Pisa Syndrome and Neurosyphilis: A Case Report in Taiwan

Background: Pisa syndrome, defined as more than 10 degrees tonic lateral flexion in upright spine without any significant associated vertebral rotation resembled the leaning tower of Pisa, is considered to be related to neuroleptics. Unfamiliarity of this disease, many neuro- and orthopedic surgeons can lead to unnecessary diagnostic and interventions. Method: We report an extremely rare case of neurosyphillis presenting with PISA syndrome in order to assess the clinical presentation and treatment. Results: A 49-year-old man, who has neurosyphillis and psychotic disorder due to general medical condition, treated by valproic acid 500 mg twice and quetiapine 200 mg once daily for as an unchanged regimen for the past 1 year. Five days after treatment with clozapine for poor controlled psychosis, he was noted leaned to one side. Physical examinations revealed a severe right truncal shift associated with left cervical tilt. We discontinued all medication except adding an anticholinergic drug (2 mg biperiden twice daily). After 7 days, the deformity disappeared with normal body posture. His psychosis flared up and we rechallenged clozapine 25mg daily. He was noticed leaned to one side again. Conclusions: orthopedic and neurological surgeons visiting patients with abnormal postures of the trunk need to evaluate medications especially with neuropsychiatric disease. Even drugs with a minimum risk of extrapyramidal symptoms, such as clozapine, can cause Pisa syndrome in even short duration and low dosage.