Acute Dystonic Drug Reaction

Presentation

The patient with a dystonic reaction to a neuroleptic or other agent typically presents to the emergency department (ED) or urgent care center with posturing, facial grimacing and involuntary muscle movements, and/or difficulty speaking. Pain is minimal, if at all. The jaw, tongue, lip, throat, and neck muscles are frequently involved. Hyperextension and lateral deviation of the neck along with upward gaze is a classic presentation ( Fig. 1.1 ). Often no history is available. The patient may not be able to speak, may not be aware of taking any phenothiazines or butyrophenones (e.g., Haldol that has been used to cut heroin), may not admit to using an illicit drug or psychotropic medication, or may not make the connection between the symptoms and drug use (e.g., one dose of Compazine given to treat nausea or vomiting). The drugs that are most likely to produce a classic dystonic reaction are prochlorperazine (Compazine), haloperidol (Haldol), chlorpromazine (Thorazine), promethazine (Phenergan), and metoclopramide (Reglan), but the list is long and includes some common agents such as benzodiazepines and antihistamines. Acute dystonia usually presents with one or more of the following types of symptoms:

• Buccolingual—protruding or pulling sensation of the tongue

• Torticollis—twisted neck or facial muscle spasm

• Oculogyric—roving or deviated gaze

• Tortipelvis—abdominal rigidity and pain

• Opisthotonic—severe hyperextension of entire spinal column

Acute dystonia can resemble partial seizures, the posturing of psychosis, or the spasms of tetanus, strychnine poisoning, or electrolyte imbalance.

More chronic neurologic side effects of phenothiazines, including the restlessness of akathisia, tardive dyskinesia, and parkinsonism, do not usually respond as dramatically to drug treatment as does acute dystonia. Onset of oculogyric crisis and torticollis reactions usually occurs within a few minutes or hours but may occur 12 to 24 hours after treatment with a high-potency neuroleptic such as haloperidol.