67 Year old female with C/o involuntary movements of both upper limbs.

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CASE PRESENTATION:

67 year old woman presented with the complaints of 

Involuntary movements of right forearm since 4 months.

Involuntarily movements of left index finger and thumb since 4 months.

Patient lives at Haliya in Nalgonda district and is married to a coolie. She has 3 daughters and 4 sons. 

She had a hysterectomy 30 years back.

 She got diagnosed to be hypertensive and diabetic 3 years ago but hasn’t been regularly taking her medications. 

Since 4 months , her husband started noticing involuntary movements of her right forearm which would be more at rest and would also be present during her sleep. Over the next few days, she developed involuntary movements of her left Index finger and thumb following which she even developed on and off involuntary movements of her tongue. 

Since the last 20 days, he says she hasn't been involving herself in conversations and would respond late.

On examination:

PR - 76bm

Bp - 120/80mmhg in supine posture

110/70mmg on standing

Clinical Findings:

Masked like facies.

Asymmetrical rhythmic movements of distal muscles - right forearm and pill rolling tremors observed involving left thumb and index finger, occuring even at sleep.

Small amplitude.

Tremors present  on rest and absent on motor activity.

Slow initiation of motor activity and delayed verbal response.

Lead pipe rigidity present.

Power -  4- in all the four limbs

Reflexes.       Rt         Lt

B.                    3+.       3+

T.                    3+.       3+

S.                    3+.       3+ 

K.                   3+.       3+

A.                     -          -

P  Flexion.

Gait:   Short steps, Reduced arm swing.

HINTS: No delayed saccades on Head Impulse,

              No nystagmus noted,  

              Test for Vertical skew - Negative 

MMSE:

Orientation :  5/5

Registration:  3/5

Attention and Calculation : Doesn’t know how to calculate.

Recall : 3/5

Language:  Name two objects- 2/2

                   No ifs and buts - 1/1

                   Three stage command - 3/3

                  Read a written command - unable to ellicit.

                  Write a sentence- unable to ellicit.

CVS:

Loud ejection systolic murmur heard in aortic area till apex.

The following video shows pill rolling tremor.

In the following video we can see the reduced arm swing.

Provisional Diagnosis : Parkinson’s disease 

Severe aortic stenosis with ASD

Investigations :

On 12-12-2020

ECG:

                              Chest X ray PA view:

2D Echo :

Outside CT report :

MRI Brain : 

Treatment:

                                        Day 1:

1. Inj Optineuron 1 Amp in 100 ml NS IV / OD

2. Tab Syndopa 110 mg / PO / TID

     (Levodopa 100 mg + Carbidopa 10 mg)

                                        Day 2 :

1. Inj Optineuron 1 Amp in 100 ml NS IV / OD

2. Tab Syndopa 110 mg / PO / TID

     (Levodopa 100 mg + Carbidopa 10 mg)

                                         Day 3 :

1. Inj Optineuron 1 Amp in 100 ml NS IV / OD

2. Tab Syndopa 110 mg / PO / TID

     (Levodopa 100 mg + Carbidopa 10 mg)

          

                                      Day 4 :

    Her tremors have reduced comparatively, according to the      patient.

1. Inj Optineuron 1 Amp in 100 ml NS IV / OD

2. Tab Syndopa 110 mg / PO / TID

     (Levodopa 100 mg + Carbidopa 10 mg)

Discussion:

A multicenter, double-blind, placebo-controlled, delayed-start trial

P- A total of 445 patients were randomly assign

I- 222 Patients with  Parkinson's disease to receive levodopa (100 mg three times per day) in combination with carbidopa (25 mg three times per day) for 80 weeks (early-start group)

C- 223 placebo for 40 weeks followed by levodopa in combination with carbidopa for 40 weeks (delayed-start group).

O - Among patients with early Parkinson's disease who were evaluated over the course of 80 weeks, treatment with levodopa in combination with carbidopa had no disease-modifying effect.

https://pubmed.ncbi.nlm.nih.gov/30673543/

Carbidopa is a drug that blocks conversion of levodopa to dopamine outside of central nervous system (CNS) and thus inhibits unwanted side effects of levodopa on organs located outside of CNS during management of Parkinson's Disease (PD). PD is associated with increased expression of inflammatory genes in peripheral and central nervous system (CNS), infiltration of immune cells into brain, and increased numbers of activated/memory T cells. Animal models of PD have shown a critical role of T cells in inducing pathology in CNS. However, the effect of carbidopa on T cell responses in vivo is unknown.

In this report, we show that carbidopa strongly inhibited T cell activation in vitro and in vivo. Accordingly, carbidopa mitigated myelin oligodendrocyte glycoprotein peptide fragment 35-55  induced experimental autoimmune encephalitis  and collagen induced arthritis in animal models. The data presented here suggest that in addition to blocking peripheral conversion of levodopa, carbidopa may inhibit T cell responses in PD individuals and implicate a potential therapeutic use of carbidopa in suppression of T cell mediated pathologies.

https://pubmed.ncbi.nlm.nih.gov/28898256/#:~:text=Carbidopa%20is%20a%20drug%20that,of%20Parkinson's%20Disease%20(PD)