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| ==Differential Diagnosis== | | ==Differential Diagnosis== |
| One the basis of stiffness it can be differentiated from:
| |
| *[[Tetanus]]
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| *[[Stiff man syndrome]]
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| *[[Meningitis]]
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| *[[Tardive dyskinesia]]
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| *[[Neuroleptic malignant syndrome]]
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|
| |
|
| {| style="border: 2px solid #DCDCDC; font-size: 90%; width: 83%;"
| |
| |+ '''Differential Diagnosis of Stiffness'''
| |
| ! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Disease
| |
| ! colspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Diagnosis
| |
| ! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Treatment
| |
| |-
| |
| ! align="center" style="background:#4479BA; color: #FFFFFF;" |Symptoms
| |
| ! align="center" style="background:#4479BA; color: #FFFFFF;" |Signs
| |
| ! align="center" style="background:#4479BA; color: #FFFFFF;" |Laboratory Findings
| |
| |-
| |
| | style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Tetanus]]<ref name="pmid27538652">{{cite journal| author=Woldeamanuel YW, Andemeskel AT, Kyei K, Woldeamanuel MW, Woldeamanuel W| title=Case fatality of adult tetanus in Africa: Systematic review and meta-analysis. | journal=J Neurol Sci | year= 2016 | volume= 368 | issue= | pages= 292-9 | pmid=27538652 | doi=10.1016/j.jns.2016.07.025 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27538652 }} </ref><ref name="pmid26598719">{{cite journal| author=Thwaites CL, Loan HT| title=Eradication of tetanus. | journal=Br Med Bull | year= 2015 | volume= 116 | issue= | pages= 69-77 | pmid=26598719 | doi=10.1093/bmb/ldv044 | pmc=4674006 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26598719 }} </ref>
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| *Tonic contraction of muscles between the spasmodic episodes
| |
| *[[Trismus]] or lockjaw
| |
| * [[Neck stiffness]]
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| * [[Swallowing difficulty]]
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| * Stiffening of the calf and pectoral muscle groups
| |
| | style="background: #F5F5F5; padding: 5px; text-align: center;" |
| |
| * [[Opisthotonos]]
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| * Leg [[extension]] with arm [[flexion]]
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| * [[Risus sardonicus]]
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| * [[respiratory distress]]
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| | style="background: #DCDCDC; padding: 5px;" |
| |
| * Not significant
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| * [[Diazepam]]
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| * [[Magnesium]]
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| * Human TIG
| |
| |-
| |
| | style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Neuroleptic malignant syndrome|Neuroleptic Malignant Syndrome]] <ref name="pmid28533580">{{cite journal| author=Hosseini S, Elyasi F| title=Olanzapine-Induced Neuroleptic Malignant Syndrome. | journal=Iran J Med Sci | year= 2017 | volume= 42 | issue= 3 | pages= 306-309 | pmid=28533580 | doi= | pmc=5429500 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28533580 }} </ref><ref name="pmid28488314">{{cite journal| author=Leenhardt F, Perier D, Pinzani V, Giraud I, Villiet M, Castet-Nicolas A et al.| title=Pharmacist intervention to detect drug adverse events on admission to the emergency department: Two case reports of neuroleptic malignant syndrome. | journal=J Clin Pharm Ther | year= 2017 | volume= | issue= | pages= | pmid=28488314 | doi=10.1111/jcpt.12531 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28488314 }} </ref>
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| *History of intake of offending drugs e.g [[neuroleptics]] like:
| |
| **[[Fluphenazine]]
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| **[[Haloperidol]]
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| **[[Olanzapine]]
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| **[[Risperidone]]
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| *[[Autonomic instability]]
| |
| *[[Stiffness|Rigidity]]
| |
| *[[Disorientation]]
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| *[[Fever]]
| |
| | style="background: #F5F5F5; padding: 5px; text-align: center;" |
| |
| * [[Dysphagia]]
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| * [[Pallor]]
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| * [[Dyspnea]]
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| * [[Shuffling gait]]
| |
| * [[Agitation]]
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| ** [[Myoglobinemia]]
| |
| ** Elevated [[LDH]]
| |
| ** Elevated [[creatine kinase]]
| |
| ** [[Hyperkalemia]]
| |
| ** Elevated [[AST]] and [[ALT]]
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| ** [[Hyperphosphatemia]]
| |
| ** Elevated [[alkaline phosphatase]]
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| ** [[Hyperuricemia]]
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| * Supportive therapy
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| * Stop the offending agent
| |
| * Medical Therapy
| |
| ** [[Dantrolene]]
| |
| ** [[Amantadine]]
| |
| ** [[Bromocriptine]]
| |
| |-
| |
| | style="background: #F5F5F5; padding: 5px;" | [[Meningitis|Viral Meningitis]]<ref name="pmid24326618">{{cite journal| author=Chow E, Troy SB| title=The differential diagnosis of hypoglycorrhachia in adult patients. | journal=Am J Med Sci | year= 2014 | volume= 348 | issue= 3 | pages= 186-90 | pmid=24326618 | doi=10.1097/MAJ.0000000000000217 | pmc=4065645 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24326618 }} </ref><ref name="pmid22880096">{{cite journal| author=Leen WG, Willemsen MA, Wevers RA, Verbeek MM| title=Cerebrospinal fluid glucose and lactate: age-specific reference values and implications for clinical practice. | journal=PLoS One | year= 2012 | volume= 7 | issue= 8 | pages= e42745 | pmid=22880096 | doi=10.1371/journal.pone.0042745 | pmc=3412827 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22880096 }} </ref><ref name="pmid15319091">{{cite journal| author=Tyler KL| title=Herpes simplex virus infections of the central nervous system: encephalitis and meningitis, including Mollaret's. | journal=Herpes | year= 2004 | volume= 11 Suppl 2 | issue= | pages= 57A-64A | pmid=15319091 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15319091 }} </ref>
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| * [[Fever]]
| |
| * [[Irritability]]
| |
| * Lack of appetite
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| * [[Lethargy]]
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| * Disoriented
| |
|
| |
| * High grade [[fever]]
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| * Severe [[headache]]
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| * [[Stiff neck]]
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| * [[Photophobia|Sensitivity to bright light]]
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| * [[Nausea]]
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| * [[Vomiting]]
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| *[[Headache]]
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| *[[Photophobia]]
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| *Phonophopia
| |
| *[[Pharyngitis]] in case of [[enterovirus]] infeciton
| |
| *[[Orchitis]] (In mumps)
| |
| *[[Vesicular]] or [[macular]] [[skin rash]]
| |
| *[[Petechia|Petichiae]]
| |
| *[[Nuchal rigidity]]
| |
| *Signs of [[meningeal irritation]]:
| |
| **[[Kernig's sign]]
| |
| **[[Brudzinski's sign]]
| |
| *[[Altered mental status]]
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| *[[Hypotonia]]
| |
|
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| *[[CSF]] / [[plasma glucose]] ratio (>0.6)
| |
| *[[Lactate]] (mmols/l) (<2.1)
| |
| *[[Lymphocytes]] > [[granulocytes]]
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| * Supportive
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| ** [[Analgesics]] for [[pain]].
| |
| ** [[Acetaminophen]] for [[fever]].
| |
| * Anti-viral therapy:
| |
| ** [[Acyclovir]]
| |
| ** [[Pleconaril]]
| |
| |-
| |
| | style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Stiff man syndrome]]
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| * Marked rigidity
| |
| * [[Spasms]]
| |
| ** Intermittent
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| ** Painful
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| ** Absent during sleep
| |
| | style="background: #F5F5F5; padding: 5px; text-align: center;" |
| |
| * [[Diaphoresis]]
| |
| * [[Arterial hypertension]]
| |
| * [[Tachypnea]]
| |
| * [[Cyanosis]]
| |
| * [[Apnea]], [[tachypnea]]
| |
| * [[Respiratory arrest]]
| |
| * Dilatation of the pupils
| |
| * [[Tachycardia]]
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| * [[CSF]] has
| |
| ** Elevated [[IgG]]
| |
| ** [[Oligoclonal bands]]
| |
| * Positive anti-GAD antibodies
| |
| * Elevated [[creatine kinase]]
| |
| * Normal CBC & ESR
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| * [[Benzodiazepines]]
| |
| * B[[Baclofen|aclofen]]
| |
| * [[Vigabatrin]]
| |
| * [[Valproic Acid]], [[Neurontin]]
| |
| * Injected [[botulinum toxin]]
| |
| * [[Prednisone]], [[plasmapheresis]], [[IVIG]] ( some success)
| |
| |-
| |
| | style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Drug]] induced [[Tardive dyskinesia|(Tardive dyskinesia]])<ref name="pmid28552340">{{cite journal| author=Deng ZD, Li DY, Zhang CC, Pan YX, Zhang J, Jin H et al.| title=Long-term follow-up of bilateral subthalamic deep brain stimulation for refractory tardive dystonia. | journal=Parkinsonism Relat Disord | year= 2017 | volume= | issue= | pages= | pmid=28552340 | doi=10.1016/j.parkreldis.2017.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28552340 }} </ref><ref name="pmid28520698">{{cite journal| author=| title=Valbenazine (Ingrezza) for tardive dyskinesia. | journal=Med Lett Drugs Ther | year= 2017 | volume= 59 | issue= 1521 | pages= 83-84 | pmid=28520698 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28520698 }} </ref><ref name="pmid28510661">{{cite journal| author=Voelker R| title=Tardive Dyskinesia Drug Approved. | journal=JAMA | year= 2017 | volume= 317 | issue= 19 | pages= 1942 | pmid=28510661 | doi=10.1001/jama.2017.5537 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28510661 }} </ref>
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| *History of intake of the offending drug for at least one month
| |
| **[[Neuroleptics]] ([[antipsychotics]])
| |
| **[[Metoclopramide]]
| |
| *Eye deviation
| |
| *Head and neck jerky movements
| |
| *No tonic contraction of the muscles between the spasms
| |
| | style="background: #F5F5F5; padding: 5px; text-align: center;" |
| |
| * [[Dyskinesia]] of the tongue and lips
| |
| * [[Dyskinesia]] of the limbs
| |
| * [[Dyskinesia]] of the neck
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| * It is a clinical diagnosis depending on
| |
| ** [[Dyskinetic|Dyskinetic movements]]
| |
| ** Hx of > 1 month of [[Antipsychotics|antipsychotic]] use
| |
| * Labs may be done to rule out other differentials
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| * Stop the offending agent
| |
| * [[Benztropine]]
| |
| * [[Benzodiazepines]]
| |
| * Injection of [[botulinum toxin]]
| |
| * Valbenzine
| |
| * [[Tetrabenazine]]
| |
| |-
| |
| | style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Strychnine poisoning]]<ref>{{Cite journal
| |
| | author = [[Charlotte Duverneuil]], [[Geoffroy Lorin de la Grandmaison]], [[Philippe de Mazancourt]] & [[Jean-Claude Alvarez]]
| |
| | title = Liquid chromatography/photodiode array detection for determination of strychnine in blood: a fatal case report
| |
| | journal = [[Forensic science international]]
| |
| | volume = 141
| |
| | issue = 1
| |
| | pages = 17–21
| |
| | year = 2004
| |
| | month = April
| |
| | doi = 10.1016/j.forsciint.2003.12.010
| |
| | pmid = 15066709
| |
| }}</ref><ref>{{Cite journal
| |
| | author = [[B. A. Smith]]
| |
| | title = Strychnine poisoning
| |
| | journal = [[The Journal of emergency medicine]]
| |
| | volume = 8
| |
| | issue = 3
| |
| | pages = 321–325
| |
| | year = 1990
| |
| | month = May-June
| |
| | pmid = 2197324
| |
| }}</ref><ref>{{Cite journal
| |
| | author = [[B. J. Maron]], [[J. R. Krupp]] & [[B. Tune]]
| |
| | title = Strychnine poisoning successfully treated with diazepam
| |
| | journal = [[The Journal of pediatrics]]
| |
| | volume = 78
| |
| | issue = 4
| |
| | pages = 697–699
| |
| | year = 1971
| |
| | month = April
| |
| | pmid = 5547830
| |
| }}</ref><ref>{{Cite journal
| |
| | author = [[B. Oberpaur]], [[A. Donoso]], [[C. Claveria]], [[C. Valverde]] & [[M. Azocar]]
| |
| | title = Strychnine poisoning: an uncommon intoxication in children
| |
| | journal = [[Pediatric emergency care]]
| |
| | volume = 15
| |
| | issue = 4
| |
| | pages = 264–265
| |
| | year = 1999
| |
| | month = August
| |
| | pmid = 10460082
| |
| }}</ref>
| |
|
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| *Hx of up to date tetanus immunizations
| |
| *History of intentional or accidental intake
| |
| **''Strychnos nux vomica seeds''
| |
| **Rodenticide
| |
| | style="background: #F5F5F5; padding: 5px; text-align: center;" |
| |
| * Hypervigilance
| |
| * Anxiety
| |
| * Mydriasis
| |
| * Hypereflexia
| |
| * Clonus
| |
| * Facial and neck stiffness
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| * Blood assay
| |
| * Tissue assay
| |
| * Urine assay
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| * Initial stabilization
| |
| * High dose [[Benzodiazepines]]
| |
| * Intubation and airway securing
| |
| |-
| |
| | style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Hypocalcaemia]]<ref name="pmid27065735">{{cite journal| author=Chhabra P, Rana SS, Sharma V, Sharma R, Bhasin DK| title=Hypocalcemic tetany: a simple bedside marker of poor outcome in acute pancreatitis. | journal=Ann Gastroenterol | year= 2016 | volume= 29 | issue= 2 | pages= 214-20 | pmid=27065735 | doi=10.20524/aog.2016.0015 | pmc=4805743 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27065735 }} </ref><ref name="pmid24171002">{{cite journal| author=Desai M, Kolla PK, Reddy PL| title=Calcium unresponsive hypocalcemic tetany: gitelman syndrome with hypocalcemia. | journal=Case Rep Med | year= 2013 | volume= 2013 | issue= | pages= 197374 | pmid=24171002 | doi=10.1155/2013/197374 | pmc=3792521 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24171002 }} </ref>
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| **[[Muscle]] [[twitching]] and [[cramping]]
| |
| **Circumoral and extremity [[paresthesia]] or [[tingling]]
| |
| ** [[Altered mental status]]
| |
| ** [[Irritability]]
| |
| ** [[Depression]]
| |
| ** [[Psychosis]]
| |
| ** [[Seizure]]
| |
| | style="background: #F5F5F5; padding: 5px; text-align: center;" |
| |
| ** [[Tetany (medical sign)|Tetany]] (carpopedal spasm)
| |
| ** Latent tetany
| |
| *** [[Trousseau sign of latent tetany]]
| |
| *** [[Chvostek's sign]]
| |
| ** Hyperactive tendon reflexes
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| * Decreased blood [[calcium]] levels
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| * Two [[Ampule|ampules]] of [[intravenous]] [[calcium gluconate]] 10% is given slowly in a period of 10 minutes, or
| |
| * If hypocalcemia is severe, [[calcium chloride]] is given instead
| |
| * Maintenance doses of both calcium and [[vitamin-D]]
| |
| |-
| |
| | style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Parkinson's disease]]<ref name="pmid11402154">{{cite journal| author=Olanow CW, Watts RL, Koller WC| title=An algorithm (decision tree) for the management of Parkinson's disease (2001): treatment guidelines. | journal=Neurology | year= 2001 | volume= 56 | issue= 11 Suppl 5 | pages= S1-S88 | pmid=11402154 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11402154 }} </ref><ref name="pmid24756517">{{cite journal| author=Connolly BS, Lang AE| title=Pharmacological treatment of Parkinson disease: a review. | journal=JAMA | year= 2014 | volume= 311 | issue= 16 | pages= 1670-83 | pmid=24756517 | doi=10.1001/jama.2014.3654 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24756517 }} </ref>
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| * [[Stiffness]]
| |
| * Inability to write
| |
| * Jerky movements at rest
| |
| * [[Constipation]]
| |
| * Sleeping difficulty
| |
| * Walking difficulty
| |
| | style="background: #F5F5F5; padding: 5px; text-align: center;" |
| |
| * [[Tremor]]
| |
| * Rigidity
| |
| * [[Bradykinesia]]
| |
| * [[Postural instability]]
| |
| * Shuffling gait
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| * Clinical diagnosis
| |
| * Improvement with dopaminergic therapy confirms diagnosis
| |
| | style="background: #DCDCDC; padding: 5px;" |
| |
| * Symptomatic therapy
| |
| * [[Dopamine agonists]]
| |
| * [[Levodopa]]
| |
| * [[Amantadine]]
| |
| * [[MAO inhibitors]]
| |
| * COMT inhibitors
| |
| * [[Anticholinergics]]
| |
| |}
| |
|
| |
|
| ==References== | | ==References== |