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Pötter-Nerger M, Löhle M, Höglinger G. Akinetic crisis and withdrawal syndromes: guideline "Parkinson's disease" of the German Society of Neurology. J Neurol 2024:10.1007/s00415-024-12649-x. [PMID: 39192030 DOI: 10.1007/s00415-024-12649-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 07/22/2024] [Accepted: 08/17/2024] [Indexed: 08/29/2024]
Abstract
The akinetic crisis is a well-known, rare, potentially life-threatening condition in Parkinson's disease with subacute worsening of akinesia, rigidity, fever, impaired consciousness, accompanying vegetative symptoms and transient dopa-resistance. The akinetic crisis was historically supposed to be a "withdrawal syndrome" in the sense of discontinuation of dopaminergic medication. Recently, other "withdrawal syndromes" as the specific "dopamine agonist withdrawal syndrome" or "deep brain stimulation withdrawal syndrome" have been described as emergency situations with specific subacute symptom constellations. All three conditions require immediate start of the adequate therapy to improve the prognosis. Here, the diagnostic criteria and treatment options of these three acute, severely disabling syndromes will be reported along the current guidelines of the German Parkinson Guideline Group.
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Affiliation(s)
- Monika Pötter-Nerger
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Matthias Löhle
- Department of Neurology, University Medicine Rostock, Rostock, Germany
- German Center for Neurodegenerative Diseases (DZNE), Rostock, Germany
| | - Günter Höglinger
- Department of Neurology, LMU University Hospital, Ludwig-Maximilians-Universität (LMU) München, Munich, Germany
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
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Pötter-Nerger M, Schrader C, Jost WH, Höglinger G. The akinetic crisis in Parkinson´s disease- the upper end of a spectrum of subacute akinetic states. J Neural Transm (Vienna) 2024:10.1007/s00702-024-02817-8. [PMID: 39153024 DOI: 10.1007/s00702-024-02817-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 07/31/2024] [Indexed: 08/19/2024]
Abstract
The akinetic crisis is defined as an acute, potentially life-threatening, levodopa-resistant, severe aggravation of rigidity, severe akinesia, associated with high fever, disturbance of consciousness, dysphagia and autonomic symptoms often due to disruption of dopaminergic medication or infections. The akinetic crisis is a relatively rare event, however subacute mild-moderate motor symptom deterioration in Parkinson´s disease (PD) patients is a frequent cause of hospitalization. In this review, we propose that the akinetic crisis is the upper end of a continuous spectrum of acute akinetic states depending on the degree of the progressive levodopa-resistance. Clinical symptomatology, risk factors, and instrumental diagnostics as the DAT-SPECT reflecting a biomarker of levodopa-resistance will be discussed to evaluate the spectrum of akinetic states. Pathophysiological considerations about the potential role of proinflammatory cytokines on the progressive levodopa-resistance will be discussed and therapeutical, consensus-based guidelines will be presented.
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Affiliation(s)
- Monika Pötter-Nerger
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | | | - Wolfgang H Jost
- Center for Movement Disorders, Parkinson-Klinik Ortenau, Wolfach, Germany
| | - Günter Höglinger
- Department of Neurology, LMU University Hospital, Ludwig-Maximilians-Universität (LMU) München, Munich, Germany
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
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3
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Miller M, Zezetko A, Satodiya R. Development of Atypical Neuroleptic Malignant Syndrome After Treatment of Cocaine Intoxication: A Case Report and Literature Review. Cureus 2023; 15:e35538. [PMID: 37007397 PMCID: PMC10058510 DOI: 10.7759/cureus.35538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 03/03/2023] Open
Abstract
Neuroleptic malignant syndrome (NMS) is a life-threatening condition classically associated with the use of antipsychotic medications. NMS commonly presents with initial mental status changes, followed by muscle rigidity, fever, and eventual dysautonomia. Cocaine intoxication can present with symptoms that are very similar to those found in NMS, making differentiating the two disorders challenging. We present the case of a 28-year-old female with a history of cocaine use disorder who presented with acute cocaine intoxication. She had severe agitation associated with her intoxication, requiring the use of antipsychotic medications. Subsequently, she developed atypical NMS from abrupt dopamine withdrawal after receiving the antipsychotics. Although overlapping dopamine pathways between cocaine use and NMS could deter one from this practice and guidelines recommend against it, antipsychotics are routinely used in the emergency setting for cocaine-associated agitation. This case highlights the need for a more standardized treatment protocol, provides an explanation of why treating cocaine intoxication with antipsychotics is inappropriate, and suggests that chronic cocaine users may be more prone to NMS in this scenario. Furthermore, this is a unique case because it describes atypical NMS in the context of cocaine intoxication, chronic cocaine use, and administration of antipsychotics to an antipsychotic-naïve patient.
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Caroff SN, Watson CB, Rosenberg H. Drug-induced Hyperthermic Syndromes in Psychiatry. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2021; 19:1-11. [PMID: 33508784 PMCID: PMC7851465 DOI: 10.9758/cpn.2021.19.1.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 11/02/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022]
Abstract
Hyperthermia, or extreme elevations in body temperature, can be life-threatening and may be caused by prescription drugs or illegal substances acting at a number of different levels of the neuraxis. Several psychotropic drug classes and combinations have been associated with a classic clinical syndrome of hyperthermia, skeletal muscle hypermetabolism, rigidity or rhabdomyolysis, autonomic dysfunction and altered mental status ranging from catatonic stupor to coma. It is critical for clinicians to have a high index of suspicion for these relatively uncommon drug-induced adverse effects and to become familiar with their management to prevent serious morbidity and mortality. Although these syndromes look alike, they are triggered by quite different mechanisms, and apart from the need to withdraw or restore potential triggering drugs and provide intensive medical care, specific treatments may vary. Clinical similarities have led to theoretical speculations about common mechanisms and shared genetic predispositions underlying these syndromes, suggesting that there may be a common “thermic stress syndrome” triggered in humans and animal models by a variety of pharmacological or environmental challenges.
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Affiliation(s)
- Stanley N Caroff
- Corporal Michael J. Crescenz VA Medical Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Malignant Hyperthermia Association of the United States, Sherburne, NY, USA
| | - Charles B Watson
- Malignant Hyperthermia Association of the United States, Sherburne, NY, USA
| | - Henry Rosenberg
- Malignant Hyperthermia Association of the United States, Sherburne, NY, USA
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Carrarini C, Russo M, Dono F, Di Pietro M, Rispoli MG, Di Stefano V, Ferri L, Barbone F, Vitale M, Thomas A, Sensi SL, Onofrj M, Bonanni L. A Stage-Based Approach to Therapy in Parkinson's Disease. Biomolecules 2019; 9:biom9080388. [PMID: 31434341 PMCID: PMC6723065 DOI: 10.3390/biom9080388] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/31/2019] [Accepted: 08/14/2019] [Indexed: 12/11/2022] Open
Abstract
Parkinson’s disease (PD) is a neurodegenerative disorder that features progressive, disabling motor symptoms, such as bradykinesia, rigidity, and resting tremor. Nevertheless, some non-motor symptoms, including depression, REM sleep behavior disorder, and olfactive impairment, are even earlier features of PD. At later stages, apathy, impulse control disorder, neuropsychiatric disturbances, and cognitive impairment can present, and they often become a heavy burden for both patients and caregivers. Indeed, PD increasingly compromises activities of daily life, even though a high variability in clinical presentation can be observed among people affected. Nowadays, symptomatic drugs and non-pharmaceutical treatments represent the best therapeutic options to improve quality of life in PD patients. The aim of the present review is to provide a practical, stage-based guide to pharmacological management of both motor and non-motor symptoms of PD. Furthermore, warning about drug side effects, contraindications, as well as dosage and methods of administration, are highlighted here, to help the physician in yielding the best therapeutic strategies for each symptom and condition in patients with PD.
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Affiliation(s)
- Claudia Carrarini
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Mirella Russo
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Fedele Dono
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Martina Di Pietro
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Marianna G Rispoli
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Vincenzo Di Stefano
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Laura Ferri
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Filomena Barbone
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Michela Vitale
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Astrid Thomas
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Stefano Luca Sensi
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Marco Onofrj
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Laura Bonanni
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy.
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Koros C, Simitsi A, Prentakis A, Beratis I, Papadimitriou D, Kontaxopoulou D, Fragkiadaki S, Papagiannakis N, Seibyl J, Marek K, Papageorgiou SG, Trapali XG, Stamelou M, Stefanis L. 123I-FP-CIT SPECT [(123) I-2β-carbomethoxy-3β-(4-iodophenyl)-N-(3-fluoropropyl) nortropane single photon emission computed tomography] Imaging in a p.A53T α-synuclein Parkinson's disease cohort versus Parkinson's disease. Mov Disord 2018; 33:1734-1739. [PMID: 30288781 DOI: 10.1002/mds.27451] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 05/03/2018] [Accepted: 05/09/2018] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The p.A53T point mutation in the α-synuclein gene (SNCA) is a rare but highly relevant cause of autosomal dominant Parkinson's disease (PD). OBJECTIVES The objective of this study was to assess striatal dopaminergic denervation in a cohort of symptomatic carriers of the p.A53T SNCA mutation as compared to PD patients. METHODS Data from the Parkinson's Progression Markers Initiative database of 11 symptomatic p.A53T SNCA mutation carriers who underwent 123I-FP-CIT SPECT [(123) I-2β-carbomethoxy-3β-(4-iodophenyl)-N-(3-fluoropropyl) nortropane single photon emission computed tomography] imaging at our site were compared with those of 33 age-, sex-, and disease duration-matched PD patients. RESULTS The p.A53T mutation carriers had significantly lower caudate nucleus binding ratio both contralaterally and ipsilaterally to the most affected side (P = .002 and P = .006) and a decreased contralateral caudate/putamen signal ratio (P = .007) as compared to PD. A similar degree of striatal asymmetry was observed in both subgroups. No correlation between scores in neuropsychological tests and caudate nucleus dopaminergic denervation could be demonstrated. CONCLUSIONS PD patients harboring the p.A53T SNCA mutation show evidence of a more severe nigrostriatal denervation, especially evident in the caudate nucleus. The lack of significant differences in the putaminal binding ratios may reflect a floor effect or a true preferential targeting of the caudate terminals in p.A53T SNCA-associated PD. © 2018 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Christos Koros
- 1st Neurology Clinic, Eginition Hospital, Athens University Medical School, Athens, Greece.,2nd Neurology Clinic, Attikon Hospital, Athens University Medical School, Athens, Greece
| | - Athina Simitsi
- 1st Neurology Clinic, Eginition Hospital, Athens University Medical School, Athens, Greece.,2nd Neurology Clinic, Attikon Hospital, Athens University Medical School, Athens, Greece
| | | | - Ion Beratis
- 2nd Neurology Clinic, Attikon Hospital, Athens University Medical School, Athens, Greece
| | | | - Dionysia Kontaxopoulou
- 2nd Neurology Clinic, Attikon Hospital, Athens University Medical School, Athens, Greece
| | - Stella Fragkiadaki
- 2nd Neurology Clinic, Attikon Hospital, Athens University Medical School, Athens, Greece
| | - Nikolaos Papagiannakis
- 2nd Neurology Clinic, Attikon Hospital, Athens University Medical School, Athens, Greece
| | - John Seibyl
- Institute for Neurodegenerative Disorders, New Haven, Connecticut, USA
| | - Kenneth Marek
- Institute for Neurodegenerative Disorders, New Haven, Connecticut, USA
| | | | | | - Maria Stamelou
- 1st Neurology Clinic, Eginition Hospital, Athens University Medical School, Athens, Greece.,Neurology Clinic, Philipps University, Marburg, Germany.,Parkinson's Disease and Movement Disorders Department, HYGEIA Hospital, Athens, Greece
| | - Leonidas Stefanis
- 1st Neurology Clinic, Eginition Hospital, Athens University Medical School, Athens, Greece.,2nd Neurology Clinic, Attikon Hospital, Athens University Medical School, Athens, Greece
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8
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de Natale ER, Niccolini F, Wilson H, Politis M. Molecular Imaging of the Dopaminergic System in Idiopathic Parkinson's Disease. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2018; 141:131-172. [DOI: 10.1016/bs.irn.2018.08.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Kocyigit SE, Soysal P, Isik AT. Neuroleptic malignant syndrome associated with only one dose of metoclopramide in an older adult. Geriatr Gerontol Int 2017; 17:1232-1233. [PMID: 28849625 DOI: 10.1111/ggi.13044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 01/18/2017] [Accepted: 02/20/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Suleyman Emre Kocyigit
- Department of Geriatric Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Pinar Soysal
- Kayseri Education and Research Hospital, Geriatric Center, Kayseri, Turkey
| | - Ahmet Turan Isik
- Center for Aging Brain and Dementia, Department of Geriatric Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
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Bonanni L, Di Giacomo R, D'Amico A, Frazzini V, Franciotti R, Manzoli L, Thomas A, Onofrj M. Akinetic crisis in dementia with Lewy bodies. J Neurol Neurosurg Psychiatry 2016; 87:1123-6. [PMID: 27068351 DOI: 10.1136/jnnp-2015-312914] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 03/22/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND PURPOSE Dementia with Lewy bodies (DLB) is characterised by neuroleptic hypersensitivity. It is unclear, however, whether the neuroleptic hypersensitivity implies an increased incidence of neuroleptic malignant syndrome (NMS) or of akinetic crisis (AC), which are expressions of the same possibly lethal clinical event, and whether AC in DLB can appear independently of neuroleptic treatment. In our prospective study, we assessed the incidence of AC in a cohort of DLB as compared with that in patients with Parkinson disease (PD). METHODS In total, 614 patients with PD and 236 DLB were recruited and followed during 2005-2013. AC was diagnosed as sudden akinetic state unresponsive to dopaminergic rescue drugs, dysphagia and serological alterations without recovery for 48 h or more requiring hospital admission. Exposure to neuroleptics was specifically evaluated, because of the high implicit risk in DLB. RESULTS 24 patients with PD (3.9%) and 16 patients with DLB (6.8%) developed AC. 77 (32.6%) DLB and 32 (5.2%) PD were exposed to typical neuroleptics, but only 8 DLB and 3 PD presented with AC. Disease duration before AC was lower in DLB than in PD group (p<0.01). Outcome was fatal in 8 patients with (50%) DLB and 3 (12.5%) PD (p=0.05). When age and use of neuroleptics were adjusted for into a Cox proportional hazards model predicting time to AC, the HR of patients with DLB was 13.0 (95% CI 4.23 to 39.9; p<0.001). CONCLUSIONS AC in DLB can appear independently of neuroleptic treatment, occurs earlier and is more frequently fatal than in PD.
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Affiliation(s)
- L Bonanni
- Department of Neuroscience Imaging and Clinical Sciences and CESI, University G d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - R Di Giacomo
- Department of Neuroscience Imaging and Clinical Sciences and CESI, University G d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - A D'Amico
- Department of Neuroscience Imaging and Clinical Sciences and CESI, University G d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - V Frazzini
- Department of Neuroscience Imaging and Clinical Sciences and CESI, University G d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - R Franciotti
- Department of Neuroscience Imaging and Clinical Sciences and CESI, University G d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - L Manzoli
- Section of Epidemiology, Department of Medicine and Aging, University G d'Annunzio of Chieti-Pescara, Chieti, Italy Regional Healthcare Agency of Abruzzo, Abruzzo, Italy
| | - A Thomas
- Department of Neuroscience Imaging and Clinical Sciences and CESI, University G d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - M Onofrj
- Department of Neuroscience Imaging and Clinical Sciences and CESI, University G d'Annunzio of Chieti-Pescara, Chieti, Italy
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Rajan R, Krishnan S, Kesavapisharady KK, Kishore A. Malignant Subthalamic Nucleus-Deep Brain Stimulation Withdrawal Syndrome in Parkinson's Disease. Mov Disord Clin Pract 2016; 3:288-291. [PMID: 30363553 DOI: 10.1002/mdc3.12271] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 08/27/2015] [Accepted: 09/04/2015] [Indexed: 11/11/2022] Open
Abstract
Abrupt cessation of STN-DBS is an under-recognized cause of life-threatening akinetic crisis in Parkinson's disease (PD) and can present as a movement disorder emergency. We report on 2 patients who survived severe and prolonged akinetic crisis after abrupt cessation of STN stimulation for PD (malignant STN-DBS withdrawal syndrome). We discuss the clinical similarities and possible differences in pathophysiology from the akinetic crisis in medically-treated PD. Although early implantable pulse generator (IPG) replacement is the definitive treatment, medical and economic considerations may preclude early surgery and strategies for medical management assume importance. We reflect upon the socioeconomic concerns surrounding DBS in countries lacking health care coverage and the need for user-independent monitors and indicators of low IPG battery status.
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Affiliation(s)
- Roopa Rajan
- Comprehensive Care Center for Movement Disorders Sree Chitra Tirunal Institute for Medical Sciences and Technology Kerala India
| | - Syam Krishnan
- Comprehensive Care Center for Movement Disorders Sree Chitra Tirunal Institute for Medical Sciences and Technology Kerala India
| | - Krishna Kumar Kesavapisharady
- Comprehensive Care Center for Movement Disorders Sree Chitra Tirunal Institute for Medical Sciences and Technology Kerala India
| | - Asha Kishore
- Comprehensive Care Center for Movement Disorders Sree Chitra Tirunal Institute for Medical Sciences and Technology Kerala India
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[Neuroleptic malignant syndrome associated with quetiapine after withdrawal of olanzapine and donepezil, with EEG differential diagnosis of Creutzfeldt-Jakob disease]. Rev Esp Geriatr Gerontol 2016; 51:301-2. [PMID: 26923263 DOI: 10.1016/j.regg.2016.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 01/15/2016] [Accepted: 01/20/2016] [Indexed: 11/22/2022]
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Capasso M, De Angelis MV, Di Muzio A, Anzellotti F, Bonanni L, Thomas A, Onofrj M. Critical Illness Neuromyopathy Complicating Akinetic Crisis in Parkinsonism: Report of 3 Cases. Medicine (Baltimore) 2015; 94:e1118. [PMID: 26181547 PMCID: PMC4617089 DOI: 10.1097/md.0000000000001118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Akinetic crisis (AC) is a life-threatening complication of parkinsonism characterized by an acute severe akinetic-hypertonic state, consciousness disturbance, hyperthermia, and muscle enzymes elevation. Injectable dopaminomimetic drugs, high-dose methylprednisolone, and dantrolene are advocated as putative specific treatments. The course of the illness is frequently complicated by infections, pulmonary embolism, renal failure, disseminated intravascular coagulation, and cardiac arrhythmias. Critical illness neuromyopathy (CINM) is an acquired neuromuscular disorder characterized by flaccid quadriparesis and muscle enzyme elevation, often occurring in intensive care units and primarily associated with inactivity, sepsis, multiorgan failure, neuromuscular blocking agents, and steroid treatment. In 3 parkinsonian patients, during the course of AC we observed disappearance of rigidity but persistent hypoactivity. In all, neurological examination showed quadriparesis with loss of tendon reflexes and laboratory investigation disclosed a second peak of muscle enzymes elevation, following the first increment due to AC. Electrophysiological studies showed absent or reduced sensory nerve action potentials and compound muscular action potentials, myopathic changes, and fibrillation potentials at electromyography recordings, and reduced excitability or inexcitability of tibialis anterior at direct muscle stimulation, leading to a diagnosis of CINM in all 3 patients. In 1 patient, the diagnosis was also confirmed by muscle biopsy. Outcome was fatal in 2 of the 3 patients. Although AC is associated with most of the known risk factors for CINM, the cooccurrence of the 2 disorders may be difficult to recognize and has never been reported. We found that CINM can occur as a severe complication of AC, and should be suspected when hypertonia-rigidity subsides despite persistent akinesia. Strict monitoring of muscle enzyme levels may help diagnosis. This finding addresses possible caveats in the use of putative treatments for AC.
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Affiliation(s)
- Margherita Capasso
- From the Neurology Clinic (MC, MVD, AD, FA, LB, MO), "SS Annunziata" Hospital; and Department of Neuroscience and Imaging (LB, AT, MO), University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
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