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Donepezil-Induced Cervical Dystonia in Alzheimer's Disease: a Case

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Donepezil-Induced Cervical Dystonia in Alzheimer's Disease: a Case □ CASE REPORT □ Donepezil-induced Cervical Dystonia in Alzheimer’s Disease: A Case Report and Literature Review of Dystonia due to Cholinesterase Inhibitors Ken Ikeda, Masaru Yanagihashi, Masahiro Sawada, Sayori Hanashiro, Kiyokazu Kawabe and Yasuo Iwasaki Abstract We herein report an 81-year-old woman with Alzheimer’s disease (AD) in who donepezil, a cholinesterase inhibitor (ChEI), caused cervical dystonia. The patient had a two-year history of progressive memory distur- bance fulfilling the NINCDS-ADRDA criteria for probable AD. Mini-Mental State Examination score was 19/30. The remaining examination was normal. After a single administration of donepezil (5 mg/day) for 10 months, she complained of dropped head. Neurological examination and electrophysiological studies sup- ported a diagnosis of cervical dystonia. Antecollis disappeared completely at 6 weeks after cessation of done- pezil. Dystonic posture can occur at various timings of ChEI use. Physicians should pay more attention to rapidly progressive cervical dystonia in ChEI-treated AD patients. Key words: Alzheimer’s disease, cholinesterase inhibitor, donepezil, cervical dystonia, dropped head, Pisa syndrome (Intern Med 53: 1007-1010, 2014) (DOI: 10.2169/internalmedicine.53.1857) Introduction Case Report Tardive dystonia syndrome is known as the complication An 81-year-old woman developed a progressive global in- of prolonged treatment with antipsychotic medications, par- tellectual deterioration for two years and visited our depart- ticularly classic antipsychotics. Pisa syndrome or pleurotho- ment. The first score of Mini-Mental State Examination tonus is a distinct form of tardive dystonia characterized by (MMSE) was 19/30. The remaining neurological examina- abnormal, sustained posturing with flexion of the neck and tion was normal, showing no parkinsonism. The patient was head to one side (1). This syndrome has been described pri- diagnosed with probable AD according to the NINCDS- marily as an adverse effect of neuroleptic drugs (1-3). ADRDA criteria (8). There was no prior history of halluci- Cholinesterase inhibitors (ChEIs) are widely used in patients nation, depression, extrapyramidal disorders or medication with Alzheimer’s disease (AD). This medication rarely with neuroleptics, antiepilepics or antiemetics. Treatment causes Pisa syndrome in patients with dementia with Lewy with donepezil (5 mg daily) was started, and the dementia bodies (4), multiple system atrophy (5) and AD (6, 7). We remained stable for nine months. At that time, MMSE score herein report a patient with AD who developed cervical was 18. Ten months after donepezil administration, the pa- dystonia after a single administration of donepezil and re- tient suddenly noticed dropped head. Antecollis worsened view the literature regarding ChEI-associated dystonia in AD for two weeks. Neurological examination revealed a severe patients. degree of anterior flexion and dystonic spasm in the neck (Fig. 1A). Other cranial nerves were normal. A slight degree of anterior flexion of the upper trunk was present at walk- Department of Neurology, Toho University Omori Medical Center, Japan Received for publication October 4, 2013; Accepted for publication November 12, 2013 Correspondence to Dr. Ken Ikeda, [email protected] 1007 Intern Med 53: 1007-1010, 2014 DOI: 10.2169/internalmedicine.53.1857 dementia. Treatment with memantine hydrochloride (5 mg/ day) was initiated, and the dose was gradually increased to 20 mg/day without adverse effects. The patient has been fol- lowed carefully at our outpatient department. Discussion We herein reported the case of an AD patient who devel- oped cervical dystonia during a single administration of donepezil (5 mg/day) for 10 months. Dystonia was im- proved at 6 weeks after donepezil discontinuation. Pisa syndrome (pleurothotonus) is an acquired, persistent truncal dystonia from the cervical to lumbar musculature that appears to be reversible. The distinct posture is charac- terized by an involuntary side flexion on either side of the body and head with a backward axial rotation. The patient looks like the leaning tower of Pisa. Ekbom et al. (1) first Figure 1. Photograph of cervical dystonia in the present pa- described this syndrome as a rare adverse effect of long- tient. A) Marked anterior flexion of the neck during donepezil term classic neuroleptic medication. Pisa syndrome can be treatment. B) Normal neck position at 6 weeks after donepezil triggered by other medications, including antiemetics, val- withdrawal. proic acid, lithium and atypical antipsychotics (9-11). The single or additional administration of ChEIs also causes this ing. The patient’s muscle strength and muscle stretch re- syndrome (6, 7, 12-22). Previous cases of ChEI-induced flexes were normal. Plantar responses were flexor. There dystonia who had no other central nervous system (CNS)- were no extrapyramidal signs in the trunk and the four ex- acting medications are summarized in Table. Truncal dysto- tremities. The sensory, cerebellar and autonomic systems nia, so-called Pisa syndrome, was present in 11 of 13 pa- were normal. Routine laboratory studies were unremarkable tients (6, 7, 13, 15-17, 20). Two patients developed cervical and serum levels of creatine kinase were within the normal dystonia, resulting in antecollis (19) or torticollis (22). The range. Chest X-ray, electrocardiography and carotid ultra- underlying pathophysiology of drug-induced dystonia is sonography were normal. Brain magnetic resonance imaging complex. The functional imbalance between the dopaminer- (MRI) disclosed a mild to moderate degree of cortical atro- gic and the cholinergic system could play a major role in phy predominantly in the temporal lobe. Electroencephalo- the pathogenesis of Pisa syndrome. Acetylcholine and gram and cervical cord MRI were unremarkable. MRI dopamine might contribute to axial muscle tone. Decreased showed no signal changes in the extensor and the flexor dopaminergic neurotransmission and/or excessive cholinergic muscles of the neck. Gallium scintigraphy of whole body neurotransmission whave been speculated to be present in revealed no abnormal accumulation. 123 I- ( 3 meta ) - patients with Pisa syndrome. Serotonergic or noradrenergic iodobenzylguanidine myocardial scintigraphy showed an dysfunction has also been implicated in the dystonic mecha- early and delayed heart/mediastinum ratio of 1.89 and 1.96, nism. The frequency of ChEI-induced Pisa syndrome re- respectively. Motor and sensory nerve conduction studies mains unclear because randomized clinical trials have not were within the normal ranges. F-wave was elicited well in investigated the long-term adverse reactions of ChEIs. the median, the ulnar and the tibial nerve. Needle electro- Highly selected patients who had younger age, better cogni- myography (EMG) was normal in the neck extensor, the tive status and no other CNS-acting drugs are typically in- sternocleidomastoid, the anterior scalenus and the trapezius cluded in randomized trials of ChEIs. In general, the risk muscle. Surface EMG revealed persistent muscle contraction factors for developing Pisa syndrome include a female gen- discharges in the right and the left sternocleidomastoid, an- der, old age, organic brain disease, combined pharmacologic terior scalenus and trapezius muscles at rest (Fig. 2A). treatment and previous treatment with classic neurolep- These electrophysiological findings supported the diagnosis tics (9, 23, 24). These clinical features are also comparable of cervical dystonia. Donepezil-triggered cervical dystonia in patients with ChEI-associated dystonia (6, 7, 12-22). In was suspected, and this medication was discontinued. At 2 contrast, the patient backgrounds in randomized ChEI trials weeks after cessation of donepezil, antecollis was attenuated. seem to differ from the predisposing factors of Pisa syn- Dystonia recovered completely at 6 weeks after the with- drome. Only a few previous studies estimated the incidence drawal of donepezil (Fig. 1B). Surface EMG revealed no or the prevalence of Pisa syndrome (16, 23, 24). A Canadian persistent muscle contraction discharges in the sternocleido- study surveyed all newly admitted psychogeriatric patients mastoid, the anterior scalenus and the trapezius muscle over a 5-year period and reported a prevalence of 8.3%, (Fig. 2B). The patient’s family strongly requested a substi- 6.4% in men and 9.3% in women (23). A German tute medication for ChEI in order to slow the progression of study (22) showed 17 patients among a population of 1008 Intern Med 53: 1007-1010, 2014 DOI: 10.2169/internalmedicine.53.1857 Figure 2. Surface EMG of the neck muscles. A) Persistent muscle contraction discharges were ob- served on both sides of the sternocleidomastoid, anterior scalenus and trapezius muscles at rest. B) The persistent muscle contraction discharges disappeared following the recovery from antecollis. Table. Clinical Features of ChEI-associated Dystonia in AD Patients Treated without Other CNS-acting Drugs Age/gender Country ChEI Duration of ChEI Prognosis of dystonia after ChEI withdrawal Recurrence of dystonia after Reference treatment ChEI re-administration 57 years/male Japan Donepezil 1 month Improvement at 1 week Donepezil 13 72 years/female Spain Donepezil 2 months Improvement at 16 days 72 years/female Sardinia Galantamine 1 month Improvement after injections of botulinum toxin 15 83 years/female Italy Rivastigmine 5 months Improvement at 16 days Donepezil 16 84 years/female Italy Donepezil
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