Objective: To report the acute onset of generalized chorea as an adverse reaction to transdermal fentanyl

Background: Chorea can present with degenerative conditions or in an acquired manner[1]. Here we present a case of transdermal fentanyl provoking chorea, which to our knowledge, is the first such report in the literature.

Methods: Case report

Results: A 91-year old female with a medical history of rheumatic fever as a child presented complaining of uncontrollable, generalized movements. The movements started one month prior after she was switched to a different brand of transdermal fentanyl, Her symptoms started over a period of two days and remained constant. Laboratory evaluation included thyroid studies, Sjogren’s antibody, ANA, antiphospholipid antibody, double-stranded DNA, lead, antistreptolysin antibody, renal, hematologic, and liver profiles. All were unremarkable. She had a complicated hospital course that included group A streptococcus bacteremia , presumed endocarditis, and new onset atrial fibrillation. An MRI demonstrated multiple small areas of restricted diffusion within the right precentral gyrus, the left posterior frontal, left parietal, and left superior occipital regions. Her fentanyl was stopped and she was treated with oral morphine 15 mg twice daily for her chronic pain. She was given diazepam 5 mg three times a day. The movements gradually improved. Due to her prolonged dysphagia, she had a feeding tube placed. She was discharged and completed a 6-week course of ceftriaxone for bacterial endocarditis. After a period of 4 months, her movements had resolved. She was able to have the feeding tube removed, and returned to her prehospital level of functioning. She was seen 6 months after initial symptoms in the orthopedics office due to her continued chronic pain, and was restarted on 25 mcg of transdermal fentanyl. Choreic movements promptly returned. The medication was again stopped, with gradual resolution of symptoms.

Conclusions: Chorea is a commonly reported side effect for many medications[2]. The differential diagnosis of chorea is broad, and specific identification of causative agents can be elusive. It is important to take a detailed medication history, as there are many medications that elicit chorea. In this report, we provide case data suggesting fentanyl should be considered when alternate explanations for chorea are absent or inconclusive.

References: 1, Mestre TA. Chorea. CONTINUUM: Lifelong Learning in Neurology 2016;22(4, Movement Disorders):1186-207 doi: 10.1212/con.0000000000000349[published Online First: Epub Date]|.

2. Piccolo II. Cause and course in a series of patients with sporadic chorea. Journal of neurology;250(4):429-35 doi: 10.1007/s00415-003-1010-7[published Online First: Epub Date]|.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/fentanyl-induced-chorea-a-case-report/