Onuma, Kalu MD

PGY 4
 CASE PRESENTATION
 IDENTIFYING PROFILE.

 25 years old married Caucasian female who lives with

her husband and their 5 years old son and 3 years old
daughter in Kingsport, TN
CLINICAL PRESENTATION
 Sustained upward deviation of eyes.
 Mutism
 Restlessness
 Agitation
 Behavioral disturbance.
 Pupil dilation
 Backward flexion of neck.
 HPI
 Patient had been in apparent good health until the
death of her father in law, from which time she
became increasingly depressed, not eating and
sleeping well.

 Was subsequently admitted to psych hospital to

address worsening psychosis and mood symptoms.

 Was rushed to the ER for evaluation and treatment of

sudden onset of AMS after 48 hours of hospitalization
in the psych facility for Psychosis NOS.
 MEDICATION HISTORY.
Ambien orally 10mg QHS, Ativan taper.
Abilify PO 5mg x 1
Geodon IM 10mg bid(
Haldol IM 5mg q8hours prn(
Thorazine IM 25mg x 1

 PAST PSYCHIATRY HISTORY.

Significant for polysubstance abuse.(THC, Opiates, Benzos)
Nil previous psych hospitalization.

 PAST MEDICAL HISTORY.

None

 LABS/IMAGING STUDIES.
CMP, CBC, CT, MRI, HIV, CRP, Ammonia levels
Vit B12, Ceruloplasmin, EEG.
 DIAGNOSIS/TREATMENT
 OCULOGYRIC CRISIS

 IM Benadryl.
 PATHOGENESIS
 MIDBRAIN PATHWAYS
-Substantia nigra pars reticula---Superior Colliculi
-Substantia nigra pars compacta--Reticular formation

 BASAL GANGLIA
-subcortical component
of family of circuits{Oculomotor, Limbic, Prefrontal
Skeletal motor circuits}
 CAUSES
 MEDICATIONS
-Neuroleptics, Metoclopramide.
-Carbamazepine, lithium, PCP
-Levodopa, Amantadine, Chloroquine

 BRAIN STEM LESION

-Ischemic, Neoplastic, or Inflammatory.

 HEAD TRAUMA

 INFECTIONS
-Neurosyphylis, and Herpes Encephalitis.

 OTHERS.
-Alcohol, Emotional stress, and fatigue
-Inherited errors of metabolism
 CLINICAL FEATURES
 Involuntary, sustained deviation of the eyes.
 CLINICAL FEATURES
 Involuntary, sustained deviation of the eyes.

 Mutism, eye blinking, and pupil dilation.

 Flexion of the neck.

 Restlessness, Agitation, and Behavioral disturbances.

 Transient psychotic episodes.

-Visual hallucination.
-Auditory hallucination.

 Autonomic dysfunction.
 RISK FACTORS
 Male gender

 Young age.

 High doses

 High-potency antipsychotics

 History of substance abuse(alcohol, and or cocaine)

 Genetic susceptibility(Slow metabolizers)

 Comorbid conditions(Tourette & Parkinsonism)

 PATIENT ASSESSMENT
 Physical status.
-safety of patient and staff.
-history/collateral information.
-careful review of medications .
-review of medical records.
-physical and neurological examination.

 Mental status examination.

 DIAGNOSTIC STUDIES
 CBC
 CMP
 UDS
 VDRL
 CT
 MRI
 EEG
 EKG
 URINALYSIS
 DIFFERENTIAL DIAGNOSIS
 Seizure Disorder.

 Delirium.

 Other EPS.
-Tardive, Parkinsonism, Akathisia

 CNS lesion(focal basal ganglia or Thalamus).

 Postencephalic parkinsonism.

 Tyrosine hydroxylase deficiency.

 TREATMENT/MANAGEMENT
 Pharmacologic Intervention
-Anticholinergic medication
(Benadryl or Cogentin)

 Environmental manipulation.
-Place patient in a room near nursing station.
-Orient patient repetitively.
-Use sitter.
- Use restraints when less restrictive measures have failed.

-
COURSE(PROGNOSIS)
 Typical course usually ranges from 24-48 hours.
-upon medication withdrawal or reduction.

 Symptom relief within minutes with anticholinergics.

 Recurrent crisis maybe observed on med re-exposure.

 Excellent prognosis.
THANK YOU!
 Questions ?

 Contributions……

 References will be made available on request.

Contact: onuma@mail.etsu.edu