Acute Dystonic Reaction as Medical Emergency: A Report of Two Cases
A.A is a single 27-year-old male secondary school graduate who presented at the Accident and Emergency Unit of the hospital with 2 h history of difficulty in swallowing, painful contraction of neck muscles, and involuntary tongue protrusion. Symptoms initially resolved within 5 min without any intervention but recurred about 10 min later with increased severity and inability to talk.\nThere was a preceding 2-month history of paranoid delusions of being monitored by neighbors. As a result, he became physically and verbally aggressive to his family members and neighbors. He was occasionally noticed to be talking and fatuously laughing to self. He admitted hearing voices of unseen individuals discussing with him in clear consciousness and had disturbed sleep pattern.\nPatient's contact with orthodox medicine was a day before presentation when he had a private consultation with a “hospital worker” who placed him on unspecified dosage of medications fitting the description of haloperidol and diazepam tablets. Patient later presented at the emergency unit barely 11 h after the commencement of medications.\nOn examination, patient was in painful distress with marked respiratory difficulty associated with profuse sweating. His tongue was markedly protruding from the mouth and was deeply cyanosed as evidenced by a bluish discoloration of the tongue and oral mucosa including dusky extremities. His neck was fully extended with prominent and engorged neck veins anteriorly. Patient's shoulder appeared hyperextended and was unable to communicate verbally. Pulse rate was 120 beats/min, regular, of full volume and blood pressure was within normal limits. Chest examinations revealed markedly reduced breath sounds and air entry. Patient was immediately placed on oxygen by facemask and given intramuscular biperiden lactate 1 mg stat, while he was reassured as well as the apprehensive relatives.\nSevere dyspnea and cyanosis cleared within 5 min. Tongue protrusion, torticollis, and opisthotonus stopped within 10 min of intervention and patient began to communicate verbally within 30 min. Psychoeducation was given about neuroleptic medications, their side effects, and need to receive proper medical consultation in the hospital. Patient was subsequently placed on oral trifluoperazine 5 mg thrice daily, artane 2.5 mg thrice daily, since the relatives could not afford atypical anti-psychotic medications.