[Treatment of psychosis in Parkinson]. / Tratamiento de la psicosis parkinsoniana.

INTRODUCTION: Parkinson's disease (PD) is a chronic idiopathic neurodegenerative disorder in which there is a dopamine deficit that produces motor and other disturbances, such as autonomic, sensory and neuropsychiatric disorders, including psychosis. Psychosis in PD, which is characterised by the existence of hallucinations and delusions, is a frequent and disabling problem for the patient; it is stressing for caregivers and difficult to manage for the physician, since it predisposes the patient to higher rates of morbidity and mortality and to institutionalisation. AIM: To carry out a review of the literature on the treatment of psychosis in PD. DEVELOPMENT: In this paper we review several different aspects of psychosis in PD, such as the diagnostic criteria, pathophysiology, predisposing factors, clinical features and, above all, management, which includes the use of atypical antipsychotics (after attempts have been made to reduce the antiparkinson medication to a limit marked by the loss of motor autonomy). Additionally, we also review the evidence that is currently available on other pharmaceuticals for use to treat psychosis in PD (anticholinesterases, drugs that act on serotonin receptors and so forth). CONCLUSIONS: Psychosis in PD is a problem that is difficult to treat, with a poorly understood pathophysiology, in which the most important means of combating it (in addition to prevention and reduction of dopaminergic medication, if possible) is the use of atypical antipsychotics. Other treatments which are now offering still very preliminary, but promising, results could well end up becoming the first line of treatment for this condition in the near future.

Tratamiento de la psicosis parkinsoniana / Treatment of psychosis in parkinson

Introducción. La enfermedad de Parkinson (EP) es un trastorno crónico neurodegenerativo idiopático en el que existe un déficit dopaminérgico que provoca alteraciones motoras y otras, como autonómicas, sensitivas y neuropsiquiátricas, incluida la psicosis. La psicosis en la EP, caracterizada por la existencia de alucinaciones y delirios, es un problema frecuente e invalidante para el paciente, estresante para el cuidador y de difícil manejo para el facultativo, pues predispone a una mayor morbimortalidad y a la institucionalización del paciente. Objetivo. Realizar una revisión de la bibliografía sobre el tratamiento de la psicosis en la EP. Desarrollo. Se revisan diversos aspectos de la psicosis en la EP, como criterios diagnósticos, fisiopatología, factores predisponentes, características clínicas y, sobre todo, manejo, en el que se incluye (tras haber intentado reducir la medicación antiparkinsoniana hasta un límite marcado por la pérdida de la autonomía motora) la utilización de antipsicóticos atípicos. Además, se revisa la evidencia disponible con otros fármacos para la psicosis en la EP (los anticolinesterásicos, fármacos que actúan sobre los receptores de serotonina y otros). Conclusión. La psicosis en la EP es un problema de difícil tratamiento, con fisiopatología no bien conocida, en el que la principal arma es (además de la prevención y la reducción de la medicación dopaminérgica, si es posible) el empleo de los antipsicóticos atípicos, si bien podrían incorporarse a la primera línea del tratamiento en un futuro próximo otros tratamientos con resultados muy preliminares, aunque prometedores (AU)

Introduction. Parkinson’s disease (PD) is a chronic idiopathic neurodegenerative disorder in which there is a dopamine deficit that produces motor and other disturbances, such as autonomic, sensory and neuropsychiatric disorders, including psychosis. Psychosis in PD, which is characterised by the existence of hallucinations and delusions, is a frequent and disabling problem for the patient; it is stressing for caregivers and difficult to manage for the physician, since it predisposes the patient to higher rates of morbidity and mortality and to institutionalisation. Aim. To carry out a review of the literature on the treatment of psychosis in PD. Development. In this paper we review several different aspects of psychosis in PD, such as the diagnostic criteria, pathophysiology, predisposing factors, clinical features and, above all, management, which includes the use of atypical antipsychotics (after attempts have been made to reduce the antiparkinson medication to a limit marked by the loss of motor autonomy). Additionally, we also review the evidence that is currently available on other pharmaceuticals for use to treat psychosis in PD (anticholinesterases, drugs that act on serotonin receptors and so forth). Conclusions. Psychosis in PD is a problem that is difficult to treat, with a poorly understood pathophysiology, in which the most important means of combating it (in addition to prevention and reduction of dopaminergic medication, if possible) is the use of atypical antipsychotics. Other treatments which are now offering still very preliminary, but promising, results could well end up becoming the first line of treatment for this condition in the near future (AU)

[Usefulness of olanzapine in the levodopa-induced psychosis in patients with Parkinson's disease]. / Utilidad de la olanzapina en la psicosis inducida por levodopa en pacientes parkinsonianos.

BACKGROUND: To evaluate the antipsychotic efficacy of olanzapine (OLZ) in patients with Parkinson's disease (PD) and drug-induced psychosis (DIP) and its repercussion on the motor function. METHODS: Ten patients (5 women and 5 men) diagnosed of PD and DIP, aged 67 years (range: 50-81), with PD duration of 11.1 years (range: 6-23), treated chronically with levodopa per day, received a dose of 2.5 or 5.0 mg OLZ daily. Data concerning improvement of psychosis and worsening of motor function was based on Positive And Negative Symptoms Scale (PANSS) and Unified Parkinsons Disease Rating Scale (UPDRS) motor. RESULTS: Psychotic symptoms were improved in all patients. In most of them the improvement was almost total. Seven patients increased levodopa dose on OLZ, but significant worsening of motor function was reported just in one patient. None of the patients had agranulocytosis in the blood monitoring. Two patients presented weight gain. Seven patients improved their cognitive status. CONCLUSIONS: We conclude that OLZ at the doses studied may have efficacy for DIP which appears in PD and does not induce worsening of motor function in most of the patients.

Utilidad de la olanzapina en la psicosis inducida por levodopa en pacientes parkinsonianos / Usefulness of olanzapine in the levodopainduced psychosis in patients with Parkinson's disease

FUNDAMENTO: Valorar la eficacia antipsicótica de la olanzapina (OLZ) en pacientes con enfermedad de Parkinson (EP) con psicosis inducida por fármacos (PIF) y su repercusión sobre la función motora. MÉTODOS: Diez pacientes (5 mujeres y 5 varones) diagnosticados de EP y PIF, con una media de edad de 67 años (límites: 50-81), con una evolución media de la EP de 11,1 años (límites: 6-23), tratados crónicamente con levodopa, recibieron una dosis de 2,5 o 5,0 mg/día de OLZ. Para la valoración de la mejoría de la psicosis o del empeoramiento de la función motora se utilizaron las escalas Positive and Negative Symptoms Scale (PANSS) y Unified Parkinson's Disease Rating Scale (UPDRS) motora, respectivamente. RESULTADOS: Los síntomas psicóticos mejoran en todos los pacientes, obteniendo todos los casos una puntuación > 80 por ciento en comparación con la anterior al tratamiento. Siete pacientes necesitaron incrementar la dosis de levodopa al incorporar la OLZ, aunque sólo en uno de ellos se produjo un empeoramiento motor. Ningún enfermo presentó agranulocitosis y dos ganaron peso. La mayoría de los pacientes mejoraron claramente su estado cognitivo. CONCLUSIONES: La OLZ, a las dosis utilizadas en este trabajo, puede ser eficaz en la PIF que aparece en la EP y en la mayoría de los pacientes no parece deteriorar la función motora. (AU)

[Parkinsonism probably induced by manganese]. / Parkinsonismo probablemente inducido por manganeso.

INTRODUCTION: In all cases of young persons with clinical Parkinson s disease it should be suspected that it is secondary to some primary disorder. Therefore a battery of diagnostic tests should be done before classification as idiopathic Parkinson s disease. CLINICAL CASE: A 31 year old woman whose only previous illness had been Graves disease. She complained of difficulty with movements of her right arm and leg for some months (she had problems with walking and with rapid, repeated movements of her right hand). She also complained of tremor of her right limbs at rest. She denied taking drugs, having dysphagia, dysarthria, visual changes or sphincter disorders. Neurological examination showed her to have monotonous speech, slight facial hypomimia, slight reduction in spontaneous blinking, walking with less swing of her right arm; postural tremor of both arms, worse on the right; bradykinesia (2/4) of both right limbs and rigidity (1/4), axial and of the right limbs. The results of all the investigations done to rule out secondary Parkinsonism were normal, except for the plasma manganese level which was raised, although it returned to normal when the probable source of exposure to this metal was removed. However, the alterations of movement only disappeared after treatment with levodopa was started. CONCLUSION: In cases of Parkinsonism in young adults secondary causes should always be rules out, such as exposure to certain metals.

Dissociation between intentional and incidental sequence learning in Huntington's disease.

The ability to acquire and act upon serial order information is fundamental to almost all forms of adaptive behaviour. There is growing evidence that such knowledge may be acquired through a number of different means, each perhaps with its own neuronal substrate. One major distinction is between serial order information acquired intentionally and leading to explicit conscious knowledge of the sequence structure, and information acquired incidentally through experience. While this latter form of knowledge influences behaviour, it may do so without the participant being aware of the sequential information, i.e. it is acquired implicitly. Evidence from physiological and lesion studies in animals and imaging studies in humans suggests that these two forms of learning may have dissociable neuronal substrates. Specifically, the striato-thalamo-cortical circuit centred on the caudate nucleus is proposed to be involved in intentional sequence learning and that based on the putamen on incidental learning. The present study tested one part of this proposed dissociation by assessing patients with Huntington's disease on tasks of the two forms of learning. On the test of trial-and-error intentional learning there were marked deficits, which were closely related to disease progression and to measures of executive cognitive dysfunction. This finding was in contrast to the finding from the incidental learning task. Performance of the Huntington's disease group was essentially normal and unrelated to measures of disease progression and cognitive status. The results, although supportive of the proposed dual-system hypothesis, offer only partial confirmation. Further direct study is required using similar tasks in patients with putamenal disorder or lesions within the skeletomotor striato-thalamo-cortical circuit.

[Behçet's disease with atypical double neurological involvement]. / Enfermedad de Behçet con doble afectación neurológica atípica.

INTRODUCTION: Neurological involvement in Behçet s disease (BD) occurs in 10 30% of the cases and is usually central, with the peripheral nervous system being rarely involved. It is also unusual for the disorder to present with neurological features at the onset. CLINICAL CASE: A 51 year old man with an undefined history of brainstem encephalitis and epileptic seizures. He later developed a cerebellar syndrome and relapsing orogenital ulcers, diagnosed as BD with involvement of the central nervous system. At the present time the patient complained of marked deterioration in gait and progressive difficulty with carrying out everyday tasks using his upper limbs. On neurological examination there was paresia of the right VI cranial nerve, hyporeflexia of the left half of his body, left hypo esthesia (slight for touch and discrimination, but marked for proprioception) and dissymmetry of upper and lower left limbs. Complementary investigations showed there to be sensory polyneuropathy of the left arm and leg. Both central and peripheral nervous system alterations improved on steroid treatment. CONCLUSION: The probable onset of BD with central nervous system alterations and subsequent appearance of peripheral neuropathy are infrequent findings in BD. The relation of both disorders with vasculitis is reinforced by the good response to immunosuppressive treatment.

Parkinsonismo probablemente inducido por manganeso / Parkinsonism probably induced by manganese

Introducción. Ante todo paciente joven con clínica parkinsoniana debemos sospechar que sea secundaria a alguna patología, por lo que se debe realizar una batería de pruebas diagnósticas antes de clasificarlo como una enfermedad de Parkinson idiopática. Caso clínico. Mujer de 31 años cuyo único antecedente es una enfermedad de Graves. Consulta por notar desde hace meses dificultad en los movimientos de las extremidades derechas (tanto para caminar como para realizar movimientos rápidos y repetidos de la mano). Además, refiere temblor de reposo en dichas extremidades. Niega consumo de drogas, disfagia, disartria, alteraciones visuales o esfinterianas. La exploración neurológica objetiva habla monótona, ligera hipomimia facial, discreta disminución del parpadeo espontáneo, marcha con disminución del braceo en miembro superior derecho; temblor postural en ambos miembros superiores, más acusado en el lado derecho; bradicinesia (2/4) en ambas extremidades derechas, y rigidez (1/4) axial y de extremidades derechas. Todas las pruebas complementarias realizadas para descartar un parkinsonismo secundario fueron normales, salvo las concentraciones séricas de manganeso, que se encontraban elevadas, si bien se normalizaron tras cesar la probable fuente de exposición al metal. Sin embargo, las alteraciones del movimiento sólo se controlaron tras instaurar terapia con levodopa. Conclusión. Ante un parkinsonismo en adultos jóvenes debemos descartar siempre las causas secundarias, como la exposición a ciertos metales (AU)

Enfermedad de Behçet con doble afectación neurológica atípica / BehÇet´s disease with atypical double neurological involvement

Introducción. La afectación neurológica en la enfermedad de Behçet (EB) ocurre en el 10-30 por ciento de los casos y suele ser central, es rara la participación del sistema nervioso periférico. El inicio de la enfermedad con manifestaciones neurológicas es también infrecuente. Caso clínico. Varón de 51 años, con antecedentes de encefalitis de tronco no filiada y crisis epilépticas. Posteriormente desarrolló un síndrome cerebeloso y aftas orogenitales recidivantes, diagnosticado de EB con afectación del sistema nervioso central. Actualmente el paciente consulta por deterioro importante para la deambulación y dificultad progresiva para realizar tareas cotidianas con los miembros superiores. La exploración neurológica objetiva paresia del VI par derecho, hiporreflexia en hemicuerpo izquierdo, hipoestesia izquierda (discretas la táctil y discriminativa, y marcada la propioceptiva) y dismetría en miembros superiores e inferior izquierdo. De las pruebas complementarias, destaca una polineuropatía exclusivamente sensitiva en miembros superiores e inferior izquierdo. Tanto las manifestaciones centrales como las periféricas del sistema nervioso respondieron al tratamiento con esteroides. Conclusión. El probable inicio de la EB con manifestaciones neurológicas centrales y la posterior aparición de neuropatía periférica son hechos infrecuentes en la EB. La relación de ambas con esta vasculitis se refuerza por la buena respuesta al tratamiento inmunosupresor (AU)

[Spasmodic torticollis and vertebral hemangioma]. / Tortícolis espasmódico y hemangioma vertebral.

INTRODUCTION: Spasmodic torticollis in young patients should give rise to a clinical suspicion that this is secondary to another primary disorder. Therefore a series of diagnostic tests should be carried out before it is labelled as idiopathic. CLINICAL CASE: The patient was a thirty year old man who had had difficulty in writing with his right hand since childhood. At the age of 20 years he was diagnosed as having writer's cramp and idiopathic spasmodic torticollis. On general physical examination no abnormalities were found. On neurological examination he had: absence of reflexes of both arms, limited but painless rotation of the neck towards the left and hypertrophy of the left trapezius muscle. Laboratory, neurophysiological and neuroimaging investigations seeking a secondary cause for the torticollis were all normal. There were no Keyser-Fleischer rings. Chest X-ray showed, dorsal scoliosis with convexity to the left. CAT and MR of the spine showed a hemangioma in the body of T1. On arteriography of the supra-aortic and vertebral trunks a hemangioma was found at T1 which received contrast material via a branch of the right thyro-bi-cervico-scapular trunk. Various treatments were tried (diazepam, Botox, Dysport, tetrabenazine, baclofen, etc.) with no improvement. A definite diagnosis of secondary torticollis could not be made since the hemangioma was supplied by a very narrow vascular pedicle, so embolization was contraindicated. CONCLUSION: Cervical spinal cord alterations may cause focal dystonia due to increased excitability of the spinal motor neurone, due to dysfunction of the disinhibitory descending reciprocal paths.

Toxic psychosis following cycloplegic eyedrops.

A case of toxic psychosis due to cycloplegic eyedrops is reported. The characteristic mental symptoms of atropine intoxication include confusion with vivid visual hallucinations, restlessness, muscular incoordination, and later emotional lability. These symptoms and a short period of retrograde amnesia occurred in our patient. The adverse drug reaction was confirmed following rechallenge. The possible preventive measures against intoxication caused by atropine eyedrops are described. All healthcare professionals should be aware of the possible temporal relationship between the appearance of pathology and the administration of a drug.