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Washington University Experience | NEURODEGENERATION | Multiple Systems Atrophy (MSA) | 21A0 Case 21 History
Case 21 History ---- The patient is a 50yo male who presented in 2002 with weakness and numbness on the right side for one year and progressively worsening dexterity. In June 2001, he first began experiencing difficulty in balance, walking and pronouncing words, especially on the phone. He had tremor of his right hand for the previous 3 months, particularly when holding objects, and tremor of his left hand for one month when first seen in February 2002. He also developed progressive numbness of his right toes and poor balance. He was taking Sinemet which provided some benefit. He had difficulty with bladder control. The patient had an extensive workup including screening for urine manganese (negative) and MRI of the brain which was normal. An EMG showed right carpal tunnel syndrome. The patient had been a welder with an 18 year history of welding 8 hours per day. His family history was not significant for any neurologic illness. At the time of his first examination in the MDC (February 2002), the patient had parkinsonism stage 2 characterized by an asymmetric onset of resting tremor, rigidity, bradykinesia, and postural instability. Examinations of other systems were unremarkable. He continued to be treated with Sinemet. An assessment in December 2003 showed that he had progressed to the next stage of parkinsonism with marked progression in gait and autonomic symptoms. The possibility of multisystem atrophy was considered and Sinemet was tapered and discontinued. He then developed difficulty in swallowing and some memory difficulty. He had marked subjective and moderate objective worsening with the discontinuation of Sinemet and, as a result, treatment with Sinemet was resumed using the lowest effective dose. At the time he was last seen in February 2004, he had orthostatic hypotension and parkinsonism stage 5 with progression of gait disturbances. The patient expired at home in April 2004.
