Dysphagia due to tardive dyskinesia.

Tardive dyskinesia (TD), neuroleptic-induced delayed onset movement disorder, remains an enigmatic phenomenon and a therapeutic challenge. Only a few cases of dysphagia also have been reported in world literature and to the best knowledge of the authors no case of TD manifesting as isolated dysphagia has been reported so far from India. We report a case of TD consequent to prolonged exposure to typical neuroleptics, manifesting as isolated dysphagia who responded well to a combination of Quetiapine, Donepezil and Vit E.

Tardive dyskinesia (TD) is a well-recognized adverse effect associated with long-term use of neuroleptic therapy. The reported cumulative incidence is up to 25% after four years of drug use. As per DSM IV, it is a group of involuntary movements of the tongue, jaw, trunk or extremities developed in association with the use of neuroleptic medication.[1] TD is hypothesized to be due to the super sensitivity of Dopamine receptors in the basal ganglia.

Soon after the discovery of neuroleptics, neurological side-effects of the extra-pyramidal type were reported. “Tardive Dyskinesia” appeared in the literature in the late 1950s. The first report was by Schoeneker in 1957 who described bucco-oral movements persisting after the neuroleptics were discontinued.[2] In 1964, Faurbye et al., proposed the term “Tardive Dyskinesia”.

The disorder has expanded from the initial bucco-lingual-masticatory syndrome (rabbit syndrome) to include facial grimacing, blinking of eyes, movement of eyelids, axial hyperkinesia and difficulty in breathing. A few cases of dyspahgia have also been reported.[34] Tardive dyskinesia remains an enigmatic phenomenon and a therapeutic challenge. We describe a case of dysphagia due to TD and its response to treatment with a combination of Quetiapine, Donepezil and Vit ‘E’.

CASE REPORT

A 37-year-old serving army officer, a diagnosed case of schizophrenia for the last nine years, was on regular review and maintenance medication. Since he had two relapses due to poor drug compliance, he was on Inj. Haloperidol Decanoate every three weeks, and had achieved good remission.

Since the last one year he noticed a gradually increasing difficulty in swallowing liquid food. There was no felt difficulty to swallow solids and no odynophagia. There was no history of hand tremors, restlessness or abnormal involuntary movements of lips, tongue or neck. He was evaluated by the ENT surgeon, and the examination of the oropharynx and larynx was normal. While he was being considered for esophageal imaging studies, he was referred for routine psychiatric review.

Physical examination and mental status examinations were normal. Possibility of TD presenting as isolated dysphagia was considered, and Abnormal Involuntary Movements Score was 14. Maintenance drug was changed to Quetiapine 150 mg/day and was supplemented with Tab Donepezil 10 mg/ day, and Tab Vit E 400 IU/day. He responded to treatment quickly, became fully asymptomatic in eight weeks and is presently maintaining improvement.

DISCUSSION

Dysphagia in TD can be isolated or in combination with other bucco-lingual-masticatory features. Isolated dysphagia is rare, but it can be life-threatening also.[5] Tardive dyskinesia not only may be painful and disfiguring, but it can also predict poor outcome in schizophrenia. Although many treatments have been tried, none have proven completely efficacious. The best treatment even today is prevention.

A meta-analysis of the trials of cholinergic drugs by Tammenmaa et al., revealed that cholinergic drugs showed a minor trend for improvement of symptoms.[6] Paleacu et al., noted that Tetrabenazine was moderately effective.[7] Quetiapine was found to be effective by Navarro Pacheco et al.,.[8] Pham DQ and Plakogiannis recommended Vit E as a useful supplement.[9] Bergman et al., in a preliminary study of seven patients found that addition of Donepezil while on stable anti-psychotic therapy was associated with a clinically significant improvement in the symptoms.[10]

As one can see from the above data, a definite and reproducible therapeutic regimen has not yet been evolved for TD. Hence in our case of TD presenting with isolated dysphagia, a combination treatment was offered, and the patient has responded well. However, more case studies will be required before strongly recommending the above regimen for this disabling drug-induced illness.