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Washington University Experience | NEURODEGENERATION | Multiple Systems Atrophy (MSA) | 19A0 Case 19 History
Case 19 History ---- The patient was a 56yo male with a year and half history of Parkinsonism and autonomic insufficiency who died unexpectedly in Dec 1999 at home. The history of his present illness started in June or July 1998 when he noted difficulty dressing himself, arising from a car, a shuffling gait, stiffness and low volume of speech. In October 1998 neurologic exam revealed mild cogwheel rigidity of bilateral upper extremities, left greater than right, and a shuffling gait. No prominent tremor was noted. It was felt that he had early Parkinson's disease and Mirapex was started and titrated up. His symptoms did not respond to Mirapex. On subsequent visits his Parkinsonism worsened with more prominent upper extremity rigidity (which also started to involve lower extremities), gait instability and masked facies. Sinemet was started and titrated up in early 1999. He continued to deteriorate clinically. After a fall in May 1999 he started using a cane to ambulate, however he was still able to continue working. He was first seen at BJH in May 1999 when the dose of Sinemet 25/100 was increased. Orthostatic hypotension was also documented. According to the clinic note his blood pressure had been slowly decreasing over the past year or two: 160/90 in 11/97, 136/76 in 2/98, 122/80 in 10/98, 118/76 in 12/98 and 95/58 in 5/99. He also noted impotency, incontinence and lower extremity edema. He was admitted to BJH for work-up of his significant orthostatic hypotension and lower extremity edema. Cardiology consult felt that these were unlikely due to cardiac disease. Sinemet dose was further increased. He was alert and oriented with intact language. His concentration and calculation were somewhat poor. Cranial nerves were unremarkable. There was bradykinesia and rigidity of all extremities with left more than right. Strength was normal. Finger-nose-finger test was intact but slow. Gait was wide-based and shuffling with step turns. He had retropulsion. Reflexes were 1+ at ankles and 2+ elsewhere. Toes were down going bilaterally. He used a cane to ambulate. Lab studies: He had a normal head MRI, EEG and abdominal CT in 6/99. His past medical history was also significant for alcohol abuse. It is unclear exactly what his functional status was prior to his death. Apparently he was not feeling well the day before and was found dead the next day at home in December 1999.
