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Dr.Wagner -> RE: February case (February 5, 2008 8:38:21 AM)
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Acute Dystonic Reaction
This patient snorted medication that he got from a friend, not an uncommon occurance, thinking this medication was vicodin. It was likely an antidepressant or an antipsychotic such as Geodon or Zyprexa.
Patients often times snort narcotics to get a quicker high...
In this case, the acuity of onset, and the hallmark presentation are the keys.
No testing is necessary, only an acurate history and treatment.
- Physical examination findings may include any of the following:
- Oculogyric crisis, deviation of eyes in all directions
- Buccolingual crisis
- Protrusion of tongue
- Trismus
- Forced jaw opening
- Difficulty in speaking
- Facial grimacing
- Torticollis, usually associated with oculogyric and buccolingual crisis
- Opisthotonic crisis
- Lordosis or scoliosis
- Tortipelvic crisis - Typically involves hip, pelvis, and abdominal wall muscles, causes difficulty with ambulation
- Mental status is unaffected.
- Vital signs are usually normal.
- Remaining physical examination findings are normal.
Pathophysiology Although dystonic reactions are occasionally dose related, these reactions are more often idiosyncratic and not predictable. They appear to result from drug-induced alteration of dopaminergic-cholinergic balance in the nigrostriatum (ie, basal ganglia). Most drugs produce dystonic reactions by nigrostriatal dopamine D2 receptor blockade, which leads to an excess of striatal cholinergic output. High-potency D2 receptor antagonists are most likely to produce an acute dystonic reaction. Agents that balance dopamine blockade with muscarinic M1 receptor blockade are less likely to produce a dystonic reaction. Paradoxically, an alternative cause of dystonic reactions may be increased nigrostriatal dopaminergic activity that occurs as a compensatory response to dopamine receptor blockade.
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