Derrame pleural e hipertensión pulmonar en un paciente con enfermedad de Parkinson en tratamiento con cabergolina

Factors to Consider in the Selection of Dopamine Agonists for Older Persons with Parkinson's Disease

Dopamine agonists (DAs) are frequently used in the management of Parkinson's disease (PD), a complex multisystem disorder influenced substantially by age-related factors. Over 80% of PD patients present after age 60 years and may have clinical features exacerbated by age-related comorbidities or decline in physiological compensatory mechanisms. Pharmacotherapy for motor symptoms in older persons is more likely to involve exclusive use of levodopa combined with a peripheral decarboxylase inhibitor throughout the course of the illness. Non-ergot DAs, such as pramipexole, rotigotine and ropinirole, may be used as de novo monotherapy for the control of motor symptoms in older persons, although they are less efficacious than levodopa therapy. DAs may also be considered as adjunct therapy in older persons when motor symptoms are no longer adequately controlled by levodopa or when motor fluctuations and dyskinesia appear. DAs may be used cautiously in older persons with cognitive impairment and orthostatic hypotension but should be avoided when there is a history or risk of psychosis or impulse control disorders.

Pulmonary Artery Occlusion and Mediastinal Fibrosis in a Patient on Dopamine Agonist Treatment for Hyperprolactinemia

Unusual forms of pulmonary hypertension include pulmonary hypertension related to mediastinal fibrosis and the use of serotonergic drugs. Here, we describe a patient with diffuse mediastinal fibrosis and pulmonary hypertension while she was on dopamine agonist therapy. A young woman, who was treated with cabergoline and bromocriptine for hyperprolactinemia, presented with progressive dyspnea over several months. Based on the clinical investigation results, in particular, elevated pulmonary arterial pressures and significant perfusion defects on computed tomography (CT) pulmonary angiography and ventilation/perfusion (V/Q) scintigraphy, chronic thromboembolic pulmonary hypertension (CTEPH) was initially considered the most plausible diagnosis. However, during an attempted pulmonary endarterectomy, loose fibrous tissues were observed in the mediastinum and cryosection of the right pulmonary artery showed fibrosis and chronic inflammation. Subsequent investigations revealed that diffuse mediastinal fibrosis with concurrent pulmonary hypertension, and not CTEPH, was the most likely diagnosis and cabergoline and bromocriptine may have triggered the fibrotic changes. Both drugs are ergot-derived dopamine agonists, which are known to cause cardiac valve fibrosis and less frequently, non-cardiac fibrotic changes. The underlying mechanism is attributed to their interactions with serotonin receptors. There is much evidence that serotonin, a potent vasoconstrictor and mitogen, is involved in the pathogenesis of pulmonary hypertension. In conclusion, as CT and V/Q scintigraphy findings can occasionally be deceptive, physicians should be particularly aware of differential diagnoses in patients without obvious history of venous thromboembolism that are suspected of having chronic thromboembolic pulmonary hypertension.

Orally inhaled dihydroergotamine: reviving and improving a classic

Migraine pathophysiology continues to evolve, and additional therapeutic receptors influencing unrecognized neural networks within the cortex, brainstem and cerebral vasculature likely exist. Following the advent of the triptans, the use of dihydroergotamine (DHE) declined, because of the ease of use and improved side effect profiles of triptans. However, there remain many patients who respond poorly to triptans, yet respond significantly better to DHE. This may be due to the broader neuroreceptor targets that DHE interacts with, as opposed to the selective receptor activity of the triptans. Unfortunately, DHE is still infrequently utilized compared with other acute treatments such as triptans, primarily because of difficulty in administration and physician unfamiliarity and inexperience with its use. However, the new orally inhaled DHE appears to be as effective with a better side effect profile compared with intravenous DHE, thus eliminating the complexities typically associated with DHE administration.

[The clinical view through the Archives: the clinical notes of 2009]

The Clinical Notes published in 2009 serve as a resource to reflect on clinical aspects relevant to different clinical entities. Through this review an attempt is likewise made to bring the reader closer to the clinical reality of our environment.