Letters to the Editor
Facialis Palsy Attributable to Depot Antipsychotic Therapy
Dear Editor:
Mrs A, a 42-year-old white woman with paranoid schizophrenia, was treated for 4 years with fluphenazine decanoate 25 mg intramuscularly (IM) every 4 weeks. Owing to mild depression, the medication was changed to zuclopenthixol decanoate 50 mg IM every 4 weeks. She did not receive any other drugs and had no extrapyramidal side effects (EPSEs). After 10 months of zuclopenthixol treatment, she complained of paresthesias on the right side of her face and numbness of the tongue. Clinically, we observed mild oral dyskinesia, and the zuclopenthixol was stopped. One month later, Mrs A presented with right-side peripheral facialis palsy that had occurred overnight after 3 weeks of continued paresthesias. The consultant neurologist found a right- side mandibular deviation without any other neurological signs. There were no signs of infection or other medical condition, and her EEG and CT scans were normal. Owing to suspected preexisting dystonia, biperiden 2 mg 3 times daily and clozapine 25 mg 3 times daily were prescribed; however, the palsy did not resolve. Three years later, the mandibular deviation was severe and caused marked facial asymmetry. Because we suspected tardive dystonia, botulinus toxin was injected into the right pterygoid muscle, with almost no effect. The procedure was not repeated. To date, 10 years later, the neurological condition is unchanged. Mrs A is currently taking olanzapine 20 mg daily and is in stable remission. She was referred to a maxilofacial surgeon, who found a spastic right facialis palsy. She refused the proposed extraction of all teeth and a corrective dental prosthesis.
To our knowledge, this is the first report of nerve palsy in a patient taking zuclopenthixol. Transient palsy has been reported after intoxication with several antipsychotics (1) or after drug-induced extrapyramidal rigidity (2). Our patient was taking relatively low dosages of antipsychotics without any EPSEs. In another case, dystonia presenting as Bell’s palsy (3) occurred in a patient after taking prochlorperazine and quickly resolved after taking diphenhydramine. Anticholinergics did not benefit our patient. Three cases of bilateral facialis palsy and 4 more cases of sensory neuropathy have been reported in perazine-treated patients after intensive sun exposure (4). Since the palsy occurred in our patient in November, sun exposure was not likely the precipitating factor. Interestingly, all mentioned cases involved phenothiazines, while zuclo- penthixol is chemically a tioxanthene.
Palsy probably develops in conjunction with antipsychotic-induced EPSEs. It remains to be seen whether novel atypical antipsychotics, which cause few or no EPSEs, are safer regarding this rare but debilitating complication.
References
1. Taniguchi Y, Wada Y, Takahashi M, Harada M, Shimizu M. Multiple bullae and paresis after drug-induced coma. Acta Derm Venereol 1991;71:536–8.
2. Sampath G, Pandurangi AK. Bilateral ulnar nerve paralysis: an unreported complication of drug-induced extrapyramidal rigidity. Aust N Z J Psychiatry 1997;31:309–17.
3. Bhopale S, Seidel JS. Dystonic reaction to a phenothiazine presenting as Bell’s palsy. Ann Emerg Med 1997;30:234–6.
4. Roelcke U, Hornstein C, Hund E, Schmitt HP, Siess R, Kaltenmaier M, and others. “Sunbath polyneuritis”: subacute axonal neuropathy in perazine-treated patients after intensive sun exposure. Muscle Nerve 1996;19:438–41.
Milan Licina, MD, PhD
Rok Tavcar, MD, PhD
Ljubljana-Polje, Slovenia
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