Case presentation

A 56 year old lady was admitted with complaint of involuntary muscle twitching around eyes, face and neck. She presented with acute onset of repetitive muscle twitch and nausea within 48 hours after completing the first cycle of chemotherapy for low grade non-hodgkin lymphoma. She was taking Ondansetron 8 mg BD and Metoclopramide 10 mg TDS. She started taking these medications 24 hours prior to appearance of above symptoms.

On admission she was anxious and worried for having stroke or seizures. There was no history suggestive of similar symptoms in past. No other significant medical illness was also noted.

Physical examination revealed transient non-specific facial muscles twitchings. Rest of the general and systemic examination was unremarkable. All baseline blood tests results (Full Blood Count, Urea and Electrolytes, Liver Function Tests), CXR and ECG findings were normal. She was clinically diagnosed as acute dystonic reactions secondary to anti-emetic medications. All the medications were discontinued and she was treated with IV procyclidine 10 mg stat followed by PO procyclidine 2.5 mg TDS. She was also commenced on PO domperidone 10 mg PRN/QDS for her nauseous feelings. Within an hour of receiving IV procyclidine her symptoms gradually improved and disappeared. She was discharged with complete recovery within 24 hour hospital admission.

Discussion

Acute dystonic reactions have different manifestations (Table 1)). These reactions are usually occured as a side effect of neuroleptic and anti-emetic medications. The clinical spectrum is poorly understood and frequently led to misdiagnosis.

Causes or triggering factors include: neuroleptics, amantadine, benzodiazepines, carbamazepine, chloroquine, cisplatin, diazoxide, influenza vaccine, levodopa, lithium, metoclopramide, nifedipine, pemoline, phencyclidine, reserpine, tricyclics, postencephalitic Parkinson's, Tourette's syndrome, multiple sclerosis, neurosyphilis, head trauma, bilateral thalamic infarction, lesions of the fourth ventricle, cystic glioma of the 3rd ventricle, herpes encephalitis, juvenile Parkinson's. It is often not realized that in addition to the acute presentation, it can develop as a recurrent syndrome, triggered by stress, and exposure to the above drugs [1].

Table 1 Manifestations of acute dystonia [2]
Full size table

Transient ischaemic attacks (TIA), focal seizures or other involuntary muscle tics and spasms should be considered in differential diagnosis. The detailed history taking and thorough neurology examination help in reaching the correct diagnosis. Imaging studies of brain should be conducted to exclude other intracranial pathology and structural abnormalities leading to the above mentioned manifestations, especially if these symptoms persist.

Treatment in the acute phase of dystonic reactions involves reassurance and treatment with Procyclidine and/or Benztropine and/or Diazepam or lorazepam. Maintenance therapy with oral forms of the above medications or amantadine are indicated in more chronic recurrent cases [1].

Conclusion

It is a distressing complication of antiemtic and antipsychotic drugs. In the acute clinical settings these unpleasant symptoms can make the patients anxious and the diagnosis can be confused with other acute medical conditions such as transient ischaemic attacks. The prompt therapeutic action is essential in its management. It is not a very rare case in the daily practice. The above case is a good example for physicians dealing with acute medical admissions during on-calls.

Consent

The valid informed consent was taken from the patient for this case report and publication.