The Pisa syndrome during maintenance antipsychotic therapy

The Dystonias

Dystonia is a difficult problem for both the clinician and the scientist. It is sufficiently common to be seen by almost all physicians, yet uncommon enough to prevent any physician from gaining broad experience in its diagnosis and treatment. Each case represents a difficult challenge even to the specialist. The basic scientist is faced with investigating a disorder that is without relevant animal models and which is so rare that obtaining suitable tissue for study is a major obstacle. Dystonia may be idiopathic, or associated with lesions from many sources, including a variety of rare diseases. If idiopathic, it may be genetically transmitted or sporadic. If genetically transmitted, it may be generalized or focal, with symptoms varying in different members of the same family. It may be refractory to treatment, or it may respond to any one of a number of individual drugs that have very different mechanisms of action. For idiopathic dystonias, no clear method of genetic transmission has been established and no consistent pathology identified.

Reversible Pisa syndrome (pleurothotonus) due to the cholinesterase inhibitor galantamine: case report

We report on a case of reversible Pisa syndrome developed after treatment with galantamine in a patient with Alzheimer's disease without previous exposure to neuroleptic or other cholinesterase inhibitors. Complete and persistent resolution of the syndrome was achieved several weeks after botulinum toxin type-A injection.

Drug-induced Pisa syndrome (pleurothotonus): epidemiology and management

Long-term administration of antipsychotics occasionally produces persistent dystonia of the trunk, a disorder known as Pisa syndrome (or pleurothotonus). The development of Pisa syndrome is most commonly associated with prolonged treatment with antipsychotics; however, it has also been reported, although less frequently, in patients who are receiving other medications (such as cholinesterase inhibitors and antiemetics), in those not receiving medication (idiopathic Pisa syndrome) and in those with neurodegenerative disorders. Drug-induced Pisa syndrome predominantly develops in females and in older patients with organic brain changes. It sometimes occurs after the addition of another antipsychotic to an established regimen of antipsychotics or insidiously arises in antipsychotic-treated patients for no apparent reason. The condition generally disappears after antipsychotic drugs are discontinued. Although a pharmacological therapy for drug-induced Pisa syndrome has not been established, we have reported that anticholinergic drugs are effective in about 40% of patients who have episodes of Pisa syndrome with the remaining patients responding to the withdrawal or reduction of daily doses of antipsychotic drugs. The characteristics of its development and prognosis indicate that drug-induced Pisa syndrome consists of two types of dystonia. Some patients develop clinical features of acute dystonia, whereas others develop symptoms similar to tardive dystonia. Like that of tardive dystonia, Pisa syndrome responds better than tardive dyskinesia to a relatively high daily dose of an anticholinergic. However, the significant improvement caused by the withdrawal of antipsychotic drugs in Pisa syndrome differentiates it from tardive dystonia. Thus, Pisa syndrome including these features is considered to be an atypical type of tardive dystonia. These clinical characteristics suggest that the underlying pathophysiology of drug-induced Pisa syndrome is complex. A dopaminergic-cholinergic imbalance, or serotonergic or noradrenergic dysfunction, may be implicated. Asymmetric brain functions or neural transmission may also be considered as underlying mechanisms of the development of Pisa syndrome that is resistant to anticholinergic drugs. Idiopathic Pisa syndrome is characterised by an adult-onset, segmental truncal dystonia in patients with no previous exposure to antipsychotics. It occurs rarely but shows a complete resolution with high doses of anticholinergic drugs.

The current status of tardive dystonia

Tardive dystonia (TDt), a persistent dystonia associated with exposure to neuroleptic drugs, is an uncommon disorder. It differs from tardive dyskinesia (TDk) in epidemiology, clinical features, risk factors, pathophysiology, course, prognosis, and treatment outcome. TDt seems to develop faster and is more painful, distressing, and disabling than tardive dyskinesia. In this article, evidence is reviewed on the face, descriptive, construct, and predictive validity of this iatrogenic complication of antipsychotic drugs. It is suggested that TDt should not be lumped together with TDk. It deserves a separate nosological status as an independent diagnostic category. The subclassification of TDt into various subtypes based on coexistence of other movement disorders is suggested.

Pisa syndrome without neuroleptic exposure in a patient with dementia of the Alzheimer type

A case of Pisa syndrome in a 60-year-old man with dementia, probably of the Alzheimer type, who had never been exposed to any psychotropic medication is described. He also had some extrapyramidal features and myoclonus. Treatment with amantadine was slightly beneficial. We believe that this report is the first of its kind.

Tardive dystonia

Unlike tardive dyskinesia (TD) which is much better known by clinicians, tardive dystonia is a more recently recognised complication of neuroleptic use. It refers to chronic dystonia related to the use of neuroleptic drugs and may be an even more disabling condition than TD. This article reviews its epidemiology, clinical features and treatment aspects, and suggests that it should be separated from TD as a distinct entity.

Pisa syndrome in a Chinese patient

A Chinese female with 10 years' history of a special form of tardive dystonia (Pisa syndrome) is described. Mild improvement has occurred after 5 months' treatment with tetrabenazine despite the long duration of dystonia and the presence of secondary structural changes.

Pisa syndrome. Report of a case

Very few cases of Pisa syndrome have been reported. The syndrome consists of dystonic symptoms, namely, tonic flexion of the trunk to one side and its slight rotation. It appears to be a side effect of prolonged antipsychotic therapy. We report on a case of Pisa syndrome in which withdrawal significantly improved the dystonic symptoms. However, a severe exacerbation of schizophrenic symptoms required the immediate resumption of neuroleptic therapy which was followed by the reappearance of dystonic symptoms. Associated anticholinergic medication led to only a slight improvement.