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Amisulpride-associated acute Pisa syndrome in schizophrenia

Pisa syndrome is an unusual movement side effect of traditional antipsychotics (1). It is characterised by persistent dystonia to the cervical musculature of the trunk and tonic lateral flexion with slight rotation of the trunk (1). Recent reports showed that this rare type of truncal dystonia is also related to the use of atypical antipsychotics including clozapine (2), risperidone (3), olanazapine (4), ziprasidone (5) and aripiprazole (6). We here report a case of a schizophrenic patient who developed acute Pisa syndrome after receiving 800 mg/day of amisulpride, another atypical antipsychotic. This movement side effect was in remission right after he received anticholinergic medications and his antipsychotic medication was switched. A 29-year-old unemployed single male was diagnosed as having schizophrenia, paranoid type during his enlisting screening in 2000. Since then he had not received regular psychiatric treatment except that he was admitted to a psychiatric hospital for 3 weeks to treat his schizophrenia in 2006. The patient had a history of febrile seizure when he was 1-year old. There is no past history of head trauma or surgical illness. He has no past history of alcohol or substance abuse. There is no family history of psychiatric illnesses. The patient was brought to our psychiatry outpatient clinic in February of 2009 by his families because of exaggerated psychotic symptoms including persistent persecutory delusions, auditory hallucinations, violent behaviour and long-term social isolation. Based on the statement of his family, he did not take any medication for at least 2 years prior to this outpatient visit. His physical, neurological and laboratory examinations including magnetic resonance imaging of the brain and electroencephalogram did not reveal any remarkable finding. In addition, we evaluated his level of intelligence by using the Wechsler Adult Intelligence Scale-III, Chinese Version. The results showed that his full intelligence quotient (IQ) was 51, Verbal IQ 52, and Performance IQ 51. His mental status examination showed poor intelligence in addition to his psychosis. In our outpatient clinic, he was started with amisulpride 800 mg/day and trihexyphenidyl 2 mg/day for 1 week. Unexpectedly, on the third day, the patient developed the symptoms of leaning to right side about 45◦ and being unable to straighten up. When the patient returned to our clinic for follow-up on the 8th day, he showed tonic flexion of his trunk to right accompanied by slight backward axial rotation. Therefore, he was admitted to our acute ward for further management. After admission, the patient was given intramuscular injection of biperidin 5 mg for relieving his persistent dystonia. Furthermore, we changed his amisulpride 800 mg/day to quetiapine 800 mg/day and increased the dose of trihexyphenidyl up to 8 mg/day. With all these treatments, the