Galantamine‐induced pisa syndrome: memantine as an alternative

Dear Editor Pisa syndrome, or pleurothotonus, which was first described by Ekbom et al. (1972), is a condition characterized by sustained flexion of the body with the head to one side. It has been observed in patients with prolonged exposure to antipsychotics and also to be triggered in at least 14 reported cases by cholinesterase inhibitors (ChEIs) (Kwak et al., 2000; Miyaoka et al., 2001; Villarejo et al., 2003; Cossu et al., 2004; Vanacore et al., 2005; Huvent-Grelle et al., 2007). These case reports proposed that ChEIs-induced Pisa syndrome may resolve after the medication being discontinued or switched to another ChEIs, while others may be improved by locally injected botulinum toxin. However, the long-term management of these patients was not fully described or suggested. We report a case of galantamine-induced Pisa syndrome whose dystonia remitted after the discontinuation of galantamine and successfully switching to memantine. A 65-year-old woman with 4-year history of moderate Alzheimer’s disease (AD) was admitted to our geriatric psychiatric acute ward for amnesia, depressed mood, irritability, and disturbing behavior. At admission, she took galantamine 16mg/day, sertraline 50mg/day, and valproic acid 500mg/day, in divided doses. Her mood and behavior symptoms were then partially stabilized. The regimen remained unchanged thereafter. After 6-months therapy, she gradually developed right laterocollis with slight-right axial deviation. On examination, magnetic resonance imaging of the brain showed no focal lesions other than cortical atrophy. Pisa syndromewas diagnosed by a neurologist. Galantamine was then discontinued with sertraline and valproic acid being maintained. Four weeks later, a trial to titrate memantine to 20mg/day was initiated. Two weeks after switching