J Neurol (1994) 241 : 167-169 © Springer-Verlag 1994 Andreas Thiel Dirk Dressler Dyskinesias possibly induced by norpseudoephedrine Received: 22 December 1992 Received in revised form: 4 March 1993 Accepted: 21 June 1993 A. Thiel ([~) • D. Dressler Psychiatrische Universit/itsklinik, von Siebold-Strasse 5, D-37075 G6ttingen, Germany Abstract We report two case his- tories of previously healthy patients who both developed persistent dyski- netic syndromes (spasmodic torticol- lis and cranial dystonia, respectively) following the intake of norpseudo- ephedrine (NPE) as an appetite sup- pressant. The symptoms took a chron- ic course even after NPE intake was discontinued. Similar drug-induced dyskinesias have been described for amphetamine and neuroleptic drugs. This side effect has, however, not yet been reported for NPE, which is pharmacologically related to amphet- amine. One of the patients may also have had multiple sclerosis. Struc- tural lesions in the basal ganglia area might predispose the development of such a movement disorder. The po- tential relationship between NPE in- take and the development of dyski- nesia is discussed. Appetite suppres- sants, often taken without the neurol- ogist's knowledge, may be the cause of dyskinetic syndromes. Key words Norpseudoephedrine Dystonia • Dyskinesia • Spasmodic torticollis Introduction Dyskinetic syndromes are known to be frequent side ef- fects of neuroleptic drags [18, 22], but are also observed with amphetamines and other central stimulant substances [4, 19, 22]. No such side effects have been described for D-norpseudoephedrine (NPE) to date. We report two case histories of previously healthy female patients who, fol- lowing temporary NPE intake, developed dystonic move- ment disorders which persisted after discontinuation of NPE. Case reports Patient A A slightly adipose, healthy female patient, with unremark- able history, had taken NPE for the first time at the age of 43 years in order to lose weight. With an NPE dose of 30 rag/ day (Recatol, Woelm Pharma, Germany), tachycardia and in- creased sweating occurred initially. Following dosage reduction to 30 mg NPE every 3-4 days, these unwanted side effects re- mitted. Nine months afer initiation of NPE medication the pa- tient developed dystonic symptoms with increasing retrocollis and spasmodic torticollis to the right. She had taken no neu- roleptic drugs. Neurological examination and laboratory tests, including ery- throcyte sedimentation rate, differential blood count, rheumatoid factor, antinuclear antibodies and immunoglobulins, did not re- veal relevant pathologic findings. MRI demonstrated multiple cerebral white, matter lesions in periventricular location and in the area of the left putamen (Fig. 1). Diagnostic examination of the CSF disclosed increased oligoclonal IgG bands and evidence of specific antibody synthesis against rubella in the CNS. Total cell count and protein content of the CSF were normal. ECG, EEG and evoked responses (visual, auditory and somatosensory) were normal. Three months after the dystonic symptoms started, the patient discontinued NPE, but both spasmodic torticollis and retrocollis persisted. There were no irregular movements of the trunk. In spite of various attempts at drug therapy, the neurological symtoms per- sistent throughout the following year, and botnlinum toxin injec- tion therapy was started.