Risperidone
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Risperidone Tardive dystonia: case report
A 10-year-old boy developed tardive dystonia while receiving treatment with risperidone for behavioural aggression and selfmutilation. The boy presented to an emergency department with a 1-day history of unsteady gait, drooling and left wrist in the sustained flexion. Two years ago, he had started receiving risperidone 0.5mg nightly [route not stated] for self-mutilation and behavioural aggression. Furthermore, the dosage was increased to 1mg twice daily, with good response. He had been using his current dosage 1mg twice daily, for the past 12 months without any modifications. During current presentation, the urinalysis showed elevated sedimentation rate. A comprehensive metabolic panel revealed slightly increased level of creatinine; suggesting dehydration. He received IV fluid replacement as he had difficulty during drinking due to excessive drooling. ED physician suspected acute dystonic reaction secondary to risperidone. His treatment with risperidone was put on hold, and he was treated with one-time dose of IV diphenhydramine 25mg for presumptive acute dystonic reaction. After several minutes, there was no improvement in the sustained flexion of his left wrist. It was considered that he had new-onset neurologic findings after a recently diagnosed upper respiratory viral infection. His symptoms appeared to be confined to his left upper extremity, specifically demonstrating left arm extension at the elbow with flexion of the left wrist. He also had new-onset unsteady gait with a stooped forward posture and required assistance with walking. He had high CPK levels, but all other laboratory results, including a comprehensive metabolic panel, urine drug screen, and thyroid screening panel, were within normal limits. He was admitted to the paediatric ward and maintenance IV fluids were started due to concerns of dehydration and possible rhabdomyolysis due to his elevated CPK level. Risperidone was held throughout the hospital course due to concerns for an acute dystonic reaction. He was monitored for several days without clinical improvement and was eventually discharged home with a differential diagnosis of inflammatory mononeuropathy due to viral infection. He was told to discontinue risperidone as part of discharge instructions. Five days later, he returned to the hospital as there was no improvement in his left extremity or walking. His left elbow remained extended with left wrist in flexion. Psychiatry was consulted for further diagnostic clarity and evaluation. Despite discontinuing risperidone, there was evidence of cogwheel rigidity of the left wrist joint. Reflexes in the upper and lower extremities were 2+ and symmetrical bilaterally, suggesting intact upper and lower motor pathways. Babinski sign was absent bilaterally. He continued to have difficulty in ambulation and appeared to "fall forward" while trying to walk with assistance. Family history was negative for involuntary movements or other neurologic syndromes. He denied any recent shoulder trauma, and r
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