0
Get Alert
Please Wait... Processing your request... Please Wait.
You must sign in to sign-up for alerts.

Please confirm that your email address is correct, so you can successfully receive this alert.

1
Letters   |    
Orobuccolingual Dyskinesia After Long-Term Use of Black Cohosh and Ginseng
A. Sen, M.D.
The Journal of Neuropsychiatry and Clinical Neurosciences 2013;25:E50-E50. doi:10.1176/appi.neuropsych.12120395
View Author and Article Information

Financial Disclosure Statement: The author has not received any financial support for this clinical/scientific note.

Bakirkoy Research and Training Hospital for Psychiatry, Neurology, and Neurosurgery, Istanbul, Turkey

Correspondence: e-mail: aysehir@yahoo.com

Copyright © 2013 by the American Psychiatric Association

To the Editor: Black cohosh (BC), also known as Cimicifuga racemosa, is a frequently used herbal remedy for alleviating menopausal symptoms.1 Ginseng has been widely used as herbal medicine in eastern Asia.2 We report a on a patient who developed orobuccolingual dyskinesia (OBLD) while being treated with an herbal supplement containing BC and ginseng.

A 46-year-old woman was admitted to our hospital with a 3-month history of OBLD that interfered with her speech, tongue-biting, and eating difficulties. Her neurological examination was otherwise normal except for OBLD (Abnormal Involuntary Movement Scale Score [AIMSS]: 8). Her personal and family history were not relevant for neuropsychiatric disorders. The patient denied any exposure to dopamine-blocking drugs or other medications. She reported the use of a 2-tablet/day dose of a plant-based preparation containing 20 mg BC and 50 mg Panax ginseng to treat her menopausal symptoms for at least 15 months. The general physical examination, routine blood examinations, and comprehensive tests for movement disorders (also including genetic tests) were all normal. Her cranial computerized tomography, contrast-enhanced cranial magnetic resonance imaging, and cranial fluorodeoxyglucose positron emission tomography were also normal. The preparation was stopped. She improved substantially with a combination of baclofen 40 mg/day and clonazepame 2 mg/day (AIMSS: 2).

To our knowledge, this is the first reported case of OBLD observed after the combined use of BC and ginseng. The action mechanisms, pharmacokinetics, and metabolites of BC have not been totally identified. Recent data have demonstrated that BC may have an effect on dopaminergic, serotoninergic, and GABAergic systems.1 It has been suggested that unknown dopaminergic compounds may contribute to the pharmacological activity of BC.3 More than 30 different ginsenosides, the main components responsible for the actions of ginseng, have been isolated and identified from ginseng.2 In spite of some in-vivo studies indicating that some ginsenosides can be neuroprotective to striatal neurons,4 the results from a recently-published in-vitro study were mixed. This study has shown that low doses of some ginsenosides exhibited striatal neuroprotective effects, whereas overdoses have caused striatal toxic effects.2 Wu et al.2 reported that there could only be a fine line between the neuroprotective and toxic effects of ginsenosides. The use of ginseng can cause complications when used in combination with other medications. Adverse effects, including nervousness and insomnia,2 have been reported from long-term use and high doses of ginseng; BC has been linked to liver, cardiovascular, CNS, and peripheral nervous system adverse events. It was reported that mono-preparation of BC is safe in the short term for otherwise-healthy menopausal women, and Huntley3 recommended limiting its use to 6 months.

Estrogens have well-known neuroprotective activity. Postmenopausal estrogen deficiency leaves the dopaminergic system vulnerable to neurotoxicity.5

We suggest that BC together with ginseng could be responsible for the OBLD. Previous use of BC together with ginseng should be investigated carefully in patients with OBLD. Further studies on basic pharmacological mechanisms of actions and toxicity of BC and ginsenosides are needed.

Cicek  SS;  Khom  S;  Taferner  B  et al:  Bioactivity-guided isolation of GABA(A) receptor-modulating constituents from the rhizomes of Actaea racemosa.  J Nat Prod 2010; 73:2024–2028
[CrossRef] | [PubMed]
 
Wu  J;  Jeong  HK;  Bulin  SE  et al:  Ginsenosides protect striatal neurons in a cellular model of Huntington’s disease.  J Neurosci Res 2009; 87:1904–1912
[CrossRef] | [PubMed]
 
Huntley  A:  The safety of black cohosh (Actaea racemosa, Cimicifuga racemosa).  Expert Opin Drug Saf 2004; 3:615–623
[CrossRef] | [PubMed]
 
Lian  XY;  Zhang  Z;  Stringer  JL:  Protective effects of ginseng components in a rodent model of neurodegeneration.  Ann Neurol 2005; 57:642–648
[CrossRef] | [PubMed]
 
Vegeto  E;  Benedusi  V;  Maggi  A:  Estrogen anti-inflammatory activity in brain: a therapeutic opportunity for menopause and neurodegenerative diseases.  Front Neuroendocrinol 2008; 29:507–519
[CrossRef] | [PubMed]
 
References Container
+

References

Cicek  SS;  Khom  S;  Taferner  B  et al:  Bioactivity-guided isolation of GABA(A) receptor-modulating constituents from the rhizomes of Actaea racemosa.  J Nat Prod 2010; 73:2024–2028
[CrossRef] | [PubMed]
 
Wu  J;  Jeong  HK;  Bulin  SE  et al:  Ginsenosides protect striatal neurons in a cellular model of Huntington’s disease.  J Neurosci Res 2009; 87:1904–1912
[CrossRef] | [PubMed]
 
Huntley  A:  The safety of black cohosh (Actaea racemosa, Cimicifuga racemosa).  Expert Opin Drug Saf 2004; 3:615–623
[CrossRef] | [PubMed]
 
Lian  XY;  Zhang  Z;  Stringer  JL:  Protective effects of ginseng components in a rodent model of neurodegeneration.  Ann Neurol 2005; 57:642–648
[CrossRef] | [PubMed]
 
Vegeto  E;  Benedusi  V;  Maggi  A:  Estrogen anti-inflammatory activity in brain: a therapeutic opportunity for menopause and neurodegenerative diseases.  Front Neuroendocrinol 2008; 29:507–519
[CrossRef] | [PubMed]
 
References Container
+
+

CME Activity

There is currently no quiz available for this resource. Please click here to go to the CME page to find another.
Submit a Comments
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discertion of APA editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe



Related Content
Books
Dulcan's Textbook of Child and Adolescent Psychiatry > Chapter 49.  >
Textbook of Traumatic Brain Injury, 2nd Edition > Chapter 39.  >
Textbook of Traumatic Brain Injury, 2nd Edition > Chapter 39.  >
Textbook of Traumatic Brain Injury, 2nd Edition > Chapter 39.  >
The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition > Chapter 26.  >
Topic Collections
Psychiatric News