734 CORRESPONDENCE [Sept. OPISTHOTONUS IN DRUG-INDUCED calcification in hypo-parathyroidism was not con DYSTONIC SYNDROME sidered to be the cause of tonic convulsive in as the calcffication persisted after the con DaAR SIR, dition had been treated and it was concluded that it The occurrence of opisthotonus that responded could not have been responsible for the tetany in the dramatically to the I.V. administration of an anti firstplace (EatonandHaines, 1939; Siglinetal., 1957). parkinsonian drug has recently been described in a Since it is doubtful whether the calcification case of tranquilizer poisoning (Lichtigfeld, Brit. J. in the basal ganglia is a cause of the extra-pyramidal Psychiat., March, 1964, pp. 226-227). Lesser grades symptoms in some cases of hypo-parathyroidism, the of postural deviation such as tonic may be possibility exists that hypo-calcaemia can disrupt followed by tonic convulsive seizures and opisthotonus. nerve cell function in the basal ganglia. rt has also The latter posture is characteristic of a transverse been suggested that cases of tetany resulting after mid-brainlesioncausingdecerebrate rigidity (Walton, encephalitis lethargica (Zondek, ig@), and brain ig6i). The brain stem has also been implicated in injury (Winer, ‘¿945)were due to lesions in the the regulation of posture, and anomalies of the diencephalon interfering with the central regulation posture of the trunk (dystonia) may result from of calcium metabolism. pathology in this region (Monnier and Levy, igflo). The tranquilizers causing extra-pyramidal syn Disturbances of the basal ganglia are also involved dromes may produce their effects by their action on in the causation of involuntary movements, muscular calcium metabolism, and, conversely, calcium rigidity and abnormal postural fixations (Purdon administration may have an ameliorating effect on Martin, ig6o). Experimentally, medial thalamic drug-induced parkinsonism. It has been found that stimulation can produce opisthotonus (Monnier and the acetyicholine content of the extra-pyramidal Tissot, 1958). Thus different mechanisms are prob system is increased when reserpine is given in doses ably responsible for producing opisthotonus invarious large enough to cause drug-induced parkinsonism, clinical states. Although it is probably worth while to while the anti-parkinsonism drugs may be said, in treat opisthotonus occurring in conditions such as general, to have some sort of anti-acetylcholine rabies, poisoning and by anti action (Byisma, 1963). Calcium is necessary for the parkinsonian drugs, it remains to be seen whether action of cholinesterase to take place and in this way this treatment will have a beneficial effect in these is a factor in regulating acetyl choline metabolism, conditions. while it also has an anti-allergic and sedative action Opisthotonus has been produced experimentally by (Sandoz, 1952); actions which resemble some of the inducing in pigeons (Peters, properties of the drugs used to combat parkinsonism. ‘¿959),and by intra-cisternal injection of isotonic As a large number of drugs are capable of con citrate in dogs, presumably leading to a deficiency of trolling drug-induced dystonias resulting from ionized calcium (Huggins and Hastings, 1933). tranquilizers, it is likely that their actions may be Another condition that can produce a clinical picture mediated at the synapse. The basis for this may lie of opisthotonus is tetany (Barker, 1922). All the signs in the altered ionic equilibrium produced there. of autonomic stimulation observed in the drug Alternatively, these drugs may act on the nerve cells induced dystonic syndrome are also seen in tetany that regulate calcium metabolism. rt is suggested that (Zondek, ‘¿944),while tonic spasms of the laryngeal calcium may control some of the extra-pyramidal muscles can occur in both conditions. Tonic con symptoms caused by tranquilizers. vulsive seizures without loss of consciousness are also F. J. LrCHTIGFELD, B.Sc.,M.B. B.Ch. suggestive of hypo-calcaemic tetany, while patients suffering from disease of the basal ganglia may have 22 Oxford Road, Parktown, athetoid spasms of the hands and feet nearly identical Johannesburg,SouthAfrica. with carpo-pedal spasms of hypo-calcaemia (Talbot ci al., 1952). Extra-pyramidal symptoms have also REFERENCES been described in association with hypo-parathyroid BARKER, L. F. (1922). Endocrinology and Metabolism. Vol. i. jam (Simpson, 1952 ; Sugar, 1953 ; Doherty ci al., London : Appleton. Byi.sr@, U. G. (5963). Leech, 33, 95. 1962), and calcium deficiency states (Nesbit, 1935). DENNY BROWN, D. (1962). The Basal Ganglia. Oxford The extra-pyramidal symptoms occasionally reported University Press. in hypo-parathyroidism may be associated with DOHERTY, 0., CANARY, J. J., and Kyi@, L. H. (1962). calcffication of the basal ganglia, although most “¿Neurological Aspects of Endocrine Disorders―, in cases showing this calcification do not exhibit any Clinical Neurolog,. 2nd edition (ed. Barker, A. B.). such symptoms (Denny Brown, 1962). The cerebral Hoeber and Harper.

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EATON, L. M., and H@ns, S. F. (i@@). 3. Amer. Med. PURDON MARTIN, J. (1960). Papers on Hezeiballhsinus, Ass., 113, 749. Q@iecuSquare, London. Huooiz.is, C. B., and HASTINGS, A. B. (i@). In Sandoz Sandoz Monograph on Calcium (1952). monograph on Calcium (1952). Siour.i, I. S., EATON,L. M., [email protected]',J.D., and H.#ur@zs, S. F. (ig@7).7. din. Endocrin.,7, 433. LIOHTIGFELD, F. J. (i@6@). Brit. 3. Psjchiat., iso, 226. SIMPSON,J.(1952). Brain, 75, 76. @ Monmaa, M., and Lsvv, A. (igflo). Sc/wxiz.Arch..Weurol. SUGAR,0. Arch. Xeurol. Psjchiat., @o,86. Psychiat., 85, 200. TALBOT, N. B., SOBEL, E. H., McAamua, J. W., and CRAWFORD, J. D. (1952). Fwwtional Endocrinol@j, —¿ and TISSOT, R. (1958). In Neurological Basis of Be haviour. London: Churchill. Ch. 2. Harvard University Press. WALTON,J. N. (i@6i). Essentials of Xeurologj. Ch. 9. Nzsnrr, H. T. (i@@). Amer. 3. Dis. Child., 49, 1449. London : Pitman. @ PETERs, R. A. Biochemical Aspects of Xeurological WINER,N. J. (i@). 3. din. Endocriz., @,86. Disorders (ed. Cumings, J. N., and Kremer, M.). ZONDEK, H. (i@). The Diseases of the Endocrine Glands. Oxford. 2nd edition. London : Arnold.

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