A young male patient who is a case of schizophrenia was started on haloperidol 5 mg. On 3rd day, he came to the hospital accompanied by his father with uprolling of both eyes. A complete neurological examination revealed no spasticity or any other abnormalities. Visual acuity was found to be normal. Most likely diagnosis is:
Ans. a. Acute dystonia (Ref: Harrison 19/e p2620, 18/e p3544; Katzung 12/e p495)Bizarre muscle spasms, mostly involving tinguo-facial muscles-grimacing, torticollis, locked jaw that occurs within few hours of single dose or at the most in the first week of therapy of antipsychotic drugs (haloperidol) is highly suggestive of acute muscular dystonia.Acute Muscular Dystonia:Bizarre muscle spasms, mostly involving linguo-facial muscles-grimacing, torticollis, locked jawQOccurs within few hours of single dose or at the most in the first week of therapyQMore common in children below 10 years and in girls, particularly after parenteral administrationQTreatment: Central anticholinergicQ, promethazine or hydroxyzineNeuroleptic Induced Acute DystoniaAbout 10% of all patients experience dystonia as an adverse effect of dopamine receptor antagonist, usually in the first few hours or days of treatmentQ (early onset during the course of treatment with neuroleptics).Most common in young men (< 40 years old)Most common with high doses of high potency dopamine receptor antagonistQ especially via IM route (haloperidol is high potency drug and 20 mg/day is high dose), shortly after starting the drug or increasing its doseQ.It results from dopaminergic hyperactivity in the basal ganglia, that occurs when the CNS levels of dopamine receptor antagonist drug begin to fall between doses.Clinical Features:Dystonic movements result from a slow, sustained muscular contraction or spasm that can result in an involuntary movement. It can involve the:* Face (grimacing)Q* Neck (spasmodic torticollisQ or retrocollis)* Jaw (forced opening resulting in dislocation of jaw or trismusQ)* Tongue (protrusions, twisting)Q* Eye (oculogyric crisisQ characterized by eyes' upward lateral movement)* Dystonic posture of limb and trunkQ.* Spinal muscles (opisthotonos)Q.* Blepharospasm, glossopharyngeal and laryngopharyngeal dystonia, which can result in dysarthria, dysphagia, and even trouble breathing, which can cause cyanosisUnlike other types of dystonia, an oculogyric crisis may occur late in treatment.Children are particularly likely to exhibit opisthotonos, scoliosis, lordosis, and writhing movements.Treatment:Treatment with IM anticholinergic (benztropine) or IV/IM antihistaminic (diphenhydramine hydrochloride)Q almost always relieves the symptoms.Extra pyramidal Disturbances of anti-Psychotic drugsThese are the major dose limiting side effectsQMore prominent with high potency drugs like fiuphenazine, haloperidol. pimozide etcQ.Least with thioridazine, clozapine, olanzapine, and low doses of resperidoneQ.These are of following types:Parkinsonism:With typical manifestations-rigidity, tremor, hypokinesia, mask like facies, shuffling gaitQAppears between 1-4 weeks of therapyQTreatment: Central anticholinergic drugsQRabbit syndromeA rare form of extrapyramidal side effect is perioral tremors 'rabbit syndrome'Occurs years after of therapyTreatment: Central anticholinergic drugsQAcute muscular dystonia:Bizarre muscle spasms, mostly involving linguo-facial muscles-grimacing, torticollis, locked jawQOccurs within few hours of single dose or at the most in the first week of therapyQMore common in children below 10 years and in girls, particularly after parenteral administrationQTreatment: Central anticholinergicQ, promethazine or hydroxyzineAkathisia:Restlessness, feeling of discomfort, apparent agitation manifested as compelling desire to move about but without anxietyQBetween 1-8 weeks of therapyQNo specific antidote is availableTreatment: PropranololQMalignant neuroleptic syndrome:Occurs rarely with high doses of potent agentsQMarked rigidity, immobility, tremor, fever, semi-consciousness, fluctuating BP and heart rate, myoglobin may be present in blood-lasts 5-10 days after drug withdrawal and may be fatalQ.Treatment: Stop neuroleptic, BromocriptineQTardive dyskinesia:Occurs late in therapy (Chronic therapy ), sometimes even after withdrawal of neurolepticQManifests as purposeless involuntary facial and limb movements like constant chewing, pouting, puffing of cheeks, lip licking, choreoathetoid movementsQMore common in elderly womenQProbably a manifestation of progressive neuronal degeneration along with supersensitivity to DAAccentuated by anticholinergics and temporarily suppressed by high doses of neurolepticsQAdverse Effects of Antipsychotic Drugs* Dry mouth, blurred vision, constipation, urinary retention due to anticholinergic effectsQ, maximum with thioridazine.* Sedation maximum with chlorpromazineQ; minimum with ziprasidone* Aggravation of seizuresQ more with clozapine, olanzapine and chlorpromazine, less chances with risperidone and quetiapine.* Weight gain (with all except haloperidol).* Retinal degeneration with thioridazine.* Agranulocytosis with clozapineQ.* Cataract formation with quetiapineQ.* Cholestatic jaundice with chlorpromazineQ.* Hyperprolactinemia, amenorrhea and galactorrhoea due to D. blockade in pituitary.* Postural hypotension and inhibition of ejaculation (a-blocking property)Q
Acute dystonia
Seizures
Malingering
Akathisia
Anti-Psychotic