Pisa Syndrome in a Patient in a Wheelchair Taking Valproic Acid

Mr. A was a 65-year-old nursing home resident being treated for schizoaffective disorder. He was in a wheelchair secondary to severe arthritis. His medications were 750 mg b.i.d. of valproic acid, 200 mg b.i.d. of carbamazepine, and 3 mg b.i.d. of risperidone—a regimen that had been stable and unchanged over several months. His valproic acid and carbamazepine levels were monitored routinely and were never above the therapeutic range.

Over a few weeks, the staff noticed that Mr. A had begun leaning to one side, a change that progressed to the point at which he was tilted at a 30° angle throughout the day. He seemed unaware of and unconcerned by this change. He showed no other signs or symptoms suggestive of an extrapyramidal syndrome. The only medication change to which Mr. A consented was a trial discontinuation of valproic acid. Immediately upon discontinuation, his posture returned to a stable, upright position.