Acute Dystonic Reactions Research Articles

Acute Dystonic Reaction Following Methylphenidate Discontinuation During Combination Therapy with Risperidone: A Case Study

Acute Dystonic Reaction Following Methylphenidate Discontinuation During Combination Therapy with Risperidone: A Case Study

Successful Management of an Acute Dystonic Reaction Induced by an Anesthetic Agent

Acute dystonic reactions (ADRs) are movement abnormalities characterized by involuntary muscle contractions that typically manifest after exposure to a triggering agent, such as a medication. The specific muscle groups affected determine the type of reaction. For instance, an oculogyric crisis primarily affects the ocular muscles, while oromandibular dystonia involves jaw opening and tongue protrusion. We present the rare case of a 68-year-old man with amyotrophic lateral sclerosis who was successfully treated for an ADR. The patient was admitted with loss of consciousness due to respiratory failure. Tracheostomy was promptly performed under sedation with multiple general anesthetic agents. Immediately after tracheostomy, the patient communicated via eye-blinking without any notable abnormalities, just as before the procedure. However, the following day, he became unresponsive to verbal cues and exhibited a decreased level of consciousness, accompanied by tongue dyskinesia, deviation of both eyes to the left, and loss of visual tracking. The patient’s vital signs remained stable. Brain imaging and an electroencephalogram revealed no abnormalities. Treatment with midazolam produced initial improvement; however, due to a significant side effect of hypotension, the treatment was switched to oral diazepam. The patient’s condition gradually improved, and the medication was eventually discontinued without further ADR episodes.

Is the combination of domperidone and metoclopramide increasing the risk of developing serotonin syndrome?: a case report

Metoclopramide and domperidone are dopamine antagonists that can cause an acute dystonic reaction. Metoclopramide is a rare but major contributor to serotonin syndrome, particularly when used with other serotonergic agents. Serotonin syndrome is a rare, potentially life-threatening adverse reaction characterized by a triad of altered mental status, autonomic dysfunction, and neuromuscular hyperactivity that typically results from exposure to serotonergic agents. Herein, we report a previously healthy 9-year-old girl who was brought to the emergency department with an alteration in the level of conscious and involuntary repetitive movements after approximately 24 hours of receiving a therapeutic dose of metoclopramide and domperidone. Physical examination showed tachycardia, hyperthermia, and a Glasgow Coma Scale score of 11, as well as mydriasis and hyperreflexia. In addition to resolving the symptoms after administering midazolam and diphenhydramine, the diagnosis of serotonin syndrome was made based on the classical symptoms and signs, which met the Hunter criteria. This case indicates the need for clinical awareness of the life-threatening syndrome and caution with medications having potential interactions with metoclopramide.

How to Wean: A Case Report of Abrupt Weaning and Acute Dystonia

World Health Organization (WHO) recommends exclusive breastfeeding for the first 6 months, followed by continued breastfeeding with complementary foods until 2 years of age or beyond. Despite these recommendations, there is limited research on the timing and methods of breastfeeding cessation, with abrupt weaning potentially causing unforeseen consequences. This report describes a case involving a 33-month-old girl who experienced acute dystonic reaction following the abrupt cessation of breastfeeding. It was learned that medication containing chlorpheniramine was given to the child to alleviate the uneasiness that developed due to abrupt cessation of breastfeeding. Patient’s symptoms were consistent with an acute dystonic reaction due to medication side effects, which improved with successful medical intervention. Breastfeeding initiation, continuation, and cessation influence the mental and physical health of the mother-baby pair. Abrupt weaning can pose challenges. While there are no strict guidelines for weaning, gradual weaning is generally considered a more comfortable approach for both mother and baby. To safeguard the well-being of the mother-baby pair, healthcare professionals should inform mothers about the discontinuation of breastfeeding and support a gradual weaning process. The presented case highlights the importance of careful consideration and professional guidance during the weaning process to prevent adverse outcomes.

Tardive and Acute Dystonic Reactions Probably Related to Extended Release Methylphenidate in an Early Adolescent with ADHD

Tardive and Acute Dystonic Reactions Probably Related to Extended Release Methylphenidate in an Early Adolescent with ADHD

Acute Dystonic Reaction After Propofol Administration: A Pediatric Case Report

We present a case of a 12-year-old female with a history of infantile spasms who developed a propofol-associated acute dystonic reaction after emergence from general anesthesia for foot surgery. Uniquely, the patient’s postoperative symptoms of an acute dystonic reaction were refractory to standard treatment with anticholinergics but were successfully treated with corticosteroids. The absence of any dystonic symptoms following subsequent foot surgery under general anesthesia without propofol supported a propofol-associated etiology. This case may contribute to a better understanding of the underlying mechanisms of propofol-associated acute dystonic reactions and adds a possible new treatment option.

Antikolinerjik tedavi altındaki bir şizofreni hastasında metoklopramidle indüklenmiş bir okülojirik kriz vakası

Introduction: Oculogyric crisis (OGC) is a dystonic reaction characterized as conjugate and typically upward deviation of the eyes lasting from seconds to hours which is seen as an uncommon neurologic manifestation. Metoclopramide is a prokinetic agent that is frequently prescribed in the treatment of nausea, vomiting prophylaxis, and vomiting. One of the side effects after metoclopramide treatment is acute dystonic reactions.Case Presentation: We report a case of metoclopramide-induced OGC despite the anticholinergic treatment in patient diagnosed with schizophrenia.Conclusions: Metoclopramide-induced OGC and other acute dystonic reactions may be more frequent than expected. Therefore, clinicians should monitor patients closely during treatment with metoclopramide and necessary precautions should be taken for these reactions.Keywords: Metoclopramide, oculogyric crisis, side effect, schizophrenia

Pediatric Emergency Service Admissions due to Acute Dystonic Reaction Induced by Metoclopramide

Pediatric Emergency Service Admissions due to Acute Dystonic Reaction Induced by Metoclopramide

Recurrent Temporomandibular Joint Dislocation Due to Antiemetic Induced Acute Dystonia: A Case Report

Introduction: Drug-induced acute dystonic reaction is a common presentation to emergency department. Oromandibular dystonia is one of the focal dystonias, which can be presented as jaw clenching, jaw opening or jaw deviation and leads to impaired speech and swallowing. In this paper, we presented an adult patient with recurrent temporomandibular joint dislocation due to metoclopramide use.
 Case Report: A 21-year-old female patient came to the emergency department with the complaints of inability chew and swallow, difficulty in speaking, pain at right temporomandibular region that started a few hours ago. On physical examination, she was having dystonia of the right mandibular region and left posterior servikal region and no dystonia at other parts of the body. The patient was diagnosed with metoclopramide-induced acute dystonia. She was treated with intravenous anticholinergic.
 Conclusion: Metoclopramide is an antiemetic drug that can cause serious adverse events such as acute dystonic reaction. Among these side effects are oromandibular dystonias, which may lead to TMJ dislocation. Physicians and other healthcare professionals working in the emergency department should be familiar with such side effects.

Acute Hyperkinetic Movement Disorders as a Multifactorial Pharmacodynamic Drug Interaction Between Methylphenidate and Risperidone in Children and Adolescents.

Acute hyperkinetic movement disorders have been reported with the concomitant use of attention-deficit/hyperactivity disorder (ADHD) stimulants and antipsychotics in children and adolescents. We analyzed postmarketing reports of suspected acute hyperkinetic movement disorder associated with concomitant use of ADHD stimulants and antipsychotics. We searched for postmarketing reports of acute hyperkinetic movement disorders associated with concomitant use of ADHD stimulants-antipsychotics in the US Food and Drug Administration Adverse Event Reporting System through December 6, 2019. PubMed and EMBASE were also searched for acute hyperkinetic movement reports with the concomitant use of ADHD stimulants-antipsychotics through January 13, 2020. We identified 36 cases resulting in acute hyperkinetic movement disorder associated with the concomitant use of ADHD stimulants-antipsychotics, 19 of which were also identified in the medical literature. From an ADHD stimulant perspective, methylphenidate products accounted for the largest number of cases (n = 23 [64%]), followed by amphetamine products (n = 9 [25%]) and atomoxetine (n = 4 [11%]). From an antipsychotic perspective, all 36 cases were reported with second-generation antipsychotics, particularly risperidone (n = 20 [56%]). Most of the cases were reported in boys (n = 31 [86%]) aged 6 to 12 years (n = 27 [75%]). Approximately 53% of the cases reported a time to onset within 24 hours of the drug change. Acute dystonic reactions (n = 27 [75%]) were the most frequently reported movement disorder. As outlined in changes to the US prescribing information for all methylphenidate and risperidone products, health care professionals should be aware that changes to this combination may be associated with a pharmacodynamic drug-drug interaction resulting in acute hyperkinetic movement disorder.

Case Report: The Challenges of Assessing and Managing Dysphagia in Two Patients on Long-term Clozapine

<h3>Introduction</h3> Introduction: The risk of clozapine associated dysphagia is between 1/1000 and 1/10000 (1). The associated complications of aspiration, pneumonia and mortality are also observed to be elevated with clozapine use(2). There is also limited evidence suggesting that risk is dose and age dependent (2), We present two cases illustrating the potential complex presentations of dysphagia in patients on clozapine. <h3>Methods</h3> Methods: The first case is a 61-year-old male veteran with history of chronic schizophrenia admitted for worsening psychosis. He has been on clozapine up to 550mg since 2001, with clozapine/norclozapine levels at 452/232. Exam was remarkable for an AIMS score of 25. During admission patient reported odynophagia, dysphagia and a 40-pound weight loss. Initial workup revealed candida esophagitis. 21-day course of fluconazole yielded no improvement. Inpatient team did not increase dose due to concern for esophageal dysmotility. Manometry is pending at the writing of this case report, hydroxyzine was reduced and benztropine discontinued to reduce anticholinergic burden. The second patient was a 51-year-old female with history of schizoaffective disorder, chronic PTSD, alcohol use disorder, bulimia nervosa, temporal lobe epilepsy, iron deficiency anemia, and GERD. Patient was on clozapine from 2009 until 2016. In 2015, she reported dysphagia worsening for one year with solid food dysphagia, choking, and sialorrhea. Subsequent manometry revealed type II achalasia and clozapine was discontinued within one year and switched to aripiprazole and eventually olanzapine. Over subsequent years, patient's dysphagia worsened and led to severe malnutrition. In 2020, she underwent Heller's myotomy with Dor fundoplication, with the expectation that dysphagia may remain given multifactorial etiology including polypharmacy. Patient also received a PEG tube. In 2020-2021, patient had more than 20 admissions for recurrent aspiration pneumonitis. In July 2021, she was admitted for replacement of a PEG tube and patient went into pulseless electrical arrest. Aspiration was cited as a factor in her death. <h3>Results</h3> Discussion: Dysphagia with antipsychotics can be mediated by multiple mechanisms including parkinsonism, acute dystonic reactions, tardive dyskinesia, sialorrhea, xerostomia, and sedation. Management approaches include reduction of clozapine and switching to another antipsychotic although these interventions may not reduce dysphagia. Aspiration on clozapine leads to a release of cytokines which can increase serum concentration of clozapine and in turn, side-effects (3). <h3>Conclusions</h3> Conclusion: These two cases illustrate the challenges in assessing and managing dysphagia in patients on clozapine. In both cases, dysphagia became an issue years after initiation of clozapine. In the first case, the veteran's dysphagia was likely mediated by tardive dyskinesia and oversedation. In the second case, dysphagia was likely mediated by sialorrhea, oversedation and other multiple comorbidities. More systematic studies are needed to better characterize risk of clozapine associated dysphagia and treatment approaches. <h3>This research was funded by</h3> none

Single dose levosulpiride induced acute dystonic reaction

Movement disorders are a common presentation to the emergency department. Acute dystonic reactions pose a serious medical challenge because they are often under or misdiagnosed. This case report deals with an acute dystonic reaction following a single dose of oral levosulpiride presenting with torticollis, tongue protrusion, and truisms which resolved rapidly with the administration of intravenous promethazine.

Metoclopramide-induced acute dystonic reactions: a case report

BackgroundAcute dystonic reactions caused by drugs are uncommon in daily practice, whether in outpatient or in emergency settings. Such types of unfavorable reaction may cause the treating physician’s working diagnosis to be misled at a certain point.Case presentationA 25-year-old Hindu female from Dharan with no previous medical history was being treated for acid peptic disease. Her local physician prescribed oral tablet metoclopramide 10 mg three times a day for 7 days and tablet pantoprazole 40 mg once daily for 7 days. After 24 hours of ingestion of 10 mg of tablet metoclopramide, she was admitted to our Koirala Institute of Health Sciences emergency department with sudden history of facial twitching, slurred speech, and abnormal tongue protrusion. Metoclopramide-induced acute dystonic reaction was diagnosed. After resuscitation, her symptoms reduced quickly, and she was successfully discharged home the same day.ConclusionsEarly diagnosis would be aided by the use of clinical background along with focus on drug history usage, preventing life-threatening pitfalls. To decrease the acute dystonic reaction associated with metoclopramide use, higher frequency of prescription patterns should be taken into account.

5.4 MANAGEMENT OF DRUG-INDUCED MOVEMENT DISORDERS (DIMDS): A CHILD NEUROLOGIST’S PERSPECTIVE

Common drug-induced movement disorders (DIMDs) in children vary widely and include hyperkinetic and hypokinetic syndromes. Based on time course, they can be acute, chronic, tardive, and withdrawal. They can be emergent (eg, acute dystonic reaction) or even threatening (ie, neuroleptic malignant syndrome and serotonin syndrome). They can be chronic and disabling (eg, tardive syndromes, tremors). Therefore, it is very important for providers to be familiar with the recognition and treatment of DIMDs.

5.3 PSYCHOTROPIC MEDICATIONS RELATED TO CAUSING MOVEMENT DISORDERS IN PEDIATRICS: A CHILD AND ADOLESCENT PSYCHIATRIST’S NIGHTMARE

Common drug-induced movement disorders (DIMDs) in children vary widely and include hyperkinetic and hypokinetic syndromes. Based on time course, they can be acute, chronic, tardive, and withdrawal DIMDs. They can be emergent (eg, acute dystonic reaction) or even threatening (ie, neuroleptic malignant syndrome and serotonin syndrome), and can be chronic and disabling (eg, tardive syndromes, tremors). Therefore, it is very important for providers to be familiar with the recognition and treatment of DIMDs.

Acute pharmacogenetic dystonic reactions in a family with the CYP2D6 *41 allele: a case report

BackgroundDystonia is a known neurological complication of certain medications; however, the mechanism behind such effects is often undetermined. Similarly, the clinical pharmacogenomic effects associated with various alleles of the cytochrome P450 family of proteins, and their role in acute dystonic reactions, are also presently unknown.Case presentationWe describe a woman presenting with acute dystonic reactions to ondansetron, prochlorperazine, and metoclopramide followed by persistent focal dystonia. A similar family history was reported in her siblings and her father to prochlorperazine, drugs all metabolized by the cytochrome P450 2D6 (CYP2D6) enzyme. Pharmacogenomic testing indicated the patient was heterozygous for the intermediate metabolizer *41 allele (CYP2D6 2988G>A, NM_000106.6:c.985+39G>A, rs28371725). Her father was homozygous for this CYP2D6 *41 allele, and consequently, her siblings were obligate carriers.ConclusionsThe metabolism of ondansetron, metoclopramide, or prochlorperazine in patients with the *41 CYP2D6 allele has not been studied. In this family, clinical evidence implicates the *41 CYP2D6 allele as causing extrapyramidal adverse pharmacologic reactions. Patients with a family history of medication-induced dystonia involving these medications should be considered for pharmacogenomic testing, and patients carrying the *41 CYP2D6 allele should consider reduction or avoidance of CYP2D6-mediated medications to minimize the potential risk of adverse extrapyramidal effects.

Childhood dystonic reactions in the middle Black Sea region.

Acute dystonic reactions are a worrying reason for presentation to the pediatric emergency department and the pediatric neurology clinic in childhood. It must be diagnosed and treated quickly. The aim of this study was to examine the clinical presentations, etiological factors, and prognosis of patients presenting to our regional tertiary pediatric neurology clinic with a diagnosis of acute dystonic reactions in children.Nine pediatric patients who were treated for acute dystonic reactions between May, 2018 and May, 2020 and had adequate follow-up were included in the study. Medical record data were reviewed age, gender, etiology, features of family, treatment, and results.Three of the patients were female and 6 were male. Their average age was 11 years (4–17). All patients were evaluated as a drug-induced acute dystonic reaction. Of the 9 patients, 5 were due to metoclopramide, 3 were due to risperidone, and 1 was due to aripiprazole. It was learned that a similar situation against other drugs developed in the family history of 3 patients. As a treatment, all of them were intramuscularly applied biperiden suitable for their weight and 30 minutes dramatic improvement was observed. Additional dose had to be administered in only 1 case. All cases were discharged for 24 hours. No problem was observed in their follow-up.Drug-induced acute dystonic reaction can be diagnosed and has a clinical picture that completely resolves when effective treatment is applied. However, it should not be forgotten that it can reach life-threatening dimensions clinically.

Multiple antipsychotics linked to acute dystonic reactions in 7% of children

You have heard a lot about adverse effects of antipsychotics, but a recent study has found that acute dystonic reactions (ADRs) develop in only 7% of children and adolescents, and that the vast majority of these are due to poly‐prescribing.

Distonija uzrokovana metoklopramidom u službi hitne medicinske pomoći

Introduction: Metoclopramide is commonly prescribed drug for treatment of nausea and vomiting. Acute dystonic reaction is the most common adverse effect and occur at approximately 0.2% of population. Material: Data from original medical reports and the hospital discharge summary were used. Material: Retrospective study of the work of one physician in the City Institute for EMS Belgrade in the period from 2017 to 2018 involving 2481 patients. Case report: In November 2019, the parents brought a thirteen year old child in the EMS. The child had vomited for 3 days and his parents gave him 2 tablets of metoclopramide, 24h after the pill ingestion the child began to cramping. During the examination, the patient was fully consciousness and upset, with a noticeable trismus, oculogyric reaction, torticollis, tongue protrusion and dysphonia. Vital signs at admission: BP 100/60 mmHg, HR 120/minute, SpO2 98%, blood glucose level 5.6 mmol/l. ECG noted signs of sinus tachycardia. The patient was transported to the hospital, with the i.v infusion of 500ml 0.9% NaCl solution and with oxygen support of 3l/min. According to the medical documentation, the patient was hospitalized and treated with i.v. Diazepam and saline infusions. Two days after hospitalization, the patient was released home in a stable condition. Conclusion: We must be careful with an uncritically usage of metoclopramide because of possible extrapyramidal side effect. Drug induced dystonia is a potentially life-threatening condition, and it is important to recognize and timely take care of such a condition in EMS.

Seizure Mimics: Oculogyric Crisis Following Metoclopramide-Video

A 9-year-old girl who experienced a seizure disorder was referred to our hospital by a medical practitioner. She presented with recurrent episodes of upward deviation of eyes with neck pain. She had taken tab metoclopramide 10 mg every 8 hours one day before for gastroenteritis. She was aware but unable to voluntarily control the attacks. On examination, she had sustained conjugate upward and lateral deviation of the eyes (oculogyric crisis), without loss of consciousness ([Fig. 1] [Video 1]). Symptoms disappeared rapidly following administration of IV promethazine 0.5 mg/kg slowly, and she remained well during follow-up 1 week later. Oculogyric crisis (OGC) is characterized by a prolonged involuntary upward deviation of the eyes. These episodes generally last for minutes, but can range from seconds to hours. Etiology includes drug-induced reactions, hereditary and sporadic movement disorders, and focal brain zdlesions. The majority of OGC cases occurred as adverse effects of neuroleptics and antiemetics. OGC usually disappears within 24 to 48 hours of drug withdrawal. Administration of anticholinergics (benztropine) or antihistamines (diphenhydramine) can alleviate OGC within minutes. The incidence of metoclopramide-induced acute dystonias is 0.2% with female preponderance.[1] A systematic review and meta-analysis revealed that the most common adverse effects following metoclopramide in children were extrapyramidal symptoms (9%), diarrhea (6%), and sedation (6%).[2] Ozel et al reported acute dystonic reaction due to metoclopramide in a 20-year-old female, which was misinterpreted as conversion disorder and seizure.[3] Acute dystonic reactions due to metoclopramide can be confused with conversion disorders, seizures and encephalitis.[1] [3] Our patient was also referred to our center by a medical practitioner on account of a presumed diagnosis of seizure disorder.