Piano finger (toe) sign

Introduction More common in long-term (more than 1 year) high doses of anti-psychotic drugs that block or bind to dopaminergic receptors, especially phenothiazines such as chlorpromazine, perphenazine, butyrylbenzenes such as haloperidol Etc., can cause some TD certain dopamine drugs such as levodopa, Madopar, Parkinin, stabilizers can also cause similar TD involuntary movement. Or occasionally in patients taking antidepressants, anti-PD drugs, anti-epileptic drugs and antihistamines for a long time, reduction or withdrawal is easy to occur. The pathogenesis of tardive dyskinesia is unclear, and central dopaminergic neuron damage is a doctrine. It has also been reported that the GABA energy system is functionally reduced, the neurotoxicity of free radical production, and the direct effect of antipsychotic drugs on the nervous system.

Cause

(1) Causes of the disease

More common in long-term (more than 1 year) high doses of anti-psychotic drugs that block or bind to dopaminergic receptors, especially phenothiazines such as chlorpromazine, perphenazine, butyrylbenzenes such as haloperidol Etc., can cause TD. Certain dopamine drugs such as levodopa, Madopar, Parkinin, and tranquilizers can also cause TD-involuntary movements. Occasionally, patients who take antidepressants, anti-PD drugs, anti-epileptic drugs and antihistamines for a long time are prone to reduction or withdrawal.

Related factors include: 1 age, gender factors: old people are prone to occur, difficult to recover, more women than men; 2 brain lesions patients with antipsychotic drugs are prone to occur, negative symptoms of schizophrenia patients with early onset of TD, high incidence; 3 Drug factors: drug dose and duration of treatment are related to TD, and more common in patients with Parkinson syndrome in the early stage of treatment.

(two) pathogenesis

The pathogenesis of tardive dyskinesia is unclear, and central dopaminergic neuron damage is a doctrine. It has also been reported that the GABA energy system is functionally reduced, the neurotoxicity of free radical production, and the direct effect of antipsychotic drugs on the nervous system.

It is generally believed that long-term use of high-dose antipsychotic drugs such as phenothiazines and butyrylbenzenes can block post-synaptic dopamine receptors (DR) for a long time, and increase synaptic dopamine (DA) synthesis and release feedback. Post-synaptic DR is more sensitive to DA response, produces DR hypersensitivity, and is in a denervation hypersensitivity. Physiological doses of DA can cause dyskinesia, often induced after levodopa or discontinuation of antipsychotics. To make the symptoms worse, it also supports the refinement of TD symptoms, haloperidol can temporarily cover up the symptoms, DA synergist can make the symptoms worse.

Pathological changes: autopsy revealed degeneration and atrophy of the substantia nigra and caudate nucleus.

an examination

Related inspection

Electroencephalogram examination electromyogram

1. Occurred in older patients, especially women, with brain organic lesions mostly, with severe symptoms and slow recovery. Various antipsychotic drugs can be caused. Fluorinated anti-psychotic drugs such as fluphenazine, trifluoperazine and haloperidol are common, most of which occur after taking antipsychotic drugs for more than 1 to 2 years, and the shortest 3 to 6 Months can appear, the longest is 13 years.

The main clinical manifestations are rhythmic stereotyped repetitive involuntary movements, early manifestations of tongue tremors or salivation, the oral movement of the elderly is characteristic, and the limb involvement of young patients is common. Children's oral and facial symptoms are more prominent, the lower muscles are most often involved, showing mouth-tongue-buster triad (BLM syndrome) or buccal, tongue, chewing syndrome, showing uncontrollable movements of the lips and tongue, such as involuntary Continuously chewing, sucking, turning tongue, tongue, mouth and drumsticks, jaw and neck, sometimes the tongue involuntarily suddenly protrudes out of the mouth, called the fly-catcher tongue, which occurs in severe cases. Unclear articulation and dysphagia. The trunk muscles are affected by the body shaking, the distal part of the limb is affected by the performance of the piano finger (toe) sign, the proximal part of the limb is rarely affected, a few show dance-like movements, no purpose flapping, two legs constantly jumping, the hands and feet are moving, the trunk is twisted Sexual sports and quirky postures. Occasionally showed gastrointestinal type, stomach discomfort, nausea and vomiting occurred after sudden withdrawal. When the mood is tense and excited, the symptoms worsen and disappear when you sleep. Some patients coexist with delayed sedation, delayed dystonia, and drug-induced Parkinson syndrome. Symptoms are easily concealed and exposed when drugs are reduced or discontinued.

2. Antipsychotic drugs can cause acute idiopathic dystonia or acute sedation. It occurs within 2 days of antipsychotic drugs. It is prone to occur in children and early adulthood. It shows dramatic limbs, trunk, neck, tongue and The twitching or uncomfortable posture of the facial muscles.

3. According to the movement disorder, it is divided into the following types: 1 eye muscle movement abnormality: performance blinking, sputum, etc.; 2 facial muscle movement abnormalities: facial muscle convulsions, convulsions and frowning face; 3 mouth muscle movement abnormalities: pouting, pouting, Chewing, aspiration and lateral movement of the mandible; 4 abnormalities of tongue muscle movement: tongue extension, tongue reduction, peristalsis and labrum; 5 abnormal movement of the pharyngeal muscle: abnormal movement of the ankle affects pronunciation and swallowing; 6 abnormality of neck movement: oblique Neck, neck back, etc.; 7 trunk movement abnormalities: the body trunk movement is uncoordinated, in a strange posture, such as shrug shoulders, horn arches, twisting, twitching, tendon snoring and breathing difficulties, sometimes the whole body swings, torso Repeated flexion and extension, twisting back and forth, called body-rocking; 8 abnormal limb movement: continuous flexion and extension of the distal end of the limb, called the piano finger (toe) sign, the proximal end is rarely affected, a few performance dance-like strokes Action, throwing movement, hand and foot movements, hands repeatedly and legs or non-stop jumping; 9 muscle tension low - paralyzed movement disorder: involving the head, neck and waist, such as neck soft can not look up, waist soft Straight from the abdomen and convex, and move not walking leg, foot to trail.

4. TD subtype 1 acute withdrawal syndrome: sudden incessation of antipsychotic drug involuntary erratic non-repetitive dance movement, similar to small chorea or Honenting disease, more common in children, self-healing; Can make the dance movement gradually disappear; 2 delayed dystonia: both children and adults can occur, involuntary exercise similar to torsional dystonia or torsion sputum, persistence, does not show rapid repetitive stereotypes.

According to the patient taking antipsychotics or long-term use of antidepressants, anti-Parkinson's drugs, anti-epileptic drugs or antihistamines, dyskinesia occurs during or after 3 months of drug withdrawal, showing rhythmic stereotypes and persistent persistence Involuntary movement.

Differential diagnosis

The disease must be distinguished from the following diseases:

1. Drug-induced Parkinson syndrome: Because DR is occupied or blocked by antipsychotic drugs, endogenous DA can not bind to DR, although there is also a history of antipsychotics, but involuntary exercise shows muscle rigidity, exercise reduction and movement Eye crisis and so on.

2. Huntington's disease: According to the genetic history, chorea and dementia and other three main signs, it is not difficult to identify with TD. HD patients also use antipsychotic drugs. If there is sedation, it can't be repeated or stereotyped involuntary movement to prompt TD.

3. Meige syndrome: is a common oral dyskinesia, complete type of mouth, mandibular dystonia, there are eyelids; non-complete type only mouth, tongue, pharynx and mandibular dystonia, or only the primary Sexual eyelids; no history of antipsychotics.

4. Twisting : Involuntary movement with rapid performance, stereotyped repetition, no history of taking antipsychotics.

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