Question

What is a possible case study for Parkinson's disease?

Answer 1

Ans) Possible case study for Parkinson's disease:

- A patient is a 57-year-old, right-handed female who began to notice tremor in her right arm ~1 year ago, as well as rigidity involving the right side and bradykinesia.

- She was observed talking and moving about in her sleep. She was diagnosed with PD and was treated with carbidopa/levodopa 25/100 TID. She responded well to the medication. Within the next 6 months, her symptoms progressed; tremor and rigidity began to affect the left side. Medications were adjusted, including an increase of carbidopa/levodopa. The patient again responded somewhat to the medication, but some symptoms were less well controlled. Her balance was affected, and she started to fall frequently. Additional medications were added, including pramipexole and rasagi-line, with questionable benefit. At times the patient began to become lightheaded upon standing.

- She was brought to the clinic after losing consciousness at a grocery store. Her blood pressure was 120/89 sitting and 100/80 standing, with pulse of 72 and 76 respectively. It was thought that her medications were affecting her blood pressure; her antihypertensive agent was consequently discontinued. Eventually pramipexole was reduced and discontinued for the same reason. The patient sought consultation for deep brain stimula-tion (DBS). Her medications included carbidopa/levodopa CR 50/200 five times daily, carbidopa/levodopa 25/100 five times entacapone 200 mg five times daily, and rasagiline 1 mg daily.

- On examination, the patient’s blood pressure was 129/80 sitting and 101/77 standing, with a pulse of 76 and 68 respectively. She had a hoarse voice with somewhat dysar-thric speech, as well as a rigid tremor involving both upper extremities and her right lower extremity, with marked rigidity of the neck and both lower extremities. A lesser amount of rigidity was seen in her right upper extremity. Rapid alternat-ing movements were bradykinetic and incomplete. She was barely able to perform heel taps on the right. She was unable to stand without pushing herself up with her arms.

- On examination of gait, she had a stooped posture with a wide-based stance and shortened stride. Pull test was positive without recovery. Based upon her history and examination findings, she was counseled against DBS surgery.

- Case 2 illustrates a patient with a parkinsonian syndrome, most likely multiple system atrophy with autonomic nervous system involvement, also known as Shy-Drager Syndrome. Patients with this disorder often present with signs of PD and may even respond to similar medications early in the course of the disease. Several features distinguish parkinsonian syndromes from PD, including early falls, poor response to levodopa, symmetry of motor manifestations, lack of tremor, and early autonomic dysfunction. The latter includes symp-tomatic postural hypotension, urinary urge incontinence, fecal incontinence, urinary retention requiring catheterization, and persistent erectile dysfunction.

- There is no specific treatment for multiple system atrophy or other parkinsonian disorder. Palliative care remains the rule at present. Rapid eye movement (REM) behavior disorder (RBD) is a sleep disorder in which the patient moves during the REM stage of sleep. RBD is commonly seen in the elderly patients with PD and other degenerative disorders. RBD in combina-tion with a reduced response to medication and orthostatic hypotension is suggestive of multiple system atrophy.