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A woman developed tremor of the right hand at age 55.  The tremor disappeared during sleep and did not interfere with skilled movements such as drinking a glass of water.  Three years later, the tremor began to affect the left hand also.  Her family noted that she tended to walk with small steps, and that she smiled and blinked infrequently.  She had no history of encephalitis, and had not been exposed to manganese, psychotropic drugs, or anti-nausea medication.  Family history was negative for neurological disease.

 Neurological examination at age 60 showed the following abnormalities: she walked with tiny steps, and when pushed was unable to stop walking until she reached a wall.  There was bilateral hand tremor, “pill-rolling” in character, present at rest, minimal with posture holding, but not during finger to nose testing.  There was rigidity in all limbs and in the neck, and during passive movement of the limbs a “cog-wheeling” sensation was noted by the examiner.  She blinked infrequently and had mask-like facial immobility.  When she wrote, the first letters formed were of normal size, but subsequent words became progressively smaller.  Her mentation, strength, deep tendon reflexes, plantar reflexes, and sensation were within normal limits.

QUESTIONS: CASE SUMMARY 4a

1.  What is the most likely diagnosis?

2.  Where are the most prominent pathological changes?

3.  Should she receive medical treatment, and if so, what kind?

 4. Lack of encephalitis or exposure to manganese or psychotropic drugs or antinausea drugs is mentioned in the history.  Are these relevant? Why?

CASE SUMMARY 4b 

Ten years later, the above patient returns.  Family members note that she is falling frequently, especially when her feet “freeze” in the middle of walking.  Her medication effect, once so beneficial for at least 6 hours, now is only lasting 2 hours, and she has involuntary writhing movements as well when her medications are wearing off.

 In addition, she is forgetful, slow to speak and think, seems depressed, and has evening hallucinations.  Neuropsychological testing shows some memory impairment, poor performance on visuospatial testing, poor executive function, but no aphasia.

QUESTIONS: CASE SUMMARY 4b

1.  What is the most likely diagnosis for the patient’s new symptoms?

2.  How do you evaluate someone for causes of dementia?

3.  How do you treat her hallucinations?

4.  How do you treat her wearing off symptoms?

5. Is surgery an option?