Levodopa induced motor complications in Thai Parkinson's disease patients.

BACKGROUND: Long-term levodopa usage in Parkinson's disease (PD) patients is known to cause several motor complications. It may be related to several factors such as levodopa dosage, duration of treatment and severity of disease. OBJECTIVE: To study the prevalence of levodopa motor complications and associated factors in Thai Parkinson's disease patients. MATERIAL AND METHOD: The authors prospectively collected baseline characteristics of PD patients, details of treatment and complications from 3 hospitals in various parts of Thailand. These patients were diagnosed by UK PD Brain Bank criteria. RESULTS: A total of 154 patients aged 68.1 +/- 9.5 years were recruited. Age of onset was 61.2 +/- 9.8 years. Most patients were in Hoehn-Yahr stage 1-3. The common clinical features were bradykinesia, rigidity and resting tremor Treatments were levodopa (98.1 per cent), anticholinergic (29.9 per cent), dopamine agonists (26 per cent) and COMT inhibitor (9.1 per cent). Eighty-five per cent of the patients had excellent response to levodopa. However, 25 per cent of patients developed motor complications, which were wearing off (79 per cent), on-off fluctuation (45 per cent), freezing (42 per cent), morning dyskinesia (10.5 per cent) and permanent dyskinesia (23.7 per cent). Twelve patients developed severe levodopa induced chorea. Factors associated with levodopa side effects were earlier age of onset, long duration of disease, advanced stage, higher levodopa dosage and long duration of levodopa treatment. In the present study, age of onset was inversely correlated with H-Y stage, while dosage of levodopa was positively correlated with H-Y stage but inversely correlated with lower ADL score, which may be due to advanced disease state. CONCLUSION: Levodopa motor complications are common in Thai PD patients. Wearing off on-off fluctuation and freezing are common forms of motor complications.

Myasthenia gravis accompanied with hypokalemic periodic paralysis.

Myasthenia gravis and hypokalemic periodic paralysis are commonly related with hyperthyroidism but rarely occur together. Here, the authors reported a case of hypokalemic periodic paralysis in a Northeastern Thai woman accompanied with myasthenia gravis. She had motor weakness despite a normal level of serum potassium. Prostigmine test was positive. She dramatically improved after pyridostigmine treatment. Autoantibodies to nicotinic AchR-Ab and dihydropyridine receptor or L-type voltage gated calcium channel were postulated to explain these associated diseases.

Seizure-related injuries in northeast Thailand.

OBJECTIVE: The authors aimed to assess the frequency, characteristics, and risk of seizure-related injuries from traffic accidents, near-drowning, burns, fractures, head and soft tissue injuries. MATERIAL AND METHOD: Attending physicians assisted 300 consecutive seizure patients to complete a questionnaire. The types and frequency of injuries were then expressed in terms of the type of seizure and related activity. RESULTS: The male (154) and female (146) patients were between 13 and 91 years of age (mean, 36.27 +/- 14.55). The seizure types comprised of Generalized Tonic-Clonic (GTC) (26%), secondary GTCs (21%) and complex partials (19%). Secondary causes accounted for 34% of seizures, and post-stroke was the most common (25.5%). The total number of seizure events per year was 8,525 and of these 7,306 included a fall with soft tissue injury (70%), head injury (22%), near-drowning (3%), burns (3%) and fracture or dislocation (1%). The ranking of significant risk factors for injuries was: 1) GTC seizure; 2) seizure with a fall; and, 3) number of seizures. CONCLUSION: Seizure-related injuries are common among Thai epileptic patients; thus, consistent treatment and education about the risk of injury would protect patients.

Seizure presenting to the emergency department, Srinagarind Hospital.

The authors would like to evaluate the incidence, clinical manifestation, the appropriateness of treatment, and outcome of seizure at the emergency department (ED). All charts of patients who visited the ED of Srinagarind Hospital from 1 January 2003 to 31 December 2003 were reviewed. The profiles of patients and management at the ED were recorded. There were 33,508 cases who visited the ED with 104 cases (0.31%) presenting with seizure. Four cases (3.9%) were diagnosed as status epilepticus. Generalized tonic-clonic seizure was the most common type. Poor antiepileptic drug (AED) compliance with the low AED level was the main precipitating factor. The normal physical examination and routine laboratory tests were normal in the majority of patients. Phenytoin intravenous loading was the commonest initial treatment even in patients with non-status epilepticus. Fourteen patients (13.5%) were treated with intravenous diazepam even though seizures were discontinued. Sixty patients (57.7%) were discharged after seizure was controlled. The advice in seizure control was recorded in only 11 cases (10.6%). From this review, 12 patients presented at the ED for continuing medication without any seizures. In conclusion, seizure at the ED should be treated more appropriately with both laboratory investigation and drug treatment. Futhermore, patient education should be implemented.

Syringomyelia as a complication of tuberculous meningitis.

Tuberculous meningitis (TBM) is a common manifestation of extrapulmonary tuberculosis. Syringomyelia is a rare complication of TBM. We report a case of syringomyelia due to TBM. A 25 year old Thai male was admitted with a history of progressive paraparesis and loss of body sensation. He had a history of TBM in the previous year, and was treated with antituberculous drugs. Physical examination revealed a temperature of 37 degrees C. Motor power was grade 3/5 with generalized hyperreflexia. He had bilateral loss of pain, temperature and vibratory sensation below the T7 level. A magnetic resonance imaging of the spine demonstrated a long segment of syrinx from C4 to the conus medullaris region. A T12-L1 laminectomy and syringosubarachnoid shunt were done. His clinical symptoms improved after surgery.

Downbeating nystagmus and postural hypotension due to basilar invagination.

Downbeating nystagmus is an involuntary vertical rhythmic eye movement with the fast component in the downward direction. The sign indicates a craniocervical disorder. The most common cause is the Arnold-Chiari malformation, followed by cerebellar degeneration. Basilar invagination is a rare cause of downbeating nystagmus. However, with appropriate treatment its prognosis is good. Here, we report a case of basilar invagination which presented with downbeating nystagmus and postural hypotension. A 31 year-old Thai male patient had a 20 year history of postural hypotension. He had recurrent pneumonia and cough-induced syncope a year before admission. He complained of symptoms of an acute febrile illness and a productive cough. The physical examination showed high grade fever, postural hypotension and medium crepitation in the right upper lobe. The neurological examination showed downbeating nystagmus, atrophy and fasciculation of the right side of the tongue, atrophy of the right sternocleidomastoid muscle, mild weakness of the extremities and generalized hyperreflexia. The cervical spine X-ray revealed upward displacement of the vertebral bodies of C1 and C2, with a mild narrowing of the space between C1 and the occiput. The CT-myelogram and MRI showed upward displacement of C1 with overriding of the dens over the anterior lip of the foramen magnum; this also compressed the medulla. Syringomyelia was seen at the C1-C5 level. We report a patient who presented with postural hypotension, recurrent pneumonia and downbeating nystagmus due to basilar invagination. The symptoms were aggravated by cough which caused an increase in intracranial pressure. This resulted from medulla compression in the foramen magnum by the first cervical spine. The treatment of choice was surgical decompression.

Hallervorden-Spatz syndrome in two siblings diagnosed by clinical features and magnetic resonance imaging.

The Hallervorden-Spatz syndrome (HSS) is a rare condition characterized by extrapyramidal and pyramidal signs, dystonia, dysarthria, retinal degeneration, dementia and a progressive course. The development of magnetic resonance imaging (MRI) has increased the number of clinical and pathological reports of HSS. MRI pallidal abnormalities are called "eye of the tiger" signs. The combination of clinical features and MRI findings can be considered as highly suggestive of a diagnosis of HSS. Patient 1 was a 28 year old man who had been well until the age of 25 years. He developed dysarthria, difficulty with his gait and dystonia in his arms at the age of 28 years. Patient 2 was a 33 year old man who was the older brother of the first patient. He developed gait difficulty, tongue dystonia and dystonia of both arms at the age of 25 years. Each patient had spastic gait, dysarthria, dystonic posturing of both arms and generalized hyperreflexia, but no Kayser-Fleischer rings or retinitis pigmentosa. Blood chemistry, urine copper, serum copper and serum ceruloplasmin were all normal. MRI of the brain showed the "eye of the tiger" sign in the globus pallidus on T2 weighted images. These siblings had clinical features and MRI findings consistent with HSS. They are the first to be reported in Thailand.

Pseudotumor cerebri caused by all-trans-retinoic acid: a case report.

Pseudotumor cerebri is a condition characterized by increased intracranial pressure with normal cerebrospinal fluid composition. It is usually associated with many medical conditions and drugs. It has been reported that all-trans-retinoic acid can induce pseudotumor cerebri. The authors report a 35-year-old patient diagnosed with acute promyelocytic leukemia who developed pseudotumor cerebri after receiving all-trans-retinoic acid. The patient was treated with 60 mg/day of all-trans-retinoic acid. Two weeks later, she had severe headache and blurred vision. The neurological examination revealed papilledema and decreased visual acuity. Other physical examinations were unremarkable. Brain CT was normal. Additionally, lumbar puncture was performed and the CSF finding was normal except for high CSF pressure. According to modified Dandy criteria, the diagnosis was pseudotumor cerebri. The patient's symptoms disappeared after all-trans-retinoic acid was discontinued. To our knowledge, this is the first case report in Thailand.

Unusual manifestation in a case of nocardial meningitis.

A case of subacute progressive painful external ophthalmoplegia of the right eye in a 55-year-old woman is reported. CT scan of the brain, paranasal sinuses and orbits revealed normal findings. Tolosa-Hunt syndrome was diagnosed and high dose prednisolone was given. The patient later developed fever, confusion and stiffneck. Lumbar puncture showed grossly purulent CSF with Gram-positive coccobacilli and rod organism. CSF culture grew Nocardia spp. The patient made a complete recovery with trimethoprim-sulfamethoxazole treatment.