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1.317 A case that has been diagnosed as cirrhosis after the emergence of parkinsonism symptoms
Poster Presentations: Related Disorders 1.316 Prochlorperazine induced acute parkinsonism in a patient with HIV: A case report M. Bernbaum1° , A. Di Rocco York, USA
1 New
Objective: Parkinsonism is a known complication of AIDS. HIV infected individuals are more susceptible to extrapyramidal side effects of dopamine blocking agents, developing acute dystonic phenomena after exposure to these drugs. Parkinsonism associated with HIV is usually associated with low CD4 count or AIDS-defining complications, and develops gradually over months. We report the case of a 53 year-old patient with uncomplicated HIV infection who acutely became severely parkinsonian while treated chronically with prochlorperazine. Method: Case report, with longitudinal follow-up over one year with clinical observations and UPDRS scores. Results: The patient is a 53 year-old man with HIV infection diagnosed in 1990, and no history of opportunistic infections or AIDS defining illnesses, on chronic HAART treatment. At the time of initial observation his CD4 count was 700 cells/mm3 and the viral load 3000 copies/mL. A year earlier he had begun treatment with prochlorperazine 10 mg BID for nausea. He reported overnight onset of hand tremors and impairment of fine motor skills that quickly progressed to affect the rest of the body. Within three weeks his symptoms had become so severe that they affected his ADLs and balance. When first seen, ten weeks after the onset of his symptoms, he was severely parkinsonian with a UPDRS score of 86.0 (part III: 65.5). He had been unresponsive to carbidopa/L-dopa/entacapone (37.5/150/200) TID. Prochlorperazine was immediately discontinued and pramipexole was titrated to 0.5 mg TID. He showed significant improvement after one month (UPDRS part III = 40.5). Carbidopa/levodopa/entacapone was then discontinued while pramipexole was increased to 1.5 mg TID. One year later his UPDRS score was 22.5 (part III: 17.0), and he regained full control of his ADLs. Conclusion: This is the first reported case of acute, iatrogenic parkinsonism in uncomplicated HIV infection. Dopamine blocking agents in HIVinfected subjects may trigger unusual and severe extrapyramidal syndromes.
S81
investigations the patient has been diagnosed as cirrhosis. Generally the neurological complications of systemic diseases are being discussed; differently in that case patient referred to doctor with neurological problems and the progression of her liver disease has been diagnosed by the help of her neurological symptoms.
1.318 Malignant neuroleptic syndrome in a case of acute extrapontine myelinolysis J.-P. Stellmann1° , O. Stammel, R.F. T¨opper Germany
1 Hamburg,
Objective: Malignant neuroleptic syndrome (MNS) is a rare but severe complication of neuroleptic treatment especially of those with high affinity to dopamine D2 receptors. Except for alterations in the dopamine receptor D2 gene, cytokine overproduction and MNS in a patient’s history there are no risk factors for the development of MNS. The exact pathophysiology is unknown. Most authors suspect a striatal D2 receptor activity. Results: We present a case of extrapontine myelinolysis due to a fast change of osmolality which affected first the basal ganglia on both sides. Medication with haloperidol, which was given for treatment of severe alcohol withdraw resulted in a MNS with hypokinesia, massive rigidity, high fever and a blood level of creatinine kinase (CK) of 37,200 U/l. Long term treatment with amantadine, lorazepam and intensive physiotherapy led to a normalization of creatinine kinase and an improvement of the symptomatic Parkinsonian syndrome (PS). As psychotic symptoms persisted neuroleptic treatment with quetiapine, which is known to have a lower affinity to D2receptors, was started. Similar to the experience with other PS there was no further worsening of the extrapyramidal symptoms. Conclusion: We suggest a high vulnerability of dopaminergic neurons to osmotic stress that probably increased the sensitivity of the striatal dopaminergic system for neuroleptics with a high affinity to D2-receptors. To our knowledge this is the first case of MNS in a patient with extrapontine myelinolysis.
1.319 Effects of valproate on dopaminergic system in mice 1.317 A case that has been diagnosed as cirrhosis after the emergence of parkinsonism symptoms C. Turkmen1° , B. Ozen, D. Ince Gunal Turkey
1 Istanbul,
Objective: In this article, we aimed to discuss extrapyramidal system findings of liver diseases associated with our case. Method: A 64 year old women patient, with the complaint of fatigue, slowness of movements and hypomimia for 3 years, referred to our neurology outpatient clinic. Her neurological examination showed parkinsonism symptoms including bradymimia, bilateral bradykinesia and rigidity and gait imbalance without resting tremor. MRI imaging was performed and increased T1 signal in the bilateral globus pallidus regions has been detected. Laboratory examination has shown trombocytopenia, elongation of the Prothrombin Time and mild increase in liver transaminases. After a more detailed medical history from the patient’s relatives we have learnt that two years ago she had been diagnosed as seropositive hepatitis C and after the liver biopsy her final diagnosis had been determined as chronic hepatitis. After the gastroenterology consultation she has been diagnosed as hepatic cirrhosis and taken into follow up. Results: A variety of chronic neurological and cognitive abnormalities have been associated with chronic liver failure. Most of these symptoms involve basal ganglia dysfunction and include abnormal involuntary movements, such as choreoathetosis, tremor, myoclonus, dystonia, rigidity and dysarthria. Increased T1 signal in the basal ganglia on brain magnetic resonance imaging has been seen, and these MRI abnormalities have been related to Mn deposition in basal ganglia. Conclusion: By the emergence of the neurological symptoms we thought that patient’s liver disease might have been progressed and by detailed
E. Vamos1° , A. Csati, P. Klivenyi, L. Vecsei Hungary
1 Szeged,
Objective: Valproate has been used as an antiepileptic drug for a long time. It has been demonstrated that long term use of valproate may induce tremor in some patients, which is one of the cardinal features of Parkinson’s disease. This finding is associated with a degeneration of dopaminergic nigrostriatal neurons. This observation raises an issue, that the valproate may have direct effect on the substantia nigra (SN). Earlier data show that valproate has an effect on the adrenerg, GABAerg and dopaminerg systems. The aim of our study is to examine the effect of the valproate on motor activity of mice and to determine the immunoreactivity changes of tyrosine hydroxylase (TH) after chronic use of valproate of the SN in the mouse. Method: We used Conducta system for behaviour test and immunohistochemistry for TH cell counting. Results: We found a significant alteration in the motor activity, but not in the stereotype behaviour of the mice treated with valproate. In parallel the number of TH positive cells were decreased significantly after chronic valproate treatment of the SN in mice. Conclusion: Based on this observation valproate may have a direct effect on the basal ganglia and this action may be antidopaminergic. Further research is needed for the study of the exact pathomechanism of the neurodegeneration. These data may contribute to understanding the mechanisms of the valproate-induced symptoms. This work was supported by the RET-NORT 08/2004 grant.
1 New
Objective: Parkinsonism is a known complication of AIDS. HIV infected individuals are more susceptible to extrapyramidal side effects of dopamine blocking agents, developing acute dystonic phenomena after exposure to these drugs. Parkinsonism associated with HIV is usually associated with low CD4 count or AIDS-defining complications, and develops gradually over months. We report the case of a 53 year-old patient with uncomplicated HIV infection who acutely became severely parkinsonian while treated chronically with prochlorperazine. Method: Case report, with longitudinal follow-up over one year with clinical observations and UPDRS scores. Results: The patient is a 53 year-old man with HIV infection diagnosed in 1990, and no history of opportunistic infections or AIDS defining illnesses, on chronic HAART treatment. At the time of initial observation his CD4 count was 700 cells/mm3 and the viral load 3000 copies/mL. A year earlier he had begun treatment with prochlorperazine 10 mg BID for nausea. He reported overnight onset of hand tremors and impairment of fine motor skills that quickly progressed to affect the rest of the body. Within three weeks his symptoms had become so severe that they affected his ADLs and balance. When first seen, ten weeks after the onset of his symptoms, he was severely parkinsonian with a UPDRS score of 86.0 (part III: 65.5). He had been unresponsive to carbidopa/L-dopa/entacapone (37.5/150/200) TID. Prochlorperazine was immediately discontinued and pramipexole was titrated to 0.5 mg TID. He showed significant improvement after one month (UPDRS part III = 40.5). Carbidopa/levodopa/entacapone was then discontinued while pramipexole was increased to 1.5 mg TID. One year later his UPDRS score was 22.5 (part III: 17.0), and he regained full control of his ADLs. Conclusion: This is the first reported case of acute, iatrogenic parkinsonism in uncomplicated HIV infection. Dopamine blocking agents in HIVinfected subjects may trigger unusual and severe extrapyramidal syndromes.
S81
investigations the patient has been diagnosed as cirrhosis. Generally the neurological complications of systemic diseases are being discussed; differently in that case patient referred to doctor with neurological problems and the progression of her liver disease has been diagnosed by the help of her neurological symptoms.
1.318 Malignant neuroleptic syndrome in a case of acute extrapontine myelinolysis J.-P. Stellmann1° , O. Stammel, R.F. T¨opper Germany
1 Hamburg,
Objective: Malignant neuroleptic syndrome (MNS) is a rare but severe complication of neuroleptic treatment especially of those with high affinity to dopamine D2 receptors. Except for alterations in the dopamine receptor D2 gene, cytokine overproduction and MNS in a patient’s history there are no risk factors for the development of MNS. The exact pathophysiology is unknown. Most authors suspect a striatal D2 receptor activity. Results: We present a case of extrapontine myelinolysis due to a fast change of osmolality which affected first the basal ganglia on both sides. Medication with haloperidol, which was given for treatment of severe alcohol withdraw resulted in a MNS with hypokinesia, massive rigidity, high fever and a blood level of creatinine kinase (CK) of 37,200 U/l. Long term treatment with amantadine, lorazepam and intensive physiotherapy led to a normalization of creatinine kinase and an improvement of the symptomatic Parkinsonian syndrome (PS). As psychotic symptoms persisted neuroleptic treatment with quetiapine, which is known to have a lower affinity to D2receptors, was started. Similar to the experience with other PS there was no further worsening of the extrapyramidal symptoms. Conclusion: We suggest a high vulnerability of dopaminergic neurons to osmotic stress that probably increased the sensitivity of the striatal dopaminergic system for neuroleptics with a high affinity to D2-receptors. To our knowledge this is the first case of MNS in a patient with extrapontine myelinolysis.
1.319 Effects of valproate on dopaminergic system in mice 1.317 A case that has been diagnosed as cirrhosis after the emergence of parkinsonism symptoms C. Turkmen1° , B. Ozen, D. Ince Gunal Turkey
1 Istanbul,
Objective: In this article, we aimed to discuss extrapyramidal system findings of liver diseases associated with our case. Method: A 64 year old women patient, with the complaint of fatigue, slowness of movements and hypomimia for 3 years, referred to our neurology outpatient clinic. Her neurological examination showed parkinsonism symptoms including bradymimia, bilateral bradykinesia and rigidity and gait imbalance without resting tremor. MRI imaging was performed and increased T1 signal in the bilateral globus pallidus regions has been detected. Laboratory examination has shown trombocytopenia, elongation of the Prothrombin Time and mild increase in liver transaminases. After a more detailed medical history from the patient’s relatives we have learnt that two years ago she had been diagnosed as seropositive hepatitis C and after the liver biopsy her final diagnosis had been determined as chronic hepatitis. After the gastroenterology consultation she has been diagnosed as hepatic cirrhosis and taken into follow up. Results: A variety of chronic neurological and cognitive abnormalities have been associated with chronic liver failure. Most of these symptoms involve basal ganglia dysfunction and include abnormal involuntary movements, such as choreoathetosis, tremor, myoclonus, dystonia, rigidity and dysarthria. Increased T1 signal in the basal ganglia on brain magnetic resonance imaging has been seen, and these MRI abnormalities have been related to Mn deposition in basal ganglia. Conclusion: By the emergence of the neurological symptoms we thought that patient’s liver disease might have been progressed and by detailed
E. Vamos1° , A. Csati, P. Klivenyi, L. Vecsei Hungary
1 Szeged,
Objective: Valproate has been used as an antiepileptic drug for a long time. It has been demonstrated that long term use of valproate may induce tremor in some patients, which is one of the cardinal features of Parkinson’s disease. This finding is associated with a degeneration of dopaminergic nigrostriatal neurons. This observation raises an issue, that the valproate may have direct effect on the substantia nigra (SN). Earlier data show that valproate has an effect on the adrenerg, GABAerg and dopaminerg systems. The aim of our study is to examine the effect of the valproate on motor activity of mice and to determine the immunoreactivity changes of tyrosine hydroxylase (TH) after chronic use of valproate of the SN in the mouse. Method: We used Conducta system for behaviour test and immunohistochemistry for TH cell counting. Results: We found a significant alteration in the motor activity, but not in the stereotype behaviour of the mice treated with valproate. In parallel the number of TH positive cells were decreased significantly after chronic valproate treatment of the SN in mice. Conclusion: Based on this observation valproate may have a direct effect on the basal ganglia and this action may be antidopaminergic. Further research is needed for the study of the exact pathomechanism of the neurodegeneration. These data may contribute to understanding the mechanisms of the valproate-induced symptoms. This work was supported by the RET-NORT 08/2004 grant.