Acute dystonic reactions (ADRs) occur commonly due to drug use in the form of extrapyramidal adverse reactions particularly involuntary strong contraction of the face, neck, and back muscles. ADRs can also be a side effect of other medications, such as antiemetic, antipsychotic, antidepressant, antiepileptic, and antimalarial medications, which produce ADRs due to dopaminergic-cholinergic imbalance in the basal ganglia [3]. ADRs are characterized by involuntary contractions in the region of face, trunk, extremities, pelvis, etc [3, 4]. AL, the mainstay antimalarial drug, may cause ADRs in patients at any age, even at therapeutic dosages. The incidence of Coartem-induced oculogyric crisis has not been reported in the literature, whereas other antimalarial drugs such as artesunate/amodiaquine were reported to cause ADRs in children [3].
AL is thought to be highly effective in treating uncomplicated malaria in children and the frequency of associated side effects is not higher that other available artemisinin-based combination therapies [5]. Ghana is an endemic for malaria, where in 2013, 44% of all outpatient clinic visits and 22.3% of all under-five death were associated with malaria [6]. Artemisinin is highly effective in clearing the biomass of Plasmodium within short time and prevents the maturation of the gametocytes by its partner drug lumefantrine. Lumefantrine is an aryl amino-alcohol in the same general group as mefloquine and halofantrine, offering the maximum dual performance of AL (Fig. 2) [7]. Therefore, the aim of this case report is bring to fore the association of AL as a cause of drug-induced oculogyric crisis.
Oculogyric crisis is defined as rare nonlife-threatening neurological manifestation that causes spasmodic movements of the eyeballs into a fixed position that may last from seconds to hours [3, 8]. The spasms may be followed by emotional lability, such as restlessness, compulsive thinking, anxiety, and sensations of increased brightness or visual distortions [6]. Although oculogyric crisis is mostly drug-induced, it can be seen in hereditary and sporadic movement disorders and disorders related to focal brain lesions. Oculogyric crisis must be excluded from versive seizures, eye movement tics, paroxysmal tonic upgaze syndrome, and retinal disease. Versive seizures are phenomenologically similar to oculogyric crisis, yet they are fundamentally different [3, 9]. Wyllie et al. reported that versive seizures can mimic oculogyric crisis, but they are associated with an alteration of consciousness and should be excluded with an electroencephalogram [9]. Paroxysmal tonic upward gaze is characterized by episodes of sustained conjugate upward deviation of the eyes and can be differentiated from oculogyric crisis by the presence of neck flexion and concomitant episodic ataxia [10].
Considering the important key points including the medication history and the clinical findings of the patient, a diagnosis of AL (Coartem)-induced oculogyric crisis was made. When a patient exhibits the symptoms of a neurological disorder, such as oculogyric crisis, with conscious state and normal vital signs, special attention should be given to recently administered medications. The management of drug-induced oculogyric crisis includes discontinuation or, if not possible, reducing the dose of the opposing agent. The mainstay treatment for oculogyric crisis is anticholinergics [6]. In our case, the patient’s symptoms improved within one hour after IM injection of promethazine hydrochloride.