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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