Dystonic Reactions


Article Author:
Kevin Lewis


Article Editor:
Carla O'Day


Editors In Chief:
David Wood
Andrew Wilt
Mary Cataletto


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Pritesh Sheth
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes
Kavin Sugumar


Updated:
3/23/2019 12:14:41 AM

Introduction

An acute dystonic reaction is characterized by involuntary contractions of muscles of the extremities, face, neck, abdomen, pelvis, or larynx in either sustained or intermittent patterns that lead to abnormal movements or postures. The symptoms may be reversible or irreversible and can occur after taking any dopamine receptor-blocking agents. The etiology of acute dystonic reaction is thought to be due to dopaminergic-cholinergic imbalance in the basal ganglia. Reactions usually occur shortly after initiation of an offending agent or an increased dose of a possible offending agent. Anticholinergic agents and benzodiazepines are the most commonly used agents to reverse or reduce symptoms in acute dystonic reaction. Acute dystonic reactions are often transient but can cause significant distress to the patient. Although rare, laryngeal dystonia can cause life-threatening airway obstruction.

Etiology

Antipsychotic and antiemetic agents are among the most commonly described causative agents of acute dystonic reactions. Other agents including anti-malarial, antidepressants, antihistamines, and anticonvulsants have also been implicated in cases of acute dystonic reaction. Antipsychotic agents with a dopamine-blocking mechanism are commonly used to treat acute psychosis, acute agitation, bipolar mania, and many other psychiatric conditions. All currently known antipsychotic medications carry a risk of causing an acute dystonic reaction. First-generation antipsychotics including haloperidol and thioridazine are associated with a higher risk of acute dystonic reaction. Second-generation antipsychotics including olanzapine, risperidone, and quetiapine are associated with a reduced risk of dystonic reaction which is postulated to be due to more rapid dissociation of the drugs from the D2 receptor sites. The antiemetic agents metoclopramide and prochlorperazine are also common agents leading to an acute dystonic reaction, even leading some practitioners to co-administer diphenhydramine.[1] Case reports demonstrate that drugs such as methylphenidate, albendazole, chloroquine, rivastigmine, and foscarnet have all been implicated in cases of acute dystonic reaction.[2][3][4]

Epidemiology

The incidence of acute dystonic reactions, in general, is not currently known. The incidence of metoclopramide-induced extra-pyramidal symptoms is estimated to be 1:500.[4] Risk factors for acute dystonic reaction are male gender, young age, previous episode of acute dystonia, or recent cocaine use.[5][6]

Pathophysiology

The basal ganglia are a collection of subcortical nuclei through which information from the cortex is modulated and returned to the cortex to execute a coordinated movement. Acetylcholine has grossly inhibitory effects on movement, and dopamine has grossly excitatory effects of movement. Certain medications act to block dopamine receptors, leading to a potential pro-movement state. Acute dystonic reactions are postulated to be a result of an imbalance of anticholinergic and dopaminergic effect in this pathway.[7]

History and Physical

Below are descriptions of the well-defined presentations of acute dystonic reactions.[8][9][10]

  • Buccolingual Crisis - trismus, risus sardonicus, dysarthria, dysphagia, grimacing, tongue protrusion.
  • Oculogyric Crisis - spasm of the extraocular muscles, most commonly deviated upward.
  • Torticolic Crisis - abnormal asymmetric head or neck position.
  • Tortipelvic Crisis - abnormal contractions of the abdominal wall, hip, and pelvic musculature. 
  • Opisthotonic Crisis - characteristic flexion posturing with arching of the back
  • Laryngeal Dystonia - dysphonia, stridor
  • Pseudomacroglossia - patient describes sensation of tongue swelling and protrusion. 

Evaluation

Evaluation of the patient with acute dystonic reaction should be performed with the same basic steps as any other acute presentation including assessment of airway, breathing, and circulation. Subtle signs such as dysphonia or complaints of throat discomfort following administration of a potential offending agent should raise suspicion of laryngeal dystonia. Definitive airway management with intubation should be considered in any patient who appears to be having difficulty protecting their airway or failing to ventilate or oxygenate. A thorough history and physical exam should be performed, looking for signs of other acute conditions including stroke and seizure. Special attention should be given to recently administered medications, and they should be reviewed for potential dopamine-blocking effects. Drug paraphernalia or the presence of, or report of, illicit substances may raise suspicion that the patient’s drugs may have been cut or spiked with an offending pharmacologic agent.[11] In cases of acute dystonic reaction, mental status and vital signs should remain normal.

Treatment / Management

Treatment of acute dystonic reaction centers around balancing the disrupted dopaminergic-cholinergic balance in the basal ganglia and discontinuation of the offending agent. The most commonly available drugs in the emergency setting for the treatment of acute dystonic reaction are diphenhydramine and benztropine. Symptoms usually improve or resolve dramatically within 10 to 30 minutes of administration of parenteral anticholinergics. The half-life of most antipsychotic agents is longer than that of most diphenhydramine or benztropine requiring re-dosing of anticholinergic medications.

Supportive measures such as oxygen or assisted ventilation should be provided immediately if indicated.

Diphenhydramine is used for its anticholinergic effect and central nervous system (CNS) penetration. Intravenous administration is preferred to intramuscular administration due to its faster onset. Typical dosing for diphenhydramine is 50 mg intravenous (IV) in adults and 1 mg/kg up to 50mg IV in pediatric patients. Once the acute dystonic reaction is treated and symptoms improve, diphenhydramine should be administered via the oral route every 6 hours for 1 to 2 days to prevent recurrence of symptoms.

Benztropine is another anticholinergic medication with significant CNS penetration. Use, however, may be limited due to availability in the emergent setting. IV and intramuscular (IM) routes are of similar time to onset of effect.  Typical dosing of benztropine is a single dose of 1 to 2 mg IV followed by 1 to 2 mg by mouth twice a day for up to 7 days to prevent recurrence. Benztropine use in pediatric patients for acute dystonia is considered off-label.

Second-line therapy with IV benzodiazepines may be considered for patients that fail to respond completely to anticholinergic therapy. IV or IM lorazepam at 0.05 to 0.10 mg/kg or IV diazepam at 0.1 mg/kg may be considered.

Patients who experience respiratory symptoms or required supportive oxygen should be observed for 12 to 24 hours following resolution of symptoms to monitor for recurrence.

For patients that experienced an acute dystonic reaction on an antipsychotic medication, close follow-up with psychiatry should be given. If the continuation of the offending agent is necessary, the patient should be continued on an anticholinergic medication until an agent with less potential for a dystonic reaction can be initiated.

Differential Diagnosis

The following are conditions that may mimic the acute dystonic reaction: conversion disorder, tetanus, focal seizure, strychnine poisoning, hypocalcemia, anticholinergic toxicity, meningitis, neuroleptic malignant syndrome, stroke, temporomandibular joint dislocation, mandibular fracture, orbital fracture, and clonus.

Enhancing Healthcare Team Outcomes

As with any acute medical condition, close communication between patients, physicians, nurses, and other healthcare team members is essential to the early recognition and treatment of acute dystonic reactions. Nurses, pharmacists, and physicians should be familiar with the symptoms of an acute dystonic reaction and monitor patients closely for adverse reactions following the administration of medications known to cause acute dystonic reactions.

Evidence presented in this article is derived mostly from case series and expert opinion. (Level III)


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Dystonic Reactions - Questions

Take a quiz of the questions on this article.

Take Quiz
A 35-year-old male was seen in the emergency department with a complaint of intractable vomiting. His symptoms decreased after he was given a medication for which he cannot remember the name. He reports developing sudden onset, flexion contracture of his neck shortly after discharge. What is the most likely mechanism of this condition?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old female with persistent vomiting is treated with prochlorperazine and develops lip smacking and tongue protrusion. What is the most likely diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 10-year-old male is brought to the emergency department by his mother after ingesting a pill left by his grandfather at his home. He has spasms of his neck and twisting of his neck muscles. The patient is given 50 mg of diphenhydramine intramuscularly and the spasms immediately stop. Which of the following drugs do you suspect the patient ingested?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 9-year-old female develops spasms of her neck and arms after receiving prochlorperazine in the emergency department. What is the most likely diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
An adult patient who is taking an antipsychotic medication develops early symptoms of a dystonic reaction. What is the most appropriate intervention?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A rapid response is called on the medical-surgical floor for a 42-year-old female that recently underwent a cholecystectomy. The patient was found by her nurse with her eyes deviated upwards bilaterally and having difficulty speaking. Her blood glucose level is 122 mg/dL. Her heart rate is 89 beats/min, respiratory rate 13, blood pressure 126/72 mmHg, and SpO2 99% on room air. The patient is alert and following commands. Her nurse is concerned the patient may have had a stroke. Records show the patient received metoclopramide and morphine within the last 30 minutes ordered by the patient’s surgeon. You suspect an acute dystonic reaction secondary to metoclopramide administration. Which of the following is characteristic of an acute dystonic reaction?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following medications is an appropriate first-line therapy for acute dystonic reaction?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old male presents to the emergency department with acute neck contraction for the last 2 hours. His mother reports he was watching television at the onset of symptoms. The patient has a history of intrusive auditory hallucinations and was recently started on a new antipsychotic medication. What is the most likely diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is considered a risk factor for acute dystonic reaction?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Symptoms of acute dystonic reaction fail to resolve with parenteral diphenhydramine. What other class of drugs can be used to treat acute dystonic reaction?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Dystonic Reactions - References

References

Incecik F,Hergüner MO,Ozcan K,Altunbaşak S, Albendazole-induced dystonic reaction: a case report. The Turkish journal of pediatrics. 2011 Nov-Dec     [PubMed]
Tekin U,Soyata AZ,Oflaz S, Acute focal dystonic reaction after acute methylphenidate treatment in an adolescent patient. Journal of clinical psychopharmacology. 2015 Apr     [PubMed]
Tianyi FL,Agbor VN,Njim T, Metoclopramide induced acute dystonic reaction: a case report. BMC research notes. 2017 Jan 7     [PubMed]
Wijemanne S,Jankovic J,Evans RW, Movement Disorders From the Use of Metoclopramide and Other Antiemetics in the Treatment of Migraine. Headache. 2016 Jan     [PubMed]
Sykes DA,Moore H,Stott L,Holliday N,Javitch JA,Lane JR,Charlton SJ, Extrapyramidal side effects of antipsychotics are linked to their association kinetics at dopamine D{sub}2{/sub} receptors. Nature communications. 2017 Oct 2     [PubMed]
Albanese A, How Many Dystonias? Clinical Evidence. Frontiers in neurology. 2017     [PubMed]
Barow E,Schneider SA,Bhatia KP,Ganos C, Oculogyric crises: Etiology, pathophysiology and therapeutic approaches. Parkinsonism     [PubMed]
Digby G,Jalini S,Taylor S, Medication-induced acute dystonic reaction: the challenge of diagnosing movement disorders in the intensive care unit. BMJ case reports. 2015 Sep 21     [PubMed]
Barach E,Dubin LM,Tomlanovich MC,Kottamasu S, Dystonia presenting as upper airway obstruction. The Journal of emergency medicine. 1989 May-Jun     [PubMed]
Pinto JM,Babu K,Jenny C, Cocaine-induced dystonic reaction: an unlikely presentation of child neglect. Pediatric emergency care. 2013 Sep     [PubMed]
Deik A,Saunders-Pullman R,Luciano MS, Substance of abuse and movement disorders: complex interactions and comorbidities. Current drug abuse reviews. 2012 Sep     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Pediatric. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Pediatric, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Pediatric, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Pediatric. When it is time for the Pediatric board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Pediatric.