A large kindred with autosomal dominant Parkinson's disease

We report two large kindreds with Parkinson's disease (PD) apparently inherited in autosomal dominant fashion. Forty-one persons in four generations have been affected; we have examined 7 of them. The two kindreds originated in a single small town in southern Italy and therefore are probably related. The illness was typical for PD except for early onset at a mean age of 46.5 years and a rapid course that averaged 9.7 years from onset to death. Clinical appearance and response to levodopa were typical for PD. Only one instance of definite nonpenetrance is known. Autopsy of 2 patients in one kindred showed the pathological changes typical of PD with Lewy bodies. Disease duration among affected persons who spent most of their lives in Italy was longer than for their affected US relatives, suggesting that exogenous agents may influence the course of this genetic illness. We conclude that what is probably a single gene without an additional environmental insult can cause the pathological changes typical of PD. Our findings therefore enhance the likelihood of a significant genetic component in the cause of sporadic PD. By identifying a toxic gene product, future molecular genetic studies in our kindred(s) may provide insight into the pathogenesis of sporadic PD.

Clinically atypical expression of pathologically typical Lewy-body parkinsonism

Six patients autopsied by the neuropathology service at UMDNJ-Robert Wood Johnson Medical School between 1985 and 1988 had pathologically typical Lewy-body Parkinson's disease (PD). Review of their clinical records revealed that none had clinically typical PD. Atypical clinical features included juvenile onset, retrocollis, strong family history, and absence of tremor, flexed posture, or levodopa response. One patient had dementia without parkinsonism. We conclude that the clinical spectrum of Lewy-body PD is wider than is generally assumed and that the diagnosis of pathologically typical Parkinson's disease cannot be excluded on clinical grounds alone.

Steady plasma levodopa concentrations required for good clinical response to CR-4 in patients with 'on-off'

Ten patients with Parkinson's disease and severe motor fluctuations were given Sinemet (25/100) for 4 weeks followed by 4 weeks of Sinemet (CR-4). After each drug preparation was optimized, patients were rated by neurological examination and plasma levodopa (LD) measured at hourly intervals (9 a.m.-4 p.m.). For the group as a whole, variations throughout the day of plasma LD and clinical state were no different on the 2 formulations. Three patients whose fluctuations responded well to CR-4 had either much less variable plasma LD levels on CR-4 or were able to maintain plasma LD above a minimum threshold. In severe fluctuators, a major benefit from CR-4 can be expected only in those patients who can maintain steady plasma LD levels above the threshold for achieving the 'on' state.

Magnetic stimulation in the diagnosis of lumbosacral radiculopathy

Five patients presenting with sensory-motor disturbances consistent with a clinical diagnosis of L5 or S1 radiculopathy were studied. All had conventional nerve conduction tests and electromyography. The lumbosacral roots were stimulated in the lumbosacral region by using the Cadwell MES-10 Magneto-electric stimulator. The compound muscle action potentials were recorded bilaterally by surface electrodes applied to the soleus and tibialis anterior muscles. The latencies to the affected muscles were significantly prolonged. The appropriate root dysfunction was confirmed at operation or by the imaging techniques. It was concluded that surface stimulation of the lumbosacral roots by a magnetic coil is a potentially useful technique for the non-invasive evaluation of the function of the lumbosacral roots.

Seizures in progressive supranuclear palsy

Among 62 patients with progressive supranuclear palsy (PSP) seen over a 9-year period, we encountered seven who had seizure phenomena. We suggest that PSP patients have seizures more frequently than has been appreciated.

Paraneoplastic degeneration of the substantia nigra with dystonia and parkinsonism

A 42-year-old woman suffered unexplained weight loss followed by action tremor and difficulty initiating gait. Three months after onset of symptoms, infiltrating ductal carcinoma of the breast, metastatic to liver and lymph nodes, was diagnosed and treated briefly with cyclophosphamide, methotrexate, and 5-flourouracil (5FU). Severe symmetric action and postural tremor with a myoclonic component developed, with minimal rest tremor, severe dysarthria and dysphagia, small-stepped and slightly ataxic gait progressing to a bedbound state, and severe widespread dystonic posturing. The latter began as a typical parkinsonian posture of trunk and upper extremities and progressed to a fixed and painful flexion of the elbows and wrists and extension of fingers and neck. Sinemet, anticholinergics, baclofen, diazepam, and plasmapheresis gave no benefit. The patient died of complications of immobility 5 months after neurologic symptom onset. Autopsy revealed many pigment-laden macrophages in substantia nigra and moderate loss of pigmented neurons. Inflammation, Lewy bodies, and tumor were absent. Cerebellar Purkinje cells were moderately depleted. Mild neuronal loss and gliosis were present in globus pallidus and cerebellar cortex. Stains for anti-human IgG, IgM, kappa, and lambda were negative. This, to our knowledge, is the first report of paraneoplastic degeneration of substantia nigra or paraneoplastic parkinsonism.

Low leukocyte glutamate dehydrogenase activity does not correlate with a particular type of multiple system atrophy

Leucocyte glutamate dehydrogenase (GDH) activity was measured in 26 normal control subjects, 20 patients with multiple system atrophy presenting features of either olivopontocerebellar atrophy or striatonigral degeneration and in a heterogenous group of 15 patients with spinocerebellar degenerations. A broad range of GDH activity was found in all three groups. Low activity failed to correlate with a specific clinical entity. Patients followed to post-mortem examination to date have demonstrated histological features of at least three distinct morbid entities. It is concluded, contrary to earlier reports including the authors', that low leukocyte GDH activity does not identify a particular type of multiple system atrophy.

Supranuclear disturbances of ocular motility in Lytico-Bodig

We found abnormal supranuclear ocular or lid motility in all of 37 patients with Lytico-Bodig (amyotrophic lateral sclerosis/parkinsonism-dementia complex). Twenty-one patients had pursuit paresis, 18 abnormal vestibulo-ocular reflex (VOR) cancellation, 15 abnormal convergence, 13 abnormal optokinetic nystagmus (OKN), 12 conjugate gaze limitation, nine nystagmus, nine saccadic paresis, and six abnormal fixation. Lid abnormalities included glabellar hyperreflexia in 21, involuntary levator inhibition in three, and blepharospasm in two. Earlier reports have indicated infrequent ocular disturbances in Lytico-Bodig, but we now find supranuclear eye and lid deficits are universal and sometimes very prominent.

Risk factors for progressive supranuclear palsy

To explore possible risk factors for progressive supranuclear palsy (PSP), we conducted a case-control study of 50 cases in New Jersey. Two neurologists confirmed the diagnosis in the 41 living patients. Two hospital controls were matched by age, sex, race, date of death, and relationship of next-to-kin to each case. A structured interview was administered in person to the next-of-kin of cases and controls. Genetic, viral, toxic, medical, surgical, and personality factors were investigated. Cases lived in areas with low population as adults significantly more frequently than controls. The study identified no other factors associated with PSP including a history of stroke, hypertension, or smoking.

Long-term duodenal infusion of levodopa for motor fluctuations in parkinsonism

We report the long-term clinical responses of 2 parkinsonian patients with severe "on-off" phenomena who have been receiving continuous duodenal levodopa (LD) infusions. The rate of LD infusion needed to keep the patients just "on" declined gradually during the initial 60 days of infusion and then remained constant. Total LD intake declined rapidly during the first several days and gradually for another 60 days, after which it remained stable. Motor fluctuations virtually disappeared in both patients during the time of the day when the pump was in use. This was accompanied by a decline in the plasma LD concentration needed to just maintain the "on" stage in one patient.

Prevalence and natural history of progressive supranuclear palsy

We surveyed neurologists and chronic care facilities in and near two New Jersey counties with a combined population of 799,022, regarding cases of progressive supranuclear palsy. All suspected cases were examined personally, using rigid criteria. The prevalence ratio was 1.39/100,000. A total of 50 New Jersey cases yielded median intervals to onset of requiring gait assistance, 3.1 years; visual symptoms, 3.9 years; dysarthria, 3.4 years; dysphagia, 4.4 years; requiring wheelchair, 8.2 years; and death, 9.7 years.

Isolated jejunal pouches for levodopa delivery in parkinsonian patients with "on-off". Successful experimental model in dogs

In eight dogs, a 20 cm section of isolated jejunum with intact blood supply was externalized to the abdominal wall and used as a device for levodopa (LD) administration. Overall, Sinemet tablets and LD suspension produced similar plasma levodopa concentrations with oral and pouch administration. The most ideal plasma concentration curves were obtained for CR-3, a sustained release Sinemet preparation, given through the jejunal pouches. Plasma LD concentrations rose within the first hour after administration of CR-3 and remained constant for the next 3 h, before falling slowly. Isolated jejunal pouches may therefore be an effective, simple means of maintaining constant plasma LD concentrations in parkinsonian patients with motor fluctuations and may diminish the deleterious effects of erratic gastric emptying and competition with food-derived amino acids at the gut/blood transport system.

Role for monoamine oxidase-A (MAO-A) in the bioactivation and nigrostriatal dopaminergic neurotoxicity of the MPTP analog, 2'Me-MPTP

1-Methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) administration leads to the selective destruction of the dopaminergic neurons of the nigrostriatal pathway in experimental animals including monkeys and mice. The neurotoxicity of MPTP is dependent upon its monoamine oxidase-B (MAO-B)-catalyzed conversion to the 1-methyl-4-phenylpyridinium species (MPP+). A methylated analog of MPTP. A methylated analog of MPTP, namely 1-methyl-4-(2'-methylphenyl)-1,2,3,6-tetrahydropyridine (2'Me-MPTP), is a more potent dopaminergic neurotoxin than MPTP in mice. Although the selective inhibition of MAO-B is sufficient to protect mice against MPTP-induced neurotoxicity, it is reported here that complete inhibition of MAO-B failed to prevent 2'Me-MPTP-induced dopaminergic neurotoxicity. However, the neurotoxicity of 2'Me-MPTP was completely prevented and 2'Me-MPP+ formation was markedly attenuated in mice in which both MAO-A and MAO-B were almost totally inhibited. This information about the role of MAO-A in the bioactivation of 2'Me-MPTP may be of relevance to those who speculate that the MAO-B catalyzed bioactivation of MPTP or a similar compound may be the cause of idiopathic Parkinson's disease.

Continuous duodenal infusions of levodopa: plasma concentrations and motor fluctuations in Parkinson's disease

Four parkinsonian patients received continuous duodenal infusions of levodopa (LD) for severe "on-off" phenomena associated with Sinemet (carbidopa/levodopa) therapy. All patients had marked decreases in motor fluctuations on the infusions compared with tablets. Two factors that appear related to this improvement are the ability of duodenal infusions to produce steadier plasma LD concentrations and/or to maintain LD concentrations above a minimum threshold needed to achieve the "on" state.

Deprenyl in the treatment of symptom fluctuations in advanced Parkinson's disease

Deprenyl, a selective inhibitor of monoamine oxidase, type B, which is free of the "tyramine effect," may ameliorate symptom fluctuations in advanced Parkinson's disease (PD). We randomized 96 patients with marked symptom fluctuations at three centers to receive either deprenyl 5 mg b.i.d. or placebo in parallel fashion in addition to a previously optimized levodopa/carbidopa (Sinemet) regimen. Disability was recorded hourly at home by patients 3 days weekly during the 2-week baseline and the 6-week treatment period. Disability during the "on" state was assessed each week by examination. Mean hourly self-assessment of gait improved in 28 of 50 patients (56%) receiving deprenyl (mean degree of improvement 0.25 points on a 0-2 scale) and in 14 of 46 (30.4%) taking placebo (mean 0.15). Mean hourly overall symptom control improved in 29 (58%) taking deprenyl (mean 0.34) and in 12 (26.1%) taking placebo (mean 0.15) (p less than 0.01 for each parameter). No significant improvement occurred in the objective quality of the "on" state with deprenyl. Mean daily Sinemet dosage decreases were 17% in the deprenyl group and 7% in the placebo group. Adverse effects included nausea, light-headedness, dyskinesias, and hallucinations, all of which abated after the Sinemet dose was reduced. We conclude that deprenyl is of moderate benefit in a majority of patients with symptom fluctuations complicating PD and is generally well tolerated.

Progressive supranuclear palsy

Progressive supranuclear palsy (PSP) was first recognized as a distinct morbid entity by Richardson, Steele and Olszewski a quarter century ago. Subsequent experience has confirmed and extended their original observations. PSP has become familiar as a chronic progressive disorder with extrapyramidal rigidity, bradykinesia, gait impairment, bulbar palsy, dementia and a characteristic supranuclear ophthalmoplegia. It is an important cause of parkinsonism. Its etiology remains obscure. Familial concentrations have not been observed. Some cases exhibit no oculomotor dysfunction. Dementia is usually mild. Recent neuropsychological studies have defined features consistent with frontal lobe cortical dysfunction. Seizures and paroxysmal EEG activity may occur. CT and MRI scans show midbrain atrophy early and later atrophy of the pontine and midbrain tegmentum and the frontal and temporal lobes. PET scans have shown frontal hypometabolism and loss of striatal D-2 dopamine receptors. Postmortem studies have documented involvement of both dopaminergic and cholinergic systems. Treatment remains palliative and unsatisfactory.

A physiologic and pharmacologic study in anticholinergic-responsive essential myoclonus

We report the physiologic and pharmacologic analysis in two women, aged 18 and 17 years, with essential myoclonus. Both responded to benztropine mesylate and had been functioning normally. The physiologic analysis suggested ballistic movement overflow and audiogenic stimulus-sensitive myoclonus. The pharmacologic study showed a direct and mutual antagonism of physostigmine and anticholinergic agent on myoclonus, implying cholinergic hyperactivity in the pathophysiology of myoclonus.

Computed tomographic findings in progressive supranuclear palsy: correlation with clinical grade

We report clinical and computed tomography (CT) findings in 17 patients with progressive supranuclear palsy (PSP). Patients were divided into four clinical groups according to the severity of the disease and functional disability. In Grade 1, patients demonstrated minor disability and decreased anteroposterior (AP) diameter of the midbrain tegmentum was present. As the disease progressed clinically to Grade 2, more severe atrophy of the pons and midbrain and dilatation of the quadrigeminal plate cistern were noted. The most severe stages of clinical disability (Grades 3 and 4) were characterized radiologically by dilatation of the aqueduct, progressive dilatation of the third and fourth ventricles and atrophy of the temporal lobes. Cortical atrophy was variable and not a prominent radiological feature. Midbrain and pontine AP diameters were significantly smaller in PSP patients than normal patients. Serial studies showed progressive involution of the pons and midbrain and enlargement of the third ventricle. While the most obvious CT changes in PSP occur late in the disease, CT may in fact suggest the correct diagnosis long before the classic clinical picture is evident.

Hereditary dystonia-parkinsonism syndrome of juvenile onset

We studied a family with an extrapyramidal disorder characterized by childhood onset of lower-limb and axial dystonia, followed by parkinsonism. Dramatic response to levodopa therapy and minimal progression in adult life was seen. The family included five generations of affected members of both sexes in an autosomal dominant pattern.