possibilities

[sid360]

I have symtoms very much like parkinsons but do not respond to PD meds. What are some other possible diagnosis? Maybe some type of infection? My symtoms are: weakness, some shaking on right side, balance problems, coordination problems, fatique, burning eyes. sinus problems. red skin on face, urinary burning.  

[Joyce K Lee, MD]

Dear sid360,

Thank you for submitting your question.
Please be reminded that this is solely for educational purposes and should in no way be a substitute for a formal evaluation by a certified physician.

Parkinson’s disease (PD) is a common disorder that should be, and usually is, easy to diagnose.  The most widely accepted modern version is from the UK Parkinson’s Disease Society Brain Bank whose criteria for a diagnosis of Parkinson’s disease are bradykinesia (slowness of initiation of voluntary movement with progressive reduction in speed and amplitude of repetitive actions) and at least one of the following:

* muscular rigidity (stiffness or increased tonicity) on passive range of motion,
*4–6 Hz resting tremor,
*postural instability (difficulty maintaining an upright posture) not caused by primary visual, vestibular, cerebellar or proprioceptive function.

Nevertheless, studies have demonstrated that even in the best of hands the correct diagnosis is missed in approximately 20% of cases.
Disorders like progressive supranuclear palsy and the multiple systems atrophy syndromes (i.e., striatonigral degeneration, olivopontocerebellar atrophy, Shy-Drager syndrome, corticobasal degeneration) make up the remaining 20% that are often misdiagnosed -- these are termed, the atypical parkinsonian syndromes, rather than the idiopathic or typical form (the one that is most publicized.)


If you would allow me to briefly describe each atypical syndromes, you may find it useful in sorting out your own symptoms.
A. Progressive Supranuclear Palsy
This is a drug resistant parkinsonism. It is characterized by the inability to move the eyes in an up and down movement, neck dystonia (a  peculiar posturing of the neck causing the head to be fixed skyward), dysphagia (difficulty swallowing) and dysarthria (difficulty speaking), and a tendency to suddenly lose balance.

The facial expression may take on a surprised look with elevation of the eyebrows.
Early symptoms are often vague and include mild disequilibrium with slowing, easy fatigability, minor personality changes and subtle visual symptoms such as blurring or double vision. With disease progression, walking becomes slow and deliberate with broad-based steps and progressive loss of balance. The facial expression is fixed and associated with frowning, and rapid blinking can occur.
Loss of memory and other problems with concentration is frequent. Tremor is rare. Common personality changes are apathy, depression and irritability.
Complaints often associated with the problem moving the eyes up or  down include the inability to read, write, eat properly, or dress. Going down stairs can be very difficult. In advanced stages the eyes may not move at all. As the disease progresses falling becomes more frequent,  often without warning. Swallowing often becomes the major problem putting the patient at risk of choking and developing pneumonia.
This diagnosis is made on the basis of findings on the in office  neurologic examination. The characteristic eye movement problem and shrinkage of the brainstem on CT scan can confirm the diagnosis.
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B. Cortico-basal-ganglionic Degeneration (CBGD)
This is a rare drug resistant parkinsonism. It is characterized by the marked asymmetry of the Parkinsonian features until late in the disease. The patients will frequently have apraxia (inability to properly use a limb for complex tasks despite normal power and only mild incoordination), action myoclonus (i.e. jerky abnormal movements superimposed on normal movements), "alien limb phenomenon"(one limb seems to have a mind of its own, sometimes actively interfering  with planned movements), and stimulus sensitive myoclonus (involuntary jerking in response to light touch).
Early on the condition may be misdiagnosed as Parkinson's disease. Marked often painful rigidity may occur late in this disorder. Tremor is  not as common as in Parkinson's disease.
CT scanning, or MRI may identify local atrophy (shrinkage) of the surface (cortex) of the brain late in this condition.
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The Multi-System Atrophies

This group of disorders includes what used to be called:

Olivopontocerebellar Atrophy (OCPA)

Striato-Nigral Degeneration (SND)

Shy-Drager syndrome (SDS).

The Multi-System Atrophies are a group of progressive neurodegenerative disorders that early on can mimic, or be mistaken for, Parkinson's Disease. This diagnosis is often made only after patients  fail to improve with medication or develop atypical features.
In Parkinson's Disease only one main group of nerve cells die at an abnormally fast rate. These cells produce Dopamine, a neuro-chemical that stimulates parts of the brain responsible for movement. Without dopamine "like a motor without oil", the body slows, stiffens, and can start to shake. In Parkinson's Disease replacing dopamine in pill form  results in improved mobility. In the Multi-System Atrophies a variety of groups of nerve cells die off. The cells that dopamine stimulates are involved. In this situation the "motor is damaged and just putting more oil in doesn't usually help". Thus dopamine replacement doesn't  resolve the many problems associated with these disorders.

Although early on these disorders may be difficult for doctors to tell apart, as time goes on they develop certain distinguishing features. They all share the unfortunate characteristic of responding poorly to anti-Parkinson medications.

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I know that all this information is overwhelming and may be hard to sort out for the non-physicians.
I have personally found however, that patients are often eagerly wanting more information than less and I am very interested in providing as much exposure to education as possible.

I am not saying definitely that you have an atypical Parkinsonian syndrome, but it should be considered on the basis of the fact that you have not found an adequate response to medications used for typical PD.
The other possibility is that you don't have Parkinson's at all!

If you would allow me to, I would like to recommend our movement disorder specialists, in particular -- Drs. Walter and Itin for further evaluation.
Both are located within the Cleveland Clinic system.

Thank  you,
Hope this helps,
JKL, MD

Acknowledgements: Information courtesy of www.clinmedres.org/cgi/content/full/4/4/246 and http://www.cmdg.org/Movement_/Parkinsons_Plus/parkinsons_plus.htm  which can be used for further reading.

[sid360]

Is it possible for this to be a systemic infectuios process? If so what are some possibilities? I've been treated with diflucan for yeast without any results. I've had a syscoptsy and they noticed some redness in my bladder.

Thanks for any information,