1. Onuma, Kalu MD PGY 4

2. CASE PRESENTATION IDENTIFYING PROFILE. 25 years old married Caucasian female who lives with her husband and their 5 years old son and 3 years old daughter in Kingsport, TN

3. CLINICAL PRESENTATION Sustained upward deviation of eyes. Mutism Restlessness Agitation Behavioral disturbance. Pupil dilation Backward flexion of neck.

4. HPI Patient had been in apparent good health until the death of her father in law, from which time she became increasingly depressed, not eating and sleeping well. Was subsequently admitted to psych hospital to address worsening psychosis and mood symptoms. Was rushed to the ER for evaluation and treatment of sudden onset of AMS after 48 hours of hospitalization in the psych facility for Psychosis NOS.

5. MEDICATION HISTORY. Ambien orally 10mg QHS, Ativan taper. Abilify PO 5mg x 1 Geodon IM 10mg bid( Haldol IM 5mg q8hours prn( Thorazine IM 25mg x 1 PAST PSYCHIATRY HISTORY. Significant for polysubstance abuse.(THC, Opiates, Benzos) Nil previous psych hospitalization. PAST MEDICAL HISTORY. None LABS/IMAGING STUDIES. CMP, CBC, CT, MRI, HIV, CRP, Ammonia levels Vit B12, Ceruloplasmin, EEG.

6. DIAGNOSIS/TREATMENT OCULOGYRIC CRISIS IM Benadryl.

7. PATHOGENESIS MIDBRAIN PATHWAYS -Substantia nigra pars reticula---Superior Colliculi -Substantia nigra pars compacta--Reticular formation BASAL GANGLIA -subcortical component of family of circuits{Oculomotor, Limbic, Prefrontal Skeletal motor circuits}

11. CAUSES MEDICATIONS -Neuroleptics, Metoclopramide. -Carbamazepine, lithium, PCP -Levodopa, Amantadine, Chloroquine BRAIN STEM LESION -Ischemic, Neoplastic, or Inflammatory. HEAD TRAUMA INFECTIONS -Neurosyphylis, and Herpes Encephalitis. OTHERS. -Alcohol, Emotional stress, and fatigue -Inherited errors of metabolism

12. CLINICAL FEATURES Involuntary, sustained deviation of the eyes.

14. CLINICAL FEATURES Involuntary, sustained deviation of the eyes. Mutism, eye blinking, and pupil dilation. Flexion of the neck. Restlessness, Agitation, and Behavioral disturbances. Transient psychotic episodes. -Visual hallucination. -Auditory hallucination. Autonomic dysfunction.

15. RISK FACTORS Male gender Young age. High doses High-potency antipsychotics History of substance abuse(alcohol, and or cocaine) Genetic susceptibility(Slow metabolizers) Comorbid conditions(Tourette & Parkinsonism)

16. PATIENT ASSESSMENT Physical status. -safety of patient and staff. -history/collateral information. -careful review of medications. -review of medical records. -physical and neurological examination. Mental status examination.

17. DIAGNOSTIC STUDIES CBC CMP UDS VDRL CT MRI EEG EKG URINALYSIS

18. DIFFERENTIAL DIAGNOSIS Seizure Disorder. Delirium. Other EPS. -Tardive, Parkinsonism, Akathisia CNS lesion(focal basal ganglia or Thalamus). Postencephalic parkinsonism. Tyrosine hydroxylase deficiency.

19. TREATMENT/MANAGEMENT Pharmacologic Intervention -Anticholinergic medication (Benadryl or Cogentin) Environmental manipulation. -Place patient in a room near nursing station. -Orient patient repetitively. -Use sitter. - Use restraints when less restrictive measures have failed. -

20. COURSE(PROGNOSIS) Typical course usually ranges from 24-48 hours. -upon medication withdrawal or reduction. Symptom relief within minutes with anticholinergics. Recurrent crisis maybe observed on med re-exposure. Excellent prognosis.

21. THANK YOU! Questions ? Contributions…… References will be made available on request. Contact: onuma@mail.etsu.edu