Choreiform movements

The most serious and frequent adverse reactions seen witii levodopa include choreiform movements... 

Dyskinesias are involuntary choreiform movements, usually involving the neck, trunk, and extremities. They are usually associated with peak striatal dopamine levels. Less commonly, dyskinesias also can develop during the rise and fall of L-dopa effects (the dyskinesias-improvement-dyskinesias or diphasic pattern of response. 

Choreiform movements are purposeless, involuntary movements such as flexing and extending of fingers, raising and lowering of shoulders or grimacing. 

Tardive dyskinesia is a condition that sometimes results from chronic neuroleptic treatment lasting from months to years (Baldessarini 1996 Stahl et al. 1982). It occurs in 15-25% of treated chronic psychotic patients and is characterized by repetitive, athetoid writhing and stereotyped choreiform movements of the face, eyes, mouth, extremities, and trunk. Discontinuation of neuroleptic medication allows the symptoms to gradually decline, but sometimes they can persist indefinitely. The pathophysiology of tardive dyskinesia is poorly understood, but it appears to involve supersensitive postsynaptic dopamine receptors in the basal ganglia. 

Severe intoxication has resulted in prostration, tachycardia, blood pressure flucmations, con-vulsive seizures, choreiform movements, and psychosis. Recovery may be complete, but permanent residual effects such as ataxia, optic atrophy, tremor, mental abnormalities, and footdrop have been reported. fti cases of fatal intoxication, typical autopsy findings include pulmonary edema, necrosis of the liver, nephritis, and degenerative changes in peripheral axons. ... 

Unlabeled Uses Treatment of choreiform movement of Huntington s disease... 

Studies at the National Institutes of Health (NIH) have detailed the clinical characteristics of patients in the PANDAS subgroup (Swedo et al., 1998). The rate of neuropsychiatric comorbidity in this population is quite striking. Twenty of the 50 children (40%) met DSM-IV criteria for ADHD and/or oppositional defiant disorder (ODD), 18 (36%) for major depressive disorder, 14 (28%) for overanxious disorder, and 10 (20%) for separation anxiety disorder. Six children (12%) were enuretic, often episodically and closely correlated with periods of OCD and tic exacerbations. Depressive symptoms, ADHD, and separation anxiety disorder also waxed and waned in concert with the OCD/ tic symptoms. In addition, exacerbations of OCD and tics were accompanied frequently by the acute onset of choreiform movements (clinically distinct from chorea), emotional lability and irritability, tactile/sensory defensiveness, motoric hyperactivity, messy handwriting, and symptoms of separation anxiety (Perlmutter et al., 1998 Becker et al., 2000). 

An acute overdose of CBZ can produce significant neurological symptoms. Diplopia may be a useful clinical indicator of developing toxicity, since severity is not necessarily correlated with plasma levels. Life-threatening seizures and coma may occur when levels exceed 20 to 25 pg/ml. Lower levels can produce drowsiness, ataxia, blurred vision, dysarthria, choreiform movements, or behavioral changes (374374 and 375). Gastric lavage, hemoperfusion, and plasmapheresis may be beneficial, especially in more serious cases (77, 376). 

Mecamylamine, unlike the quaternary amine agents and trimethaphan, crosses the blood-brain barrier and readily enters the CNS. Sedation, tremor, choreiform movements, and mental aberrations have been reported as effects of mecamylamine. 

The choreiform movements and behaviors can be only partially controlled by phenothiazines or butyrophenone neuroleptics. 

Use of androgenic steroids is likely to produce a sensation of energy and euphoria, but also with a tendency to sleeplessness and irritability (1). More extreme changes in mental state can result in extreme swings in mood, ranging from depression to aggressive elation. An unusual complication in one case was a toxic confusional state and choreiform movements caused by an anabolic steroid (SED-12, 1038) (29), but it may have been due to the non-specific results of endocrine stress in a susceptible individual. 

Tilzey A, Heptonstall J, Hamblin T. Toxic confusional state and choreiform movements after treatment with anabolic steroids. BMJ (Chn Res Ed) 1981 283(6287) 349-50. 

Multiple involuntary movements, consisting of jaw grinding, oral dyskinesias, bilateral hand rolling, vermiform tongue movements, and bilateral choreiform movements of the digits, have been described in an 11-year-old boy taking thioridazine 150 mg/day and methylphenidate 10 mg bd (36). The methylphenidate was discontinued and within 4 weeks his movement disorder had completely disappeared. 

A 22-year-old man who had had ADHD since the age of 8 years took methylphenidate, and had an adequate response for 14 years (52). However, his symptoms worsened and he switched from methylphenidate to mixed amfetamine salts 20 mg bd. A month later he continued to have difficulty in focusing on tasks, and the dosage was eventually increased to 45 mg tds over several weeks, with symptomatic improvement. However, 5 days later, he awoke feeling nauseated and agitated and had choreiform movements of his face, trunk, and limbs. He had also taken escitalopram 10 mg/day for anxiety and depression for 2 months before any changes in his ADHD medications. He was treated with intravenous diphenhydramine, lora-zepam, and diazepam without improvement in the chorea. Amfetamine was withdrawn and 3 days later his chorea abated. He restarted methylphenidate and the movement disorders did not recur. 

Methadone can cause movement disorders characterized by tremor, choreiform movements, and a gait abnormality (26). 

A 41-year-old woman with a 15-year history of chronic neuropathic pain was given methadone 5 mg tds and then qds. One month after the final increase she had bilateral tremor spreading from her arm up to her neck, followed by choreiform movements of the torso, a broad-based gait, and staccato-like speech. She was switched from methadone to modified-release oxycodone 60 mg/day, with complete resolution after 3 weeks. 

Choreiform movements associated with persistent orofacial dystonia have been attributed to cibenzoline in a 77-year-old woman who took 260 mg/day for 1 week (19). When cibenzoline was eventually withdrawn the effects resolved within 1 month. 

Cimetidine crosses the blood-brain barrier and its adverse events include central respiratory depression and extrapyr-amidal and cerebellar disturbances. There have been convincing isolated reports of choreiform movements (3,4). 

Headache, dizziness, and somnolence occur in a small proportion of individuals who take piperazine (3). More serious neurological reactions occur rarely, but tend to be reported in young children, in people with neurological or renal disease, or after overdosage. Symptoms in such cases include ataxia, paresthesia, undue clumsiness, myoclonus, and nystagmus. Choreiform movements and an electroencephalogram with prominent slow waves have been reported as well as an exacerbation of petit mal (4) and absence seizures (5). In a child, horizontal nystagmus and hjrpotonia have been reported after a normal dose (6). 

Rarely valproate causes a parkinsonian-hke reaction (SEDA-18, 69) (SEDA-19, 74). Involuntary movements and twitching of the face and limbs have been also reported. Intermittent choreiform movements were observed in two girls and one man, all with pre-existing severe brain damage, after they had taken valproate for 27 years (SEDA-20, 68). 

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