REASON FOR CONSULTATION: Evaluation of dyskinesias.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old left-handed man with multiple sclerosis. The patient was in his usual state of health until approximately March, when he began having abnormal movements. His son reports that initially he was appearing to rub his hands and twiddle his thumbs frequently. It was unclear whether these movements were performed in response to a premonitory sensation or urge or whether they were suppressible. He then developed more generalized movements that involved the whole body, including the head, neck and extremities. At this stage, the movements appeared to be involuntary. They occurred all the time. The movements responded mildly to medication such as Xanax, but this did not last. It was also noted that Cymbalta had been started approximately 2 months before the movements began.
He had no other changes in his medications prior to the beginning of his movements. Though he had movement of his head and neck, there reportedly was no oral, buccal, or lingual dyskinesias and the movements did not affect his speech or his ability to swallow. He has no history of dopamine receptor blocking agents, nor did he have any history of exposure to SSRI such as Celexa or Lexapro. There was no history of abnormal movements and he denied history of obsessive-compulsive disorders. He notes that he has always been an orderly person and his son thinks he also has some attention deficit disorder. The patient had a laboratory workup that included testing for anti-phospholipid antibody syndrome, lupus, thyroid disease, Sydenham chorea and paraneoplastic syndrome, the results of which were negative. Since that time, he has increased his clonazepam and baclofen as well as had addition of amantadine. On this regimen, the patient has had significant reduction in the frequency and severity of movements, though they continue to occur when he is anxious and under stress.
Currently, the patient feels that the level of dyskinesia that he has is not significantly impairing his functioning. There was some concern about depression and he was placed on Zoloft, which he takes at 50 mg per day. He has not noticed a change in his mood on this medication. He has also not had any change or worsening of his dyskinesia since the Zoloft was introduced.
PAST MEDICAL HISTORY: Multiple sclerosis, relapsing remitting course with most recent exacerbation in May; dyskinesias of unclear etiology with improvement on a combination of Klonopin, amantadine and baclofen; recurrent papillary thyroid carcinoma status post surgery and radioactive iodine treatment; diabetes mellitus with secondary peripheral neuropathy; status post right rotator cuff surgery; left carpal tunnel syndrome status post release surgery; elevated cholesterol; vitamin D deficiency; history of episodes of vertigo.
MEDICATIONS: Rebif 44 mcg 3 times per week; Naprelan, pre-Rebif; lorazepam 1 mg at bedtime; Xanax p.r.n.; Prilosec 20 mg a day; amantadine 200 mg b.i.d.; sertraline 50 mg a day; vitamin D 1000 international units per day; baclofen 30 mg at bedtime; Zocor 40 mg a day; Klonopin 1 mg t.i.d.
SOCIAL HISTORY: The patient is divorced, lives with son. He smokes cigarettes. No alcohol or illicit drug use.
FAMILY HISTORY: Notable for a son with depression and anxiety and daughters with attention deficit disorder. His father has Parkinson disease and dementia.
REVIEW OF SYSTEMS: Neurological symptoms are described in detail above. He describes recent increased apathy and loss of energy. He has also had decreased appetite. He describes having poor concentration. He walks with a cane and has had no fall recently. No hallucinations or delusions. He describes having mild dry mouth and constipation. All other systems are negative.
PHYSICAL EXAMINATION: The patient is a pleasant man with a somewhat blunted affect, in no acute distress. Blood pressure 110/78, pulse 66, respiratory rate 18. Head is normocephalic, atraumatic. Heart rate and rhythm regular. Lungs are clear to auscultation bilaterally. Abdomen is benign. Extremities are warm with no edema. On neurological examination, he is alert and oriented to person, place and time. Affect is blunted. He also appears to be anxious during portions of the interview. Language and praxis intact. Pupils are equally round and reactive to light. Extraocular movements are intact. There is no nystagmus. There is no scleral icterus. Visual fields are full to confrontation. Facial sensation is intact to light touch in all distributions. Face is symmetric. Hearing is intact. Palate elevates symmetrically. Tongue is in the midline. Sternocleidomastoid strength is 5/5. There are head and neck dyskinesias noted, about 15% of the exam. These emerge when he is activating other parts of his body such as opening and closing movements of the hands. The dyskinesias are primarily choreiform, but occasionally they are a little more sustained and have the appearance of dystonia. Motor: He has generalized weakness that is noted more proximally than distally. He has about 3/5 weakness in the deltoids and biceps and triceps. Wrist extensors, flexors are 4/5. Iliopsoas and quadriceps muscles are weak, but more so on the right than the left. He has iliopsoas weakness of 3 on the right, 4- on the left. Quadriceps is 3 on the right and 4 on the left. Distal muscle strength is about 4/5 bilaterally in the lower extremities. Sensory exam is notable for reduced temperature in his stocking distribution as well as reduced vibratory sensory level of the ankles. Reflexes are 3+ in the upper extremities and more brisk on the right than the left. They are 2+ at the ankles and at the knees. His toes appear downgoing. Myerson sign is absent. Cerebellar: Intact finger-to-nose testing with just a slight action tremor bilaterally. It is noted that he had occasional choreiform and stereotyped movements, primarily of the upper extremities, when he was asked to concentrate and when he was placed under other types of stress during the exam. These movements were at times reminiscent of stereotypies or of akathisia, consisted of hand rubbing primarily. However, he also had mild choreiform movements of the upper extremities during portions of the interview, especially when he was asked to activate his arms such as opening and closing his hands or finger tapping. There was very little in the way of dyskinesias noted in his lower extremities. Gait: He was able to rise from a chair by pushing off his both hands. When he walked, his walking was cautious and somewhat ataxic. He used a cane when he walked. When he was walking, he had increased dyskinesias in his head and neck.
IMPRESSION AND PLAN: This is a (XX)-year-old man with multiple sclerosis who developed dyskinesias about 7-8 months ago. On exam today, he has mild, primarily overflow dyskinesias that are noted in the head, neck and the arms primarily. He also has stereotypies in the hands consisting primarily of hand wringing and finger rubbing, though he denies any feeling of restlessness. There are occasional dystonic movements noted of his neck as well. He appears to have dyskinetic syndrome and the etiology is unclear, though it could be tardive and associated with Cymbalta exposure. Alternatively, it could be secondary to his demyelinating disorder, though I do not see any involvement of deeper structures. Certainly, chorea has been described with subcortical white matter disease. I think there is also probably an element here of akathisia and an anxiety-induced movement disorder and his existing depression and anxiety disorder are probably contributing to this. He appears to have significant reduction in the dyskinesias on his current regimen, and therefore, would not recommend making any changes to it. In the future, should he have worsening, tetrabenazine could be considered. However, he would have to be followed closely as there are possible risks of depression and apathy and akathisia with this medication. Think it is also of paramount importance that he has treatment for his depression and anxiety, both with medication and with psychotherapy. Zoloft tends to be the least offending agent of the SSRIs to produce worsening of dyskinesias. However, if significant worsening is noted, would recommend tapering off this medication. Other medications that could be considered in the future for management of depression would include tricyclic antidepressants such as nortriptyline or amitriptyline. Dopamine receptor blocking agents should be avoided at all costs and would also recommend avoiding Celexa, Lexapro and Cymbalta. The patient has a followup with Dr. Doe coming up in a few months.
Thank you for allowing me to participate in the care of this pleasant patient.