Busted Basal Ganglia

64 y/o M w/ worsening Bipolar  & Spinal Stenosis with recent Abilify initiation/uptitration & opioid change is transferred from OSH with altered mental status. Careful history reveals increased difficulty with all motor actions including swallowing. Exam reveals diffuse tremor at rest with postural features superimposed on diffuse myoclonic jerks, cog-wheel rigidity & narrow-based shuffling gait.  Labs unrevealing for any toxic metabolic process and CT imaging unrevealing for any structural disease. Pt was initally diagnosed with Extrapyramidal Symptoms secondary to atypical antipsychotic use and occasional myoclonic jerks secondary to recent opioid change.

Discontinuation of offending agents showed initial improvement which then plateued. Pt then was noted to have +psychological pillow and + gegenhalten sign suggestive of Catatonia. He was empirically treated with benozos which showed symptomatic improved and is currently undergoing ECT therapy.

This case highlights the importance of

1. Delineating the type of tremor a patient has on exam.
Tremor – AAFP

2. Recognition of EPS symptoms in the setting of antipsychotic use.
Extrapyramidal symptoms with atypical antipsychotics incidence prevention and management.

3. The possibility of myclonus in patients with chronic opiod therapy.
Pathophysiology and treatment of opioid-related myoclonus in cancer patients.

4. Recognition and first line management of Catatonia.
Catatonia