Parkinsonian syndromes presenting with circadian rhythm sleep disorder–advanced sleep-phase type.

Background. Circadian rhythm sleep disorder–advanced sleep-phase type is a relatively uncommon disorder, mostly seen among the elderly population. Impaired circadian rhythms have been reported in neurodegenerative conditions; however, there are no reports of any circadian rhythm sleep disorder among patients with Parkinsonian syndromes. We report two patients who presented with this circadian rhythm disorder, and were then diagnosed with a Parkinsonian syndrome. The cases. A 65-year-old retired man presented with history of abrupt change in sleep schedules, sleeping around 6.30–7 p.m. and waking up around 3–4 a.m. for the last 2 months. On detailed examination, the patient was observed to have symmetrical bradykinesia and cogwheel rigidity of limbs. A diagnosis of multiple system atrophy was made, supported by MRI findings and evidence of autonomic dysfunction. Symptoms of change in sleep–wake cycles resolved over the next 1 year, while the patient was treated with dopaminergic therapy. A 47-year-old man, who was being evaluated for presurgical investigation for refractory temporal lobe epilepsy, presented with complaints suggestive of dysarthria, bradykinesia of limbs and frequent falls for 5 months. Simultaneously, he began to sleep around 7 p.m. and wake up at about 2–3 a.m. Examination revealed severe axial rigidity, restricted vertical gaze and bradykinesia of limbs. A diagnosis of progressive supranuclear palsy was made. Conclusion. This is the first report of Parkinson’s plus syndromes presenting with a circadian rhythm sleep disorder– advanced sleep-phase type. More prospective assessment for circadian sleep disorders may introduce useful insights into similar associations. Natl Med J India 2015;28:233–5

Isolated Primary Tubercular Prostatic Abscess presenting as Pyrexia of unknown origin.

The genito-urinary tract is a common site of involvement in extra-pulmonary tuberculosis. However, an isolated tubercular abscess in the prostate with no evidence of disease elsewhere in the urinary tract is extremely uncommon unless the patient is immuno-compromised. We report an extremely rare instance of an isolated prostatic abscess presenting solely as pyrexia of unknown origin in a young male with no evidence of immuno-suppression.