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Washington University Experience | NEURODEGENERATION | Multiple Systems Atrophy (MSA) | 7A0 Case 7 History
Case 7 History ---- The 79yo male had a PMH of Parkinsonism, two severe head injuries, BPH s/p TURP and bilateral cataract surgery, who presented in February 2016 to BJH for management of “passing out.” He had a four-to-five-year history of Parkinsonism, consisting of bilateral hand tremor, slowing of movements, difficulty walking, gait freezing and occasional falls. He was treated with Sinemet and trihexyphenidyl, which slightly improved his movements and tremor. Starting approximately one year prior to presentation, he began having syncopal episodes. Episodes would occur while sitting, usually after standing or walking around, but not while lying down. After waking up, he was occasionally confused but generally would return to his usual mentation. Cardiac workup showed profound orthostatic hypotension, with pressures dipping as low as 50s/30s and two syncopal episodes while in the hospital. Carotid ultrasound showed no flow-limiting stenosis, and echocardiogram showed left ventricular hypertrophy without decreased ejection fraction or outflow obstructions. He was started on Midodrine and Florinef due to concern for autonomic dysfunction and transferred to BJH by request of the patient’s wife for a second opinion. A 2012 MRI showed mild generalized cerebral volume reduction and a remote lacunar infarct in the deep white matter of the left frontal lobe and a few punctate nonspecific foci of T2-FLAIR signal hyperintensity within the deep bihemispheric white matter thought to represent sequelae of chronic microvascular ischemic disease. The clinical team continued Midodrine and Florinef but started weaning the Sinemet and trihexyphenidyl. On physical exam at admission, he was noted to have upper airway congestion with a poor cough and small tidal volumes with decreased air movement. By day 2 of admission, he was noted to be tachypneic. His lung sounds were coarse and an arterial blood gas showed a pH of 7.24 with a pCO2 of 68 mm Hg. The family was consulted and informed of his respiratory decline, and per family decision, only supportive care was given due to the patient’s DNR/DNI status. The patient was found with absent breaths, pulse, and died.
