Spot Diagnosis

Acute Oromandibular Dystonia

Inês Afonso Belo1, Ana Rita Ramos2, João Nuno Franco2
1Department of Pediatrics, Centro Hospitalar de Leiria, Portugal, 2Department of Pediatrics, Hospital Garcia de Orta, Portugal

Address for Correspondence: Inês Belo, Hospital de Santo André - Rua das Olhalvas, Leiria, Portugal
Postal address: 2410-197 Leiria, Portugal
Keywords : Metoclopramide, acute dystonia, side effects
Question :
A previously healthy 14-year-old girl was brought to the Emergency Department by the paramedics due to a sudden onset of painful involuntary oromandibular muscle contraction and swollen lips. She also referred sporadic vomiting, once or twice a day, and abdominal pain for three days. On physical examination, she exhibited an oromandibular muscle contraction, deviating to the right side and angioedema of the lips (Figure 1). Her physical and neurological examination was otherwise unremarkable. She had no sialorrhea, no dyspneia, no rash and no tongue swelling. She weighted 41 Kg (between the 10th and 25th percentiles) and her height was 156 cm (25th percentile).
On the previous day, her primary care physician prescribed metoclopramide, 10 mg three times a day (0.7 mg/kg/day) for the vomiting, in the context of a probable gastrointestinal infection.
Due to the hypothesis of an extrapyramidal effect of metoclopramide, intravenous biperiden was administered and there was a resolution of the dystonia and the edema within a few minutes (Figure 2).

What is the diagnosis?
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