Crozet Annals of Medicine: A Therapeutic Misadventure


by Dr. Robert C. Reiser

A crowd of interns and residents had gathered at the bedside by the time I first saw the patient and a lively discussion was going on about the nature of the symptoms. The majority opinion was that the patient was somehow in the throes of both swallowing and being strangled by his own tongue, while a sanguine bunch held forth that such a thing was not possible. The wild, terrified look in the patient’s eyes put him firmly in the former camp. Whatever the truth, it was clear that the patient’s tongue had turned against him. Writhing and curling backwards into his throat, it threatened to occlude his airway. Meanwhile his lip appeared to be hooked by an invisible fishhook which slowly and spasmodically wrenched his neck and head upward, around and backward. Even when his head could be spun no further his jaw continued its rotational journey, being pulled by some invisible force right into dislocation. Bizarre.

Having seen this scenario a number of times in my career, I had already asked a nurse to procure something for me and while I waited at the bedside I quizzed (“pimped” for those who read last month’s column) the residents about the etiology of this ghastly process. “Seizure?” volunteered the intern who obviously hadn’t read last month’s column.

“No. The rhythm of the movements is wrong, too slow.”


“No. I’ll give you the contractions of the jaw (lockjaw) but it is too asymmetric.”

“Faking it?” from the upper level resident.

“No. The fear is too real. But I’ll give you points for cynicism.”

“Sydenham’s Chorea?” (a very rare complication of Rheumatic Fever, itself a rarity in the modern era), from the medical student.

“No. Some of the grimacing fits, but at 28 he’s too old. But I’ll give you points for obscurity. Could this be a drug effect?” I asked.

“I looked him up in the computer, he has no medications listed” replied his intern.

“And yet this is a classic dystonic reaction, almost certainly from the antipsychotic medication Haldol.”

“I looked him up,” the intern insisted. “He has no psychiatric history.” The intern and the computer were in synch.

“Sir, have you taken any Haldol?”

An emphatic, gurgled ‘no’ issued from the patient. The intern seemed pleased. The computer was unmoved.

I took in the patient’s thin disheveled appearance and his obviously homemade prison tattoos. This was like shooting fish in a barrel.

“Sir do you do any cocaine?” He gave a weary, tiny nod of his skewed head.

“Cocaine should not cause dystonia,” riposted the intern.

“True. Sir, did you take anything to help with the crash?” A crash comes at the end of a cocaine binge and is characterized by irritability, depression and anxiety. It is quite unpleasant.

“Valium” was the strangled answer. Valium is well known by the addict population to ease the crash that inevitably comes when you run out of money and cocaine. I looked at the intern and cocked an eyebrow. No meds indeed.

“Valium does not cause dystonia,” the intern soldiered on.

“True. But where did you get the Valium, sir?”

Choking that sounded like “Bought it from a guy” came up from his throat.

“OK, I think we can help you.”

With that the nurse appeared at the bedside with three medicines. One was a small blue pill, Valium, which I showed to the intern. The other was a nearly identical blue pill, Haldol, which the patient identified as the drug that was actually sold to him on the street as Valium. Haldol is a very powerful antipsychotic and also a major tranquilizer once widely used in psychiatry. Being much easier to obtain illicitly than Valium, Haldol is often fraudulently sold on the street as Valium. Besides the ignominy of being swindled by a drug dealer, the buyer can also suffer from the rare Haldol side effect of acute life-threatening dystonia, just as this gentleman was. If you are going to buy drugs on the street, make sure they are from a dealer you trust.

The third medicine the nurse brought was Benadryl, which cleared up his distress in an almost magically quick 30 seconds after being administered IV. His tongue untied itself, his head came back to midline, the fear left his eyes and his jaw spontaneously relocated with the help of some gentle tugging. I recommended Benadryl for the next 48 hours and referral for substance abuse counseling.

I thought this medical detective work and miraculous life saving cure would impress the intern but it was hard to tell as his back was to me, updating the medication list in the computer.