Orofacial dyskinesia induced by nasal Ritalin® (methylphenidate) sniffing

Abstract

Ritalin® (methylphenidate) is an amphetamine-like prescription stimulant commonly used in the treatment of attention deficit hyperactivity disorder in children and adults. Recently, the recreational use of Ritalin has increased, particularly among young adults. Well-known symptoms of intoxication include signs of sympathetic nervous stimulation, such as agitation, anxiety, tachycardia, hypertension, headache, tremor, and dizziness. This case report describes oral dyskinesia as a rare presentation of Ritalin intoxication, with the review of pathophysiology and some epidemiological data.

Differences in Methylphenidate Abuse Rates Among Methadone Maintenance Treatment Patients in Two Clinics

“…The primary clinical syndrome of methylphenidate overdose involves prominent neurological and cardiovascular effects, while secondary complications can involve renal, muscle, pulmonary, and gastrointestinal effects. In overdose, the patient may present with mydriasis, tremor, agitation, hyperreflexia, combative behavior, confusion, hallucinations, delirium, anxiety, paranoia, movement disorders, and seizures (Marti, Fattinger, Zimmermann, & Exadaktylos, 2013;Spiller, Hays, & Aleguas, 2013). The second (and not less important) is the urge (presented already to the regulatory authorities in Israel) to add methylphenidate to the list of drugs of abuse checked-for in the routine urine tests.…”

Psychostimulants and Movement Disorders

“…For methylphenidate intoxication, sympathetic nervous system stimulation signs are characteristic, including hypertension, tachycardia, agitation, anxiety, psychosis, headache, and dizziness. Tremor, tics, chorea, and orofacial dyskinesias have been described as neurologic side effects of methylphenidate abuse ( 94 , 95 ). When injected, methylphenidate may cause serious toxicity resulting in tissue necrosis, and occasional intra-arterial injections have lead to the amputation of fingers ( 96 ).…”

Dyskinesia in Treatment-Naive and Stimulant-Treated Children With ADHD

“…In the past few decades, and especially in recent years, an emerging number of case studies concerning the association between stimulant (mostly methylphenidate) treatment and dyskinesias have been reported (Balázs, Besnyő, & Gádoros, 2007; Case & McAndrew, 1974; Gay & Ryan, 1994; Heinrich, 2002; Hollis & Thompson, 2007; Marti, Fattinger, Zimmermann, & Exadaktylos, 2013; Mattson & Calverley, 1968; Mendhekar & Andrade, 2008; Morgan, Winter, & Wooten, 2004; Potter, John, & Coffey, 2012; Sallee, Stiller, Perel, & Everett, 1989; Senecky, Lobel, Diamond, Weitz, & Inbar, 2002; Singh, Singh, & Chusid, 1983; Thiel & Dressler, 1994; Yilmaz et al, 2013; Weiner, Nausieda, & Klawans, 1978; Willemsen & van der Wal, 2008). According to Balázs, Dallos, Keresztény, Czobor, and Gádoros (2011), these case reports can be categorized into two groups.…”

“…In the first group, studies report cases in which dyskinesia arises many weeks after the first administration of the stimulant, and diminishes only months after the withdrawal of the therapy (Gay & Ryan, 1994; Mattson & Calverley, 1968; Mendhekar & Andrade, 2008; Morgan et al, 2004; Potter et al, 2012; Sallee et al, 1989; Singh et al, 1983; Thiel & Dressler, 1994; Weiner et al, 1978). The second group of studies includes cases where the emergence, and also the cessation of the dyskinesia, occurs on the same day of (or in some days following) the first administration of the stimulant (Balázs et al, 2007; Case & McAndrew, 1974; Heinrich, 2002; Hollis & Thompson, 2007; Marti et al, 2013; Mattson & Calverley, 1968; Senecky et al, 2002; Yilmaz et al, 2013; Willemsen & van der Wal, 2008).…”

“…Regarding the body area in methylphenidate induced dyskinesias, most studies reported that both the face and orofacial region (e.g., Balázs et al, 2007; Hollis & Thompson, 2007; Marti et al, 2013; Potter et al, 2012; Senecky et al, 2002; Yilmaz et al, 2013) and, in some cases, also the extremities (e.g., Balázs et al, 2007; Hollis & Thompson, 2007; Potter et al, 2012; Yilmaz et al, 2013) could be affected.…”