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Successive extrapyramidal reactions to two phenothiazines in one patient
Successiveextrapyramidal reactions to two phenothiazinesin one patient Report
of
a case
Roger A. Meyer, D.D.S., U.X.D.,” Belli?Lgham, Wash.
E
xtrapyramidal reactions to phenothiazine derivatives are by no means rare. A recent report cited nine cases of dislocation of the mandibular condyles resulting from extrapyramidal phenothiazine reactions. l Severe oral soft-tissue trauma with life-threatening sequelae has also occurred.2 These reactions are thought to be due to overdoses of the phenothiazine involved.2 The phenothiazine drugs (Compazine, Trilafon, Tigan, Phenergan, Vesprin, Stelazine, Thorazine, etc.) are well known for their antiemetic and tranquilizing properties. I1 Phenothiazine-induced reactions occur either as parkinsonian effects (postural abnormalities with varying degrees of rigidity, tremor, and salivation), motor restlessness (akathisia), or dystonia (spasms or cramping of muscle groups). The most common and most severe of the dystonic reactions involve the head and neck (neck-face syndrome). Dysarthria, dysphasia, trismus, torticollis, spasm of the masticatory muscles, protrusion of the tongue, and oculogyric crises are components of the neck-face syndrome.lO If untreated, these reactions may persist (particularly in elderly patients with brain damage) for days, weeks, or months. A review of the literature l -lo failed to reveal a case similar to the one reported here, in which a patient had successive extrapyramidal reactions to two different phenothiazine derivatives.
CASE May
REPORT
A 23.year-old woman was admitted to the emergency room of the hospital at 7 P.M. on 19, 1969, with the chief complaint of “the left jaw repeatedly slipping out of joint.”
*Staff Instructor, Vancouver,
48
Oral Surgeon, St. Luke’s General Department of Oral Surgery, Faculty B. C., Canada.
Hospita!, Bellingham, of Dentistry, University
Wash., and Clinical of British Columbia,
Extrapyramidal
Volume 30 Number 1
reactions to two phenothiazines
49
She apparently was suffering excruciating pain. The history revealed that she had visited her physician earlier in the day for treatment of an “anxiety state” and that he had prescribed Stelazine (trifluoperazine). Approximately 45 minutes after she had taken the first tablet, the patient began to experience spasms of the left side of the face and neck. These spasms and the neck muscles and resulted in the involved the tongue, the muscles of mastication, spontaneous dislocation of the left mandibular condyle. The patient had experienced previous episodes of dislocation of the mandible following the administration of phenothiazines, in which rather heroic measures were performed to reduce the dislocation. Because of these traumatic experiences, she did not seek treatment for the current episode until the pain became unbearable. The history further revealed that in July, 1968, the patient had been given Compazine (prochlorperazine) as a tranquilizer. Shortly afterward she experienced spasms of the left facial muscles and dislocation of the left mandibular condyle. She was seen by a physician, who reduced the dislocation and held it in position by means of intermaxillary fixation. The patient suffered intense pain in the left side of the face for approximately 24 hours before the muscle spasm subsided. No specific therapy was given for that extrapyramidal reaction. Physical examination revealed a well-developed, well-nourished, white woman in extreme pain. She had a grimacing facial expression with obvious spasms of the left facial and masticatory musculature. The mandible deviated to the right. The blood pressure was 144/84, and the pulse was 100, regular, and strong. The remainder of the physical examination findings were unremarkable. The clinical impression was that the patient was experiencing an extrapyramidal reaction to a phenothiazine. Accordingly, 50 mg. of Benadryl (diphenhydramine) was administered intravenously. Within 1 minute, the muscle spasms subsided and the mandible returned to its normal position, Within 5 minutes, the patient was free of pain. She was placed on a regimen of oral Benadryl, 50 mg. three times a day for 3 days, and instructed to return as an outpatient for further observation. The patient was seen 24 and 72 hours after discharge. On both occasions she was free of symptoms and the physical findings were normal. She was advised to avoid the use of any of the phenothiazine drugs in the future.
DISCUSSION
This case brings up the possibility of an allergic or cross-sensitization phenomenon being involved in the extrapyramidal phenothiazine reactions. The patient had experienced severe episodes of muscular spasms on previous occasions when she had taken Compazine. The current episode immediately followed the ingestion of another phenothiazine, Stelazine. This certainly suggests the possibility of a cross-sensitization between the two drugs. Because of this possibility, it would seem prudent to avoid the use of any of the phenothiazine derivatives in patients who have experienced extrapyramidal reactions. Several methods of treating the extrapyramidal reactions have been suggested, including antiparkinsonian agents, barbiturates, and caffeine.2 In my experience with four cases of extrapyramidal reactions and in the experience of others,lt 3 Benadryl is the drug of choice. The administration of 50 mg. of Benadryl intravenously for immediate relief of symptoms, followed by oral medication of 50 mg. three times a day for 24 to 48 hours to prevent recurrences, has proved uniformly successful. SUMMARY
AND
CONCLUSIONS
A case of successive extrapyramidal reactions to two different phenothiazine drugs in a patient has been reported. The possibility of cross-sensitization
50
Meyer
Oral Surg. July, 1970
between the phenothiazines involved in extrapyramidal reactions has been suggested. Rapid recognition and treatment of extrapyramidal reactions may prevent severe discomfort or oral trauma secondary to the muscle spasms. Benadryl appears to be the drug of choice in the immediate and follow-up treatment of extrapyramidal reactions to phenothiazines. REFERENCES 1. Ryan,
2. 3. 4. r 3. 6. 7. 8. 9. 10. 11.
M., and LaDow, C.: Subluxation of the Temporomandibular Joint After Administration of Prochlorperazine: Report of Two Cases, J. Oral Surg. 26: 646, 1968. Azaz, B., and Shteyer, A.: Intraoral Complications After Dystonic Reactions Due to Overdose of Phenothiazine, ORAL SURG. 27: 161, 1969. Report of Case, J. Oral Abelson, C. B.: Phenothiazine Induced Neck-Face Syndrome: Surg. 26: 649, 1968. O’Hara, V. S.: Extrapyramidal Reactions in Patients Receiving Prochlorperazine, New Eng. J. Med. 259: 826, 1956. After the Administration Shapiro, R. D., Doner, J. M., and Reichman, L.: Pseudotetanus of Prochlorperazine: Report of Case, J. Oral Surg. 23: 544, 1965. Lynch, B., and Hoover, E.: Extrapyramidal Syndrome Due to Compazine Therapy, ORAL SURG. 14: 1142, 1961. Perez-Semper, L. M. : Neuromuscular Reactions Secondary to the Administration of Prochlorperazine, Amer. Practitioner 11: 962, 1960. of the Mandible During ProHiatt, W., and Schwartz, R.: Spontaneous Dislocation chlorperazine Therapy: Report of Case, J. Oral Surg. 24: 365, 1966. Shannon, J. : Neuromuscular Symptoms Simulating Conversion Hysteria Caused by Perphenazine (Trilafon), Dis. Nerv. Syst. 20: 24, 1959. Side Effects of Trifluoperazine, Neuropsychiat. 4: 236, Vilkin, M. I.: Extrapyramidal 1963. Basis of Therapeutics, ed. 3. Goodman, L. S., and Gillman, A.: The Pharmacological New York, 1965, The Macmillan Company, pp. 162-178.
of
a case
Roger A. Meyer, D.D.S., U.X.D.,” Belli?Lgham, Wash.
E
xtrapyramidal reactions to phenothiazine derivatives are by no means rare. A recent report cited nine cases of dislocation of the mandibular condyles resulting from extrapyramidal phenothiazine reactions. l Severe oral soft-tissue trauma with life-threatening sequelae has also occurred.2 These reactions are thought to be due to overdoses of the phenothiazine involved.2 The phenothiazine drugs (Compazine, Trilafon, Tigan, Phenergan, Vesprin, Stelazine, Thorazine, etc.) are well known for their antiemetic and tranquilizing properties. I1 Phenothiazine-induced reactions occur either as parkinsonian effects (postural abnormalities with varying degrees of rigidity, tremor, and salivation), motor restlessness (akathisia), or dystonia (spasms or cramping of muscle groups). The most common and most severe of the dystonic reactions involve the head and neck (neck-face syndrome). Dysarthria, dysphasia, trismus, torticollis, spasm of the masticatory muscles, protrusion of the tongue, and oculogyric crises are components of the neck-face syndrome.lO If untreated, these reactions may persist (particularly in elderly patients with brain damage) for days, weeks, or months. A review of the literature l -lo failed to reveal a case similar to the one reported here, in which a patient had successive extrapyramidal reactions to two different phenothiazine derivatives.
CASE May
REPORT
A 23.year-old woman was admitted to the emergency room of the hospital at 7 P.M. on 19, 1969, with the chief complaint of “the left jaw repeatedly slipping out of joint.”
*Staff Instructor, Vancouver,
48
Oral Surgeon, St. Luke’s General Department of Oral Surgery, Faculty B. C., Canada.
Hospita!, Bellingham, of Dentistry, University
Wash., and Clinical of British Columbia,
Extrapyramidal
Volume 30 Number 1
reactions to two phenothiazines
49
She apparently was suffering excruciating pain. The history revealed that she had visited her physician earlier in the day for treatment of an “anxiety state” and that he had prescribed Stelazine (trifluoperazine). Approximately 45 minutes after she had taken the first tablet, the patient began to experience spasms of the left side of the face and neck. These spasms and the neck muscles and resulted in the involved the tongue, the muscles of mastication, spontaneous dislocation of the left mandibular condyle. The patient had experienced previous episodes of dislocation of the mandible following the administration of phenothiazines, in which rather heroic measures were performed to reduce the dislocation. Because of these traumatic experiences, she did not seek treatment for the current episode until the pain became unbearable. The history further revealed that in July, 1968, the patient had been given Compazine (prochlorperazine) as a tranquilizer. Shortly afterward she experienced spasms of the left facial muscles and dislocation of the left mandibular condyle. She was seen by a physician, who reduced the dislocation and held it in position by means of intermaxillary fixation. The patient suffered intense pain in the left side of the face for approximately 24 hours before the muscle spasm subsided. No specific therapy was given for that extrapyramidal reaction. Physical examination revealed a well-developed, well-nourished, white woman in extreme pain. She had a grimacing facial expression with obvious spasms of the left facial and masticatory musculature. The mandible deviated to the right. The blood pressure was 144/84, and the pulse was 100, regular, and strong. The remainder of the physical examination findings were unremarkable. The clinical impression was that the patient was experiencing an extrapyramidal reaction to a phenothiazine. Accordingly, 50 mg. of Benadryl (diphenhydramine) was administered intravenously. Within 1 minute, the muscle spasms subsided and the mandible returned to its normal position, Within 5 minutes, the patient was free of pain. She was placed on a regimen of oral Benadryl, 50 mg. three times a day for 3 days, and instructed to return as an outpatient for further observation. The patient was seen 24 and 72 hours after discharge. On both occasions she was free of symptoms and the physical findings were normal. She was advised to avoid the use of any of the phenothiazine drugs in the future.
DISCUSSION
This case brings up the possibility of an allergic or cross-sensitization phenomenon being involved in the extrapyramidal phenothiazine reactions. The patient had experienced severe episodes of muscular spasms on previous occasions when she had taken Compazine. The current episode immediately followed the ingestion of another phenothiazine, Stelazine. This certainly suggests the possibility of a cross-sensitization between the two drugs. Because of this possibility, it would seem prudent to avoid the use of any of the phenothiazine derivatives in patients who have experienced extrapyramidal reactions. Several methods of treating the extrapyramidal reactions have been suggested, including antiparkinsonian agents, barbiturates, and caffeine.2 In my experience with four cases of extrapyramidal reactions and in the experience of others,lt 3 Benadryl is the drug of choice. The administration of 50 mg. of Benadryl intravenously for immediate relief of symptoms, followed by oral medication of 50 mg. three times a day for 24 to 48 hours to prevent recurrences, has proved uniformly successful. SUMMARY
AND
CONCLUSIONS
A case of successive extrapyramidal reactions to two different phenothiazine drugs in a patient has been reported. The possibility of cross-sensitization
50
Meyer
Oral Surg. July, 1970
between the phenothiazines involved in extrapyramidal reactions has been suggested. Rapid recognition and treatment of extrapyramidal reactions may prevent severe discomfort or oral trauma secondary to the muscle spasms. Benadryl appears to be the drug of choice in the immediate and follow-up treatment of extrapyramidal reactions to phenothiazines. REFERENCES 1. Ryan,
2. 3. 4. r 3. 6. 7. 8. 9. 10. 11.
M., and LaDow, C.: Subluxation of the Temporomandibular Joint After Administration of Prochlorperazine: Report of Two Cases, J. Oral Surg. 26: 646, 1968. Azaz, B., and Shteyer, A.: Intraoral Complications After Dystonic Reactions Due to Overdose of Phenothiazine, ORAL SURG. 27: 161, 1969. Report of Case, J. Oral Abelson, C. B.: Phenothiazine Induced Neck-Face Syndrome: Surg. 26: 649, 1968. O’Hara, V. S.: Extrapyramidal Reactions in Patients Receiving Prochlorperazine, New Eng. J. Med. 259: 826, 1956. After the Administration Shapiro, R. D., Doner, J. M., and Reichman, L.: Pseudotetanus of Prochlorperazine: Report of Case, J. Oral Surg. 23: 544, 1965. Lynch, B., and Hoover, E.: Extrapyramidal Syndrome Due to Compazine Therapy, ORAL SURG. 14: 1142, 1961. Perez-Semper, L. M. : Neuromuscular Reactions Secondary to the Administration of Prochlorperazine, Amer. Practitioner 11: 962, 1960. of the Mandible During ProHiatt, W., and Schwartz, R.: Spontaneous Dislocation chlorperazine Therapy: Report of Case, J. Oral Surg. 24: 365, 1966. Shannon, J. : Neuromuscular Symptoms Simulating Conversion Hysteria Caused by Perphenazine (Trilafon), Dis. Nerv. Syst. 20: 24, 1959. Side Effects of Trifluoperazine, Neuropsychiat. 4: 236, Vilkin, M. I.: Extrapyramidal 1963. Basis of Therapeutics, ed. 3. Goodman, L. S., and Gillman, A.: The Pharmacological New York, 1965, The Macmillan Company, pp. 162-178.