A 39-Year-Old Woman With Past Cocaine Use, Rash, and Seizure

Kenneth B.V. Gross, MD


March 13, 2020

The patient in this case has no history of acute antipsychotic, anxioloytic, or antiemetic use. Her remote history of psychotropic drugs and metachlopramide are not substantial enough to imply their role in the orofacial dyskinesias described. Numerous agents can cause acute and chronic tardive dyskinesias. They include metoclopramide, the aforementioned phenothiazine and others in this class (eg, thioridazine, prochlorperazine), haloperidol, newer atypical psychotics (eg, olanapine, quetiapine, risperidone), selective serotonin reuptake inhibitors (SSRIs), and duloxetine.[2,3] However, the patient in this case used some of these medications long ago, which would not explain her current presentation. Latent schizophrenia is also unlikely in this case, as no evidence suggests a thought disorder. Absent drug-induced tardive dyskinesia, other variants were considered.

Neither Tourette syndrome or neuroacanthocytosis feature fever, rash, or possible nephritis; however, they both can have onsets in adulthood and present with oro-facial tics, as noted here. In addition, total creatinine test results are generally high with neuroacanthocytosis, and red cell abnormalities are noted on peripheral smears. Huntington disease can rarely be associated with this type of dyskinesia. However, the patient in this case had no family history. Lesch-Nyhan syndrome is strongly associated with orofacial dyskinesia, if not tongue biting; however, this is a childhood illness of purine metabolism. Thyroid disease, particularly hyperthyroidism can feature hyperkinesia; however, tremor is most common. Isolated oral facial dyskinesia is extremely unusual in thyroid disease. In various tardive dyskinesia-related syndromes, tongue protrusion or blepharospasm can dominate the clinical picture.[4]

Returning to autoimmunity and movement disorders, antiphospholipid antiboides may have explained the patient's spontaneous abortions but also may be contributing to her lupus-related neurological syndrome. The patient's elevated erythrocyte sedimentation rate is nonspecific but is clearly linked to her likely positive antinuclear antibody levels and related autoantibodies.

More broadly, various tardive dyskinesia-like entities are tied to autoimmune disease.[5] In addition to lupus and antiphospholipid conditions, which can exist without lupus, other disorders are associated with various autoimmune diseases. These include Sydenham chorea, pediatric autoimmune neuropsychiatric disorders associated with streptococcus, SLE, antiphospholipid syndrome, gluten sensitivity, and paraneoplastic and autoimmune encephalopathies. Tremors, dystonia, akathisia, catatonia, chorea, ballism, myoclonus, Parkinsonism, and ataxia may be the initial and even the only presentation of these autoimmune diseases.[6] Although antibodies directed against various cellular components of the central nervous system have been implicated, the pathogenic mechanisms of these autoimmune movement disorders have not yet been fully elucidated. The patient in this case did have a rash, not one that suggested dermatomyositis.


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