Reflex Sympathetic Dystrophy-Like Syndrome, Possibly Caused by Aripiprazole, in an Adolescent Patient

[Author Affiliation]Anu Upadhyay. Department of Child and Adolescent Psychiatry, Rutgers University Behavioral Health Care, Piscataway, New Jersey.Address correspondence to: Anu Upadhyay, MD, Department of Child and Adolescent Psychiatry, Rutgers University Behavioral Health Care, 671 Hoes Lane, Piscataway, NJ 08824, E-mail: anuaditya2002@yahoo.comTo The Editor:I present a case of possible aripiprazole-induced reflex sympathetic dystrophy-like syndrome in a 15-year-old girl, which to my knowledge is the only case described in an adolescent on antipsychotic medication.Reflex sympathetic dystrophy syndrome (RSDS) is characterized by disabling pain, swelling, vasomotor instability, sudomotor abnormality, and impairment of motor function that usually follows regional trauma, subsequent to various diseases (Albazaz et al. 2008). Reflex sympathetic dystrophy was first described by Mitchell in 1864 during the American Civil War (Mitchell et al. 1864). Some drugs such as isoniazid, phenobarbital, and some immune suppressants have been implicated in the onset of RSDS (Marshall et al. 2000). Several authors agree on the importance of psychological factors in childhood RSDS (Maillard et al. 2004). Since it was first described, it has been given different titles, such as causalgia or sympathetic maintained pain syndrome, and more recently, it has been known as chronic regional pain syndrome type (CPRS 1) (Stanton-Hicks et al. 1995).The pathophysiology of this syndrome is related to impaired tissue microvasculature under the influence of abnormal sympathetic reflex hyperactivity.Reflex sympathetic dystrophy is less common in children than adults, hence it is rarely mentioned in pediatric textbooks, but clinicians are becoming more aware of the problem. In children, there are a different presentation and treatment response. Generally, there is less often an antecedent history of trauma or surgery in children who develop RSDS, and the outlook for recovery is better than in adults (Stanton-Hicks et al. 1995). RSDS is more common in girls than boys (3:1), and tends to occur in adolescence (median age 12 years). The lower limb is more affected than the upper limb (2:1) (Murray et al. 2000).Case ReportMM was a 15-year-old female of Hispanic descent who presented to the outpatient psychiatry clinic with complaints of extreme anger, aggression, and impulsivity. Aripiprazole was accepted by the patient and her parents, to help with the presented symptoms, because of the relatively safe side effect profile. Patient was started on aripiprazole 2 mg orally at night, which she tolerated well. On third day, the dose of aripiprazole was increased to 4 mg orally at night. Two days after the aripiprazole dose was increased, the patient noticed redness on both her feet and gradually increasing swelling, so much so that she could not wear her regular footwear. She also noticed sharp shooting pain in her feet, the intensity of which varied from 5 to 8 on a 10 point scale. She described it as diffuse, intermittent, and mainly on the ventral surface of her feet. She reported that the pain was worse when she was walking, and was a bit better when she was at rest, although a dull achy feeling remained. She had no history of trauma or surgery in the recent past. She had a first degree relative with osteoarthritis, but there was no family history of any other joint problems (Murray et al. 2000).Interestingly, the pain and swelling was localized to the feet, and her lower limbs were unaffected. Aripiprazole was discontinued, and patient was sent to her pediatrician for appropriate follow-up. After a thorough physical examination and laboratory testing consisting of a comprehensive metabolic profile, complete blood count, urine analysis, and urine drug screen, which revealed normal results, the symptoms were deemed to be a possible side effect of aripiprazole. Meanwhile the patient was advised to begin with gentle weight bearing, and slowly progress to active weight bearing, wearing comfortable footwear, and to take nonsteroidal anti-inflammatory drugs (NSAIDs) as needed for pain (Brunnekreef et al. …