Quetiapine‐induced Dystonia and Agitation in Parkinson's Disease With Dementia: A Case Report

Abstract

poses a risk for extrapyramidal symptoms. Quetiapine is considered first line, because it appears to have the lowest risk. The following describes the case of a patient with PD who developed dystonia after only one dose of quetiapine. DESCRIPTIONAn 80-year-old Caucasian man with a 4-year history of idiopathic PD with dementia had new-onset hallucinations, describing ''cats in the walls,'' 2 weeks before presentation. This escalated to aggressive behavior toward his wife and falls that resulted in hospitalization.His past medical history was remarkable for PD since 2003, a diagnosis of dementia in 2006, and hypertension. He was dependent in activities of daily living except eating. Medications were carbidopa/levodopa, 25/100 mg 1.5 tab three times a day; verapamil; hydrochlorothiazide/triamterene; fosinopril; citalopram; and trazodone.At admission, he had stable vital signs, and he was alert and awake, but with limited attention. Oriented to person only, he was unable to answer most questions appropriately. Physical examination was remarkable for cog wheeling and rigidity in all four extremities. Laboratory studies upon admission showed a blood urea nitrogen of 20 mg/dL and serum creatinine of 1.8 mg/dL.His mental status improved with intravenous hydration, but the aggressive behavior continued. A trial dose of quetiapine 12.5 mg orally was given. Within 3 hours of administration, the patient became more restless with increased muscle tone, twitching and spasms of arms and legs, and contracture-like positioning, but he remained afebrile with stable vital signs. Evaluation was negative for stroke, seizure, infection, or cardiac disease, suggesting a reaction to quetiapine manifested as dystonia and restlessness. Quetiapine was discontinued, and lorazepam was used to control agitation and relax the musculature. Dystonic symptoms improved within 48 hours, and after stabilization of other medical problems, the patient was transferred to a skilled nursing facility for ongoing care. DISCUSSIONThe presence of hallucinations a few weeks before hospitalization led to a presumptive diagnosis of LBD. Patients with LBD are sensitive to the emergence of extrapyramidal symptoms such as akathisia, rigidity, and dystonia associated with antipsychotics. The interaction between an atypical antipsychotic such as quetiapine and an abnormal basal ganglia system, along with use of dopaminergic agents, could cause this dystonic reaction, as suggested by the time course. In addition, this patient was taking a selective serotonin reuptake inhibitor, which has also been associated with extrapyramidal symptoms. 1 The addition of quetiapine could prompt a detrimental serotoninergicdopaminergic imbalance. 2 In the case of this patient, reversibility of dystonia after quetiapine discontinuation suggests causality.Based on review of the literature, this is the third case reported of a patient with PD and new-onset hallucinations suggestive of LBD who developed a dystonic reaction after quetiapine. This patient was similar to a previous case, a ...

Dyskinesias and impulse control disorders in Parkinson's disease: From pathogenesis to potential therapeutic approaches

“…The 5-HT 2A non-selective antagonists clozapine and quetiapine have also shown good anti-dyskinetic potential in some but not all preclinical and clinical studies (Baron and Dalton, 2003;Durif et al, 2004;Katzenschlager et al, 2004;Leey et al, 2009;Oh et al, 2002;Visanji et al, 2006). This is despite the fact that they are non-selective drugs that interact with dopaminergic and adrenergic receptors (Newman-Tancredi and Kleven, 2011), making it difficult to assess the molecular mechanisms by which they act to reduce the severity of LID (Huot et al, 2013).…”

“…Controversial results (Baron and Dalton, 2003;Katzenschlager et al, 2004;Leey et al, 2009) Controversial results (Kurlan, 2004;Raja and Bentivoglio, 2012) Clozapine D4R and 5-HT 2A antagonist in a doble-blind placebo-controled trial (Durif et al, 2004) PG in a case report (Rotondo et al, 2010) DDS in a retrospective case-control study (Cilia et al, 2014) repetitive behavior in a case report (Kurlan, 2004) ICD reported in authors' experience (Raja and Bentivoglio, 2012) Citalopram SSRI binge eating, hypersexuality and compulsive shopping in pilot studies (Koran et al, 2003;McElroy et al, 2003;Wainberg et al, 2006) Fluoxetine SSRI in a open-label study (Durif et al, 1995) binge Controversial results (Mestre et al, 2013;Thomas et al, 2010) PG in a case report (Pettorruso et al, 2012) (Manson et al, 2001;Rascol et al, 1994) recurrent PG in a case report (Bosco et al, 2012) impulsivity in a phase III clinical trial (Papay et al, 2014) substance addiction in several studies (Adi et al, 2007;King et al, 2013;Morgenstern et al, 2012;Tiihonen et al, 2012) PG (Grant et al, 2008) and hypersexuality (Bostwick and Bucci, 2008;Raymond et al, 2010) Nalmefene…”

Quetiapine-induced cervical dystonia

“…Doses varied between 12.5mg and 400mg and onset at between three hours and two weeks of quetiapine commencement. [6][7][8][9] This case presents someone who was vulnerable to antipsychotic side effects, having developed EPSEs while on risperidone and quetiapine. Prior use of risperidone may have potentially sensitized the patient to developing dystonia on quetiapine.…”

An Acute Dystonia Case Induced by Addition of Quetiapine With a Single Dose on Fluoxetine and Trazodone

“…22 The appearance period of quetiapine induced dystonia and its relation with dose show differences in related reports. [13][14][15][16][17][18] Generally when there appears to be no organic defect in the base with quetiapine induced dystonia cases the dose is approximately 400-600mg/day with a duration of 2-4 weeks, 14,15 but in the presence of a defect in the base (such as Parkinson's Disease, head trauma) a very low dose such as 12.5 mg and a very short time, 13 or rather high dose and a very short period of time dystonia is induced.…”

“…12 Solely there are a few dystonia cases reported connected to quetiapine. [13][14][15][16][17][18] Combined drug usage causes interactions such as increasing or decreasing effectiveness of pharmacologic agents, and in turn it is a wellknown fact that many side effects are potentialized. Hereby, in the reported case we discussed a dystonia case in which dystonia emerged as a result of combined usage of antidepressant and atypical antipsychotic agents.…”