haloperidol and high levels of paracetamol and naproxen are deliberated upon. A 25-year-old Asian female was admitted after an intentional overdose of medications (paracetamol, naproxen and pregabalin). She received 5 mg of IM haloperidol injection for agitation. 21 hours later she experienced mild intermittent ocular deviation in an upward and outward direction and generalised stiffness, which were self-resolving. An hour later, she required another 2.5 mg of IM haloperidol injection for further agitation. In the 35 hours following her first IM haloperidol (13 hours after the second IM haloperidol), she developed a total of three episodes of oculogyric crisis (OGC) with torticollis. Each episode was treated promptly with IM diphenhydramine 25 mg, and there was remission of symptoms within 15 minutes of treatment. An objective causality assessment revealed a definite relationship between the episodes of acute dystonia with IM haloperidol therapy. Where oral alternatives and IM atypical antipsychotics/benzodiazepines are unavailable, rapid tranquillisation with a high-potency typical antipsychotic is a possibility. However, consideration should be made to combine haloperidol with an anticholinergic agent as prophylaxis against acute dystonia, especially in the setting of drug overdose, even if it is that of a non-neuroleptic drug (in this case, paracetamol and naproxen).

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.

An unusual cause of cervical kyphosis

BACKGROUND CONTEXT

Acute fixed cervical kyphosis may be a rare presentation of conversion disorder, psychogenic dystonia, and potentially as a side effect from typical antipsychotic drugs. Haldol has been associated with acute dystonic reactions. In some cases, rigid deformities ensue. We are reporting a case of a fixed cervical kyphosis after the use of Haldol.

PURPOSE

To present a case of a potential acute dystonic reaction temporally associated with Haldol ingestion leading to fixed cervical kyphosis.

STUDY DESIGN

This is a case report.

METHODS

A patient diagnosed with bipolar disorder presented to the emergency room several times with severe neck pain and stiffness. The neck appeared fixed in flexion with extensive osteophyte formation over a 3-month period.

RESULTS

The patient's condition was resolved by a posterior-anterior-posterior surgical approach. It corrected the patient's cervical curvature from 88° to 5°.

CONCLUSIONS

Acute dystonic reactions have the potential to apply enough pressure on bone to cause rapid osteophyte formation.

Managing Agitation Associated with Schizophrenia and Bipolar Disorder in the Emergency Setting

Introduction

Patient agitation represents a significant challenge in the emergency department (ED), a setting in which medical staff are working under pressure dealing with a diverse range of medical emergencies. The potential for escalation into aggressive behavior, putting patients, staff, and others at risk, makes it imperative to address agitated behavior rapidly and efficiently. Time constraints and limited access to specialist psychiatric support have in the past led to the strategy of “restrain and sedate,” which was believed to represent the optimal approach; however, it is increasingly recognized that more patient-centered approaches result in improved outcomes. The objective of this review is to raise awareness of best practices for the management of agitation in the ED and to consider the role of new pharmacologic interventions in this setting.

Discussion

The Best practices in Evaluation and Treatment of Agitation (BETA) guidelines address the complete management of agitation, including triage, diagnosis, interpersonal calming skills, and medicine choices. Since their publication in 2012, there have been further developments in pharmacologic approaches for dealing with agitation, including both new agents and new modes of delivery, which increase the options available for both patients and physicians. Newer modes of delivery that could be useful in rapidly managing agitation include inhaled, buccal/sublingual and intranasal formulations. To date, the only formulation administered via a non-intramuscular route with a specific indication for agitation associated with bipolar or schizophrenia is inhaled loxapine. Non-invasive formulations, although requiring cooperation from patients, have the potential to improve overall patient experience, thereby improving future cooperation between patients and healthcare providers.

Conclusion

Management of agitation in the ED should encompass a patient-centered approach, incorporating non-pharmacologic approaches if feasible. Where pharmacologic intervention is necessary, a cooperative approach using non-invasive medications should be employed where possible.

A case of metoclopramide-induced oculogyric crisis in a 16-year-old girl with cystic fibrosis

Oculogyric crisis is a neurologic reaction characterized by bilateral dystonic elevation of visual gaze as well as hyperextension of the neck. This reaction is most commonly explained as an adverse effect of numerous medications, such as dopamine receptor blocking agents or neuroleptic medications and traditional antipsychotic or antiemetic drugs, such as prochlorperazine or metoclopramide. A case of oculogyric crisis induced by metoclopramide is described in this paper.