Fast Five Quiz: How Much Do You Know About Tardive Dyskinesia?

Matthew Swan, MD

Disclosures

April 30, 2019

For patients in whom TD is suspected, dark rings at the outer edges the irises might be Kayser-Fleischer rings due to copper deposition in part of the cornea (Descemet membrane). In some patients, slit-lamp examination is necessary to visualize the rings. This finding, together with the patient’s age and symptoms, raises concerns about Wilson disease, an uncommon autosomal recessive disorder of copper metabolism. In Wilson disease, copper accumulates in multiple organs, most importantly the brain and liver. Wilson disease should be considered in patients younger than 50 years who have movement disorders. The patient can manifest symptoms of tremors, reduced dexterity, choreiform movements, dystonia, rigidity, and/or dysarthria. Psychiatric features occur in 10%-20% of patients and can precede the movement disorder. Pathologic accumulation of copper in the liver can result in jaundice, abdominal pain, or hepatomegaly; untreated, Wilson disease may lead to fulminant liver failure. At a minimum, whenever Wilson disease is suspected, serum copper and ceruloplasmin levels should be checked, brain MRI should be performed, and an ophthalmologic consultation should be conducted. Results of a brain MRI in Wilson disease may demonstrate the classic “face of the giant panda” sign in the midbrain on T2-weighted images.

If a patient with hyperkinesia resembling TD has cognitive changes, then Huntington disease should also be considered.

If hyperkinesia resembling TD is focal (ie, affecting one limb), and especially if it co-occurs with other focal neurologic deficits (eg, asymmetric reflexes, hemiparesis), imaging should be performed to exclude a structural brain lesion.

Hudson-Stahli lines and Ascher intrastromal corneal rings are clinically insignificant ophthalmologic findings and are not part of the differential diagnosis for TD.

For more on the differential diagnosis of TD, read here and here.

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