DDx: Parkinsonism Flashcards Preview

08 NEUROLOGY > DDx: Parkinsonism > Flashcards

Flashcards in DDx: Parkinsonism Deck (20):
1

Differential Diagnosis of Parkinsonism:

Degenerative Parkinsonism:

Idiopathic Parkinson disease

Multiple system atrophy

Progressive supranuclear palsy

Corticobasal degeneration

Dementia with Lewy bodies

Secondary Parkinsonism:

Drug (antipsychotic agents, antiemetics, metoclopramide, reserpine, lithium, tetrabenazine,

or flunarizine)

Toxin (manganese, MPTP, mercury, methanol, ethanol, or carbon monoxide)

Cerebrovascular disease

Head trauma (including pugilistic encephalopathy)

Hydrocephalus

Creutzfeldt-Jakob disease

Paraneoplastic syndrome

Hepatocerebral degeneration

Hypothyroidism

Selected Hereditary Disorders Associated With Parkinsonism:

Wilson disease

Familial amyotrophy-dementia-parkinsonism

Spinocerebellar ataxia

Huntington disease

Fragile X-associated tremor/ataxia syndrome

Essential Tremor

2

Parkinson disease

Parkinson disease is a clinical diagnosis based on any combination of five cardinal features: (1) tremor in a limb at rest, (2) rigidity, (3) bradykinesia, (4) loss of postural reflexes, and (5) gait freezing (disturbance).

A tremor at rest is perhaps the most obvious feature of Parkinson disease and is a common presenting symptom. The tremor at rest readily disappears when sustaining a posture or during manual activities, in contrast to an essential tremor, which is an action tremor. Bradykinesia is manifested by paucity of spontaneous movement with severely affected patients sitting unnaturally still and demonstrating a lack of facial expressiveness (“facial masking”). In addition to whole-body slowness and impairment in fine motor movements, other consequences of advanced bradykinesia include drooling of saliva due to a lack of spontaneous swallowing, soft monotonous speech, micrographia (small, cramped handwriting), reduced arm swing when walking, and a short, shuffling gait.

Tx: Sustained response to levodopa therapy is expected in patients with Parkinson disease and helps confirm the clinical diagnosis. Features suggesting an alternative condition include symmetric symptoms or signs, early falls, rapid progression, poor or waning response to levodopa, dementia, early autonomic failure, and ataxia.

3

Multiple system atrophy

Ataxia, dysautonomia

4

Progressive supranuclear palsy

Early falls, impaired vertical eye movement

5

Corticobasal degeneration

Asymmetric spasticity and rigidity, alien limb movement, myoclonus

6

Dementia with Lewy bodies

Dementia, hallucinations

7

Secondary Parkinsonism:

Drug (antipsychotic agents, antiemetics, metoclopramide, reserpine, lithium, tetrabenazine,

or flunarizine)

Exposure history

8

Toxin (manganese, MPTP, mercury, methanol, ethanol, or carbon monoxide)

Exposure history

9

Cerebrovascular disease

History; MRI showing stroke

10

Head trauma (including pugilistic encephalopathy)

History of head trauma

11

Hydrocephalus

Lower-body parkinsonism; MRI showing possible contusion

12

Creutzfeldt-Jakob disease

Rapidly progressive; signs/symptoms of ataxia, dementia, myoclonus, dystonia

13

Paraneoplastic syndrome

Rapidly progressive; signs/symptoms of ataxia, encephalopathy, myoclonus

14

Hepatocerebral degeneration

History of liver disease; MRI changes in basal ganglia

15

Hypothyroidism

Rare; resolves with treatment

16

Selected Hereditary Disorders Associated With Parkinsonism:

Wilson disease

Must be ruled out in patients aged <50 y; hepatic and psychiatric disease; tremor, dystonia, ataxia

17

Familial amyotrophy-dementia-parkinsonism

Cognitive/behavioral change; extremity weakness, atrophy; rigidity, bradykinesia

Autosomal dominant; begins in early life; ataxia predominates

18

Huntington disease

Hereditary, progressive, neurodegenerative disorder characterized by increasingly severe motor impairment, cognitive decline, and psychiatric symptoms. In addition to chorea, other motor symptoms include ataxia, dystonia, slurred speech, impaired swallowing, and myoclonus. Various psychiatric symptoms, such as dysphoria, agitation, irritability, anxiety, apathy, disinhibition, delusions, and hallucinations, commonly occur.

19

Fragile X-associated tremor/ataxia syndrome

Ataxia, tremor, dementia

20

Essential Tremor

The most likely diagnosis in a younger (<50 years of age) patient with a symmetric action/postural movement disorder.  Lifestyle changes, such as getting enough sleep and reduction of caffeine, can be helpful. Essential tremor characteristically improves with alcohol intake, and patients with essential tremor are at increased risk of alcohol misuse because of this. If lifestyle modifications do not adequately control essential tremor symptoms, medications, including β-blockers (such as propranolol) and anticonvulsants (such as primidone), are usually effective.