Metoclopramide-Related Pisa Syndrome in Clozapine Treatment

SIR: Pleurothotonus or Pisa syndrome is a rare acute dyskinesia, which was first described by Ekbom and co-workers in the early 1970s.¹ Although it was first known as an adverse effect of psychopharmacy with butyrophenones, recent epidemiological data show that factors like female gender, old age, previous treatment with at least one classical neuroleptic, the presence of an organic brain disorder, and a combination of pharmacologic treatment increase the risk for the development of a Pisa syndrome.² Even acetylcholinesterase inhibitor therapy has been associated with pleurothotonus.³ Clozapine is the prototype of new or atypical neuroleptics, as it has potential therapeutic advantages and a favorable extrapyramidal side effect profile.⁴ Most of the adverse effects of clozapine are predictable from the pharmacologic profile of the compound. However, nausea is not explicable through pharmacological understanding, although it is a common adverse effect in many patients who receive clozapine for a certain time. Metoclopramide was recommended for nausea, but its use was controversial.^4,5

We report here an additional case of Pisa syndrome from the German multicenter drug safety surveillance project in psychiatry.⁶