Movement disorders emergencies

Acute chorea: case series from the emergency room of a Brazilian tertiary-level center

BACKGROUND

Chorea is a movement disorder characterized by random, brief and migratory involuntary muscle contractions. It is defined as acute when present within hours to days. Three main causes for this scenario have emerged as most likely: vascular, toxic-metabolic and inflammatory.

OBJECTIVES

To identify the prevalence of the main etiologies and major clinical findings of acute chorea in the emergency room of a tertiary-level referral center; and to suggest an approach for guiding the diagnostic workup and clinical management.

METHODS

We retrospectively reviewed the clinical aspects and neuroimaging data of 10 patients presenting with acute chorea at the neurological emergency room of our hospital from 2015 to 2019.

RESULTS

Stroke was the most common etiology (50% of the cases). All of them were ischemic. It was noteworthy that only one case demonstrated the classical ischemic topographic lesion at the contralateral subthalamic nuclei. Regarding nonvascular etiologies, nonketotic hyperglycemia was the major cause, followed by drug-related chorea. One patient showed inflammatory etiology, which was probably Sydenham chorea reactivation.

CONCLUSION

Acute chorea is an uncommon and challenging problem at the emergency room, often associated with potentially treatable causes. We suggest that use of the acronym DANCE (Diagnosis of chorea, Acute stroke protocol, Normal glucose levels, Check neuroimaging, Exposure to drugs) could form a potential initial approach in the evaluation, in order to emphasize causes that require prompt proper management (e.g. thrombolysis).

Follow-Up of Advanced Parkinson's Disease Patients after Clinical or Surgical Emergencies: A Practical Approach

Background

Patients with advanced stage Parkinson's disease (PD) typically present with a myriad of motor and nonmotor symptoms in addition to comorbidities and, as a consequence, polypharmacy.

Objective

To analyze a series of cases of advanced PD in which a clinical or surgical emergency played a trigger role in the irreversible progression of landmarks of the course of the disease.

Methods

Data were collected during a 13-month observational period of a cohort of 230 PD patients, in 751 medical appointments. We included a total of 13 (5.65% of the total number) patients with advanced PD defined by Hoehn & Yahr (H&Y) stage ≥3 who presented with various clinical and surgical complications which, with the contribution of drug interventions, led to significant worsening of patients' overall clinical condition.

Results

Hip fractures and infections were the most common complications identified. As part of this scenario, most patients presented with delirium, often requiring treatment with dopamine receptor blocking agents and/or had dopaminergic treatment withdrawn. Upon reassessment after 3 months, all patients remained bed or wheel chair bound (H&Y 5) and presented significant worsening of their UPDRS part III score of at least 10 points (mean 51.5 ± 3.3; paired t-test two-tailed p < 0.0001 compared to baseline). The mean dose of levodopa at baseline was 907.7 ± 149.8 mg (600–1200) and significantly higher (paired t-test two-tailed p < 0.0001) on follow-up, 1061.5 ± 175.8 mg (700–1300).

Conclusion

Clinical and surgical emergencies are major determinants for a progression of PD to more advanced stages.

Hypermetabolic Syndrome and Dyskinesia After Neurologic Surgery for Labrune Syndrome: A Case Report

A 20-year-old man with a rare neurodegenerative disease developed hypermetabolic symptoms with dyskinesia after a third ventriculostomy for hydrocephalus. The initial presentation was concerning for an acute dystonic reaction after metoclopramide was administered for nausea. He concurrently developed hypermetabolic symptoms, including hyperthermia, tachycardia, and a lactic acidosis. The diagnosis was broadened to include neuroleptic malignant syndrome, serotonin syndrome, and malignant hyperthermia. Although perhaps less intellectually satisfying but more true to clinical reality, we did not isolate a single diagnosis but treated effectively all 3 with dantrolene sodium and benzodiazepine.

[Not Available]

Zusammenfassung. Eine 69-jährige Patientin wurde wegen einer wahnhaften Störung mit Neuroleptika behandelt. Sie wurde notfallmässig wegen einer Verschlechterung der Vigilanz in Kombination mit einer erhöhten Körpertemperatur, generalisiertem Rigor und erhöhter Kreatinkinase aus der psychiatrischen Klinik überwiesen. Nach Ausschluss einer Meningitis und anderer Infektionen wurde ein malignes Neuroleptika-Syndrom (MNS) diagnostiziert und mit Amantadin i.v. behandelt. Nach überstandenem MNS persistierte ein invalidisierender Rigor an den Beinen.