Jumpy stump triggered by tardive dyskinesia

Abstract

A 66-year-old man with a previous diagnosis of hypertension, diabetes and hypercholesterolemia underwent a below-knee amputation of his right leg in 2008 related to vascular insufficiency. Few days later, he presented with ‘‘pruritus’’ in the phantom right foot. Over the months, this sensation faded but did not disappear completely. Eighteen months after the surgery, the patient complained of visual hallucination and was started on haloperidol by a psychiatrist. Six months later, he noticed stiffness, slowness, speech disturbance, lip smacking as well as involuntary movements in the right stump. Examination revealed orofacial dyskinesia, rigidity, bradykinesia, slurred speech and painless involuntary movements of adduction, flexion and extension of the right stump (Videotape Segment 1). After haloperidol withdrawal, there was persistence of the orofacial dyskinesia and jumpy stump movements, although there was improvement in rigidity and bradykinesia. Tetrabenazine was prescribed (25 mg/day) and the patient became asymptomatic, without movements of the amputated stump and significant reduction of the orofacial dyskinesia (Videotape Segment 2). Jumpy stump is defined as a movement disorder that occurs after limb amputation. Regarding the phenomenology, it can present either as myoclonic spasm or choreiform, jerky or tremulous movements. Firstly described as ‘‘convulsive movement of the stump [1]’’, this phenomenon frequently starts after a period of weeks or even months after the amputation procedure [2]. Although its pathogenesis remains to be elucidated, jumpy stump is probably a movement disorder related to peripheral nerve injury [2, 3]. Several involuntary movement disorders occur as a consequence of peripheral nerve dysfunction or injury, including hemifacial spasm and painful legs and moving toes. Considerable controversy surrounds the pathogenesis of these movement disorders occurring in these particular contexts [2]. The occurrence of involuntary movements of stumps following amputation has been recognized for over 100 years. The spasms of amputation stump often occur in the postoperative period [2]. Our patient developed involuntary movements of stump 2 years after amputation and following exposure to haloperidol. The oro–lingual–facial stereotypies displayed by the patient are typical of tardive dyskinesia [4]. We concluded that in this case the jumpy stump represented a feature of tardive dyskinesia. There is little published data about motor aspects of the phantom limb in the context of tardive dyskinesia. To our knowledge, this is the first videotaped case of a jumpy stump movement triggered by tardive dyskinesia. Non-videotaped case reports by Jankovic and McCalley-Whitters suggest that the symptoms of phantom limb were reactivated by tardive dyskinesia. The former case report describes a 58-year-old woman who received chemotherapy for carcinoma of her breast. In an attempt to prevent nausea and vomiting, metoclopramide IV was used and caused hand tremor, akathisia and truncal and orofacial dyskinesia. These symptoms resolved but she remained with a persistent shoulder stump chorea [5]. The other report describes a 42-year-old schizophrenic man who lost his right foot and Electronic supplementary material The online version of this article (doi:10.1007/s10072-012-0954-8) contains supplementary material, which is available to authorized users.