1
|
Gupta HV, Lenka A, Dhamija RK, Fasano A. A video-atlas of levodopa-induced dyskinesia in Parkinson's disease: terminology matters. Neurol Sci 2024; 45:1389-1397. [PMID: 37987930 DOI: 10.1007/s10072-023-07209-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 11/15/2023] [Indexed: 11/22/2023]
Abstract
Dyskinesia is a common complication of long-term levodopa therapy in patients with Parkinson's disease (PD), which often worsens the quality of life. It is usually dose-dependent and emerges possibly due to pulsatile stimulation of dopamine receptors. Delineating the pattern of dyskinesia is crucial for determining the most effective therapeutic approach, a task that often presents challenges for numerous neurologists. This article comprehensively describes various patterns of dyskinesia in PD patients and features video demonstration of some of the common forms of dyskinesia. We have used a real case scenario as an example to lead the discussion on the phenomenology, distinguishing features, and management of various types of dyskinesia. A comprehensive literature search was conducted in PubMed using "dyskinesia" as a keyword. The prototype case with videos highlights the differentiating features of dyskinesia along with the treatment strategies. A wide range of descriptive rubrics have been used for certain dyskinesia which are described in detail in this article. The newer types of dyskinesia associated with continuous dopaminergic stimulation in patients with advanced PD and their implications have been described. As there are distinct ways of managing various types of dyskinesia, understanding the phenomenology and chronology of dyskinesia is vital for the optimal management of dyskinetic PD patients. We suggest that dyskinesia should be classified broadly into peak-dose dyskinesia (PDD), biphasic dyskinesia (BD), and OFF-period dystonia. The occurrence of low-dose dyskinesia and complex dyskinesia of continuous dopaminergic treatments should be known to specialists and will require additional studies.
Collapse
Affiliation(s)
- Harsh V Gupta
- Department of Neurology, Memorial Healthcare System, Hollywood, FL, USA.
| | - Abhishek Lenka
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Rajinder K Dhamija
- Department of Neurology, Institute of Human Behaviour and Allied Sciences, New Delhi, India
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, ON, Canada
- Division of Neurology, University of Toronto, Toronto, ON, Canada
- Krembil Brain Institute, Toronto, ON, Canada
- Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Canada
| |
Collapse
|
2
|
Beckers M, Lees AJ, Nutt JG, Bloem BR. Turning Back the Clock in Parkinson's Disease: Practical Recommendations for Managing Diurnal Symptom Worsening. JOURNAL OF PARKINSONS DISEASE 2021; 11:1471-1473. [PMID: 33967059 DOI: 10.3233/jpd-212711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Milan Beckers
- Donders Institute for Brain, Cognition and Behavior, Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Andrew J Lees
- Reta Lila Weston Institute of Neurological Studies, University College London, London, UK
| | - John G Nutt
- Department of Neurology, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Bastiaan R Bloem
- Donders Institute for Brain, Cognition and Behavior, Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
3
|
Mastering nocturnal jigsaws in Parkinson's disease: a dusk-to-dawn review of night-time symptoms. J Neural Transm (Vienna) 2020; 127:763-777. [PMID: 32172472 DOI: 10.1007/s00702-020-02170-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 03/05/2020] [Indexed: 12/11/2022]
Abstract
Finding out about night-time symptoms from Parkinson's disease (PD) patients can be a challenge as many patients and their carers cannot recall many symptoms that occur during the night, resulting in an under-recognition or a large variability of responses from clinical interviews and scales. Moreover, technology-based assessments for most night-time symptoms are still not universally available for use in a patient's home environment. Therefore, most physicians rely on their clinical acumen to capture these night-time symptoms based on pieces of patients' history, bedpartner's reports, clinical features, associated symptoms or conditions. To capture more night-time symptoms, the authors identified common nocturnal symptoms based on how they manifest from dusk to dawn with selected features relevant to PD. While some symptoms occur in healthy individuals, in PD patients, they may impact differently. The authors intend this narrative review to provide a practical guide on how these common night-time symptoms manifest and highlight pertinent issues by focusing on prevalence, clinical symptomatology, and specific relationships to PD. It is also important to recognise that PD-specific sleep disturbances increase with advancing disease with additional contributions from ageing, comorbidities, and medication side effects. However, the relative contribution of each factor to individual symptom may be different in individual patient, necessitating clinical expertise for individual interpretation. While there are debatable issues in certain areas, they underlie the complexity of night-time symptoms. Understanding night-time symptoms in PD is like re-arranging jigsaw pieces of clinical information to create, but never complete, a picture for physicians to instigate appropriate management.
Collapse
|
4
|
Marano M, Naranian T, di Biase L, Di Santo A, Poon YY, Arca R, Cossu G, Marano P, Di Lazzaro V, Fasano A. Complex dyskinesias in Parkinson patients on levodopa/carbidopa intestinal gel. Parkinsonism Relat Disord 2019; 69:140-146. [PMID: 31759188 DOI: 10.1016/j.parkreldis.2019.11.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 11/09/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Levodopa-carbidopa intestinal infusion is an effective treatment for motor fluctuations in Parkinson's disease. However, it has been recently associated with emergent complex/atypical dyskinesias. We sought to characterize patients who developed these dyskinesias after levodopa infusion initiation, and to compare these patients to a control population with conventional motor fluctuations. METHODS 208 Parkinson's disease patients, treated with levodopa intestinal infusion due to motor fluctuations, were screened for onset and/or worsening of dyskinesias after initiation of levodopa infusion, resistant to the routine titration, and presenting with atypical or unexpected patterns. Patients with extensive follow-up data were enrolled for a longitudinal analysis. Cases were compared to a control sample with conventional motor fluctuations in order to investigate predisposing factors, difference in dyskinesia phenotype, management strategies and dropouts. RESULTS Thirty patients out of 208 (14.4%) reported atypical (i.e. long-lasting) biphasic, biphasic-like (i.e. continuous) or mixed (peak-dose and continuous biphasic) dyskinesias after levodopa infusion. They were compared at baseline and follow-up to a sample of 49 patients with conventional motor fluctuations on levodopa infusion. Both groups had similar demographic and clinical features, except the former having higher prevalence of biphasic dyskinesias while on oral therapy. Biphasic-like dyskinesias in nearly half the number of cases improved with increasing the dopaminergic load, while mixed dyskinesias had the worst outcome and highest dropout rate (58%). CONCLUSIONS Atypical biphasic, biphasic-like and complex dyskinesias could hinder the course of patients treated with levodopa infusion. This study further informs the selection process of advanced therapies, particularly in dyskinetic patients.
Collapse
Affiliation(s)
- Massimo Marano
- Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine, Campus Bio-Medico of Rome University, Rome, Italy
| | - Taline Naranian
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Centre and the Toronto Western Hospital, UHN, Toronto, Ontario, Canada
| | - Lazzaro di Biase
- Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine, Campus Bio-Medico of Rome University, Rome, Italy
| | - Alessandro Di Santo
- Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine, Campus Bio-Medico of Rome University, Rome, Italy
| | - Yu-Yan Poon
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Centre and the Toronto Western Hospital, UHN, Toronto, Ontario, Canada
| | - Roberta Arca
- Department of Neurology, Bruneck Hospital, ASDAA, Bruneck, Italy
| | | | - Pietro Marano
- Department of Neuro-rehabilitation, Madonna del Rosario Clinic, Catania, Italy
| | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine, Campus Bio-Medico of Rome University, Rome, Italy
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Centre and the Toronto Western Hospital, UHN, Toronto, Ontario, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada; Krembil Brain Institute, Toronto, Ontario, Canada; CenteR for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, ON, Canada.
| |
Collapse
|
5
|
Kataoka H, Sawada Y, Shimozato N, Inatomi S, Yoshiji H, Sugie K. Levodopa-responsive retrocollis on the background of choreic dyskinesia. Int J Neurosci 2019; 130:461-463. [PMID: 31714814 DOI: 10.1080/00207454.2019.1692836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Purpose/aim: Retrocollis can substantially disturb the daily living of individuals with Parkinson's disease (PD). Clinician often encounter the difficulty in managing the retrocollis. Materials and Methods: We describe a patient with PD who presented with choreic dyskinesia and levodopa-responsive retrocollis. Results: The patient had dyskinesia and the off periods, and received levodopa (700 mg, 14 times/day). The patient received levodopa-carbidopa intestinal gel (LCIG) treatment. After several months, the patient complained of difficulty in swallowing and speech due to severe retrocollis. Thirty minutes following a fast levodopa infusion of LCIG, the retrocollis improved. As a result, a frontal view was obtained, and her talking abilities showed improvement. Conclusions: Severe retrocollis can be superimposed on choreic dyskinesia, and it was likely to increase during the off periods. Duodenal levodopa infusion may reduce the severity of retrocollis.
Collapse
Affiliation(s)
- Hiroshi Kataoka
- Department of Neurology, Nara Medical University, Kashihara, Japan
| | - Yasuhiko Sawada
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Naotaka Shimozato
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | | | - Hitoshi Yoshiji
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Kazuma Sugie
- Department of Neurology, Nara Medical University, Kashihara, Japan
| |
Collapse
|
6
|
Caverzasio S, Amato N, Manconi M, Prosperetti C, Kaelin-Lang A, Hutchison WD, Galati S. Brain plasticity and sleep: Implication for movement disorders. Neurosci Biobehav Rev 2018; 86:21-35. [DOI: 10.1016/j.neubiorev.2017.12.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 12/15/2017] [Accepted: 12/18/2017] [Indexed: 12/31/2022]
|
7
|
Smolensky MH, Portaluppi F, Manfredini R, Hermida RC, Tiseo R, Sackett-Lundeen LL, Haus EL. Diurnal and twenty-four hour patterning of human diseases: acute and chronic common and uncommon medical conditions. Sleep Med Rev 2014; 21:12-22. [PMID: 25129839 DOI: 10.1016/j.smrv.2014.06.005] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 06/12/2014] [Accepted: 06/12/2014] [Indexed: 01/30/2023]
Abstract
The symptom intensity and mortality of human diseases, conditions, and syndromes exhibit diurnal or 24 h patterning, e.g., skin: atopic dermatitis, urticaria, psoriasis, and palmar hyperhidrosis; gastrointestinal: esophageal reflux, peptic ulcer (including perforation and hemorrhage), cyclic vomiting syndrome, biliary colic, hepatic variceal hemorrhage, and proctalgia fugax; infection: susceptibility, fever, and mortality; neural: frontal, parietal, temporal, and occipital lobe seizures, Parkinson's and Alzheimer's disease, hereditary progressive dystonia, and pain (cancer, post-surgical, diabetic neuropathic and foot ulcer, tooth caries, burning mouth and temporomandibular syndromes, fibromyalgia, sciatica, intervertebral vacuum phenomenon, multiple sclerosis muscle spasm, and migraine, tension, cluster, hypnic, and paroxysmal hemicranial headache); renal: colic and nocturnal enuresis and polyuria; ocular: bulbar conjunctival redness, keratoconjunctivitis sicca, intraocular pressure and anterior ischemic optic neuropathy, and recurrent corneal erosion syndrome; psychiatric/behavioral: major and seasonal affective depressive disorders, bipolar disorder, parasuicide and suicide, dementia-associated agitation, and addictive alcohol, tobacco, and heroin cravings and withdrawal phenomena; plus autoimmune and musculoskeletal: rheumatoid arthritis, osteoarthritis, axial spondylarthritis, gout, Sjögren's syndrome, and systemic lupus erythematosus. Knowledge of these and other 24 h patterns of human pathophysiology informs research of their underlying circadian and other endogenous mechanisms, external temporal triggers, and more effective patient care entailing clinical chronopreventive and chronotherapeutic strategies.
Collapse
Affiliation(s)
- Michael H Smolensky
- Department of Biomedical Engineering, Cockrell School of Engineering, The University of Texas at Austin, Austin, TX, USA.
| | - Francesco Portaluppi
- Hospital S. Anna and Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Roberto Manfredini
- Hospital S. Anna and Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Ramon C Hermida
- Bioengineering & Chronobiology Laboratories, University of Vigo, Campus Universitario, Vigo, Spain
| | - Ruana Tiseo
- Hospital S. Anna and Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Linda L Sackett-Lundeen
- Department of Laboratory Medicine & Pathology, University of Minnesota, HealthPartners Institute for Education and Research and the Department of Pathology, Regions Hospital, St. Paul, MN, USA
| | - Erhard L Haus
- Department of Laboratory Medicine & Pathology, University of Minnesota, HealthPartners Institute for Education and Research and the Department of Pathology, Regions Hospital, St. Paul, MN, USA
| |
Collapse
|
8
|
Apetauerova D, Ryan RK, Ro SI, Arle J, Shils J, Papavassiliou E, Tarsy D. End of day dyskinesia in advanced Parkinson's disease can be eliminated by bilateral subthalamic nucleus or globus pallidus deep brain stimulation. Mov Disord 2006; 21:1277-9. [PMID: 16637040 DOI: 10.1002/mds.20896] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We report the therapeutic effects of deep brain stimulation (DBS) in 2 patients with Parkinson's disease (PD) with severe end of dose dyskinesia that was resistant to medical therapy. In both patients, severe, end of day ballistic dyskinesias occurred when the last levodopa dose of the day was wearing off. Globus pallidus (GPi) DBS in 1 case and subthalamic (STN) DBS in the second case produced full resolution of end of day dyskinesia.
Collapse
Affiliation(s)
- Diana Apetauerova
- Department of Neurology, Lahey Clinic Medical Center, Burlington, Massachusetts, USA
| | | | | | | | | | | | | |
Collapse
|
9
|
Bankiewicz KS, Daadi M, Pivirotto P, Bringas J, Sanftner L, Cunningham J, Forsayeth JR, Eberling JL. Focal striatal dopamine may potentiate dyskinesias in parkinsonian monkeys. Exp Neurol 2005; 197:363-72. [PMID: 16337943 PMCID: PMC2766604 DOI: 10.1016/j.expneurol.2005.10.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2005] [Revised: 09/27/2005] [Accepted: 10/09/2005] [Indexed: 11/19/2022]
Abstract
Striatal neurons convert L-dopa to dopamine (DA) following gene transfer of aromatic L-amino acid decarboxylase (AADC) via adeno-associated virus (AAV) in parkinsonian monkeys. We investigated whether AAV-AADC could reduce or eliminate L-dopa-induced dyskinesias (LIDs) and side effects in MPTP-treated monkeys. Five monkeys were made parkinsonian by bilateral MPTP lesions. The optimal therapeutic dose of L-dopa was determined using an acute dose response regimen. After 3 weeks of chronic L-dopa treatment, AAV-AADC or control vector was bilaterally injected into the striatum. Animals were assessed for 6 months with the same L-dopa dosing as presurgery as well as chronic oral L-dopa treatment. Presurgery LID was observed at doses greater than 5 mg/kg. The AAV-AADC-treated animals displayed an average 7.3-fold decrease in the therapeutic dose of L-dopa throughout the 6-month follow-up period. Only AAV-AADC-treated monkeys were susceptible to dyskinesias even at sub-clinical doses. Immunohistochemical analysis revealed well-delineated foci of AADC within the striatum. These results suggest that high levels of focal DA were generated in response to L-dopa administration and may be responsible for the exacerbation of dyskinesias. This may be similar to focal dopaminergic activity in PD patients that developed off-drug or "runaway" dyskinesias following fetal mesencephalic grafts.
Collapse
Affiliation(s)
- Krystof S Bankiewicz
- Department of Neurological Surgery, University of California San Francisco, Mission Center Building 0555, 1855 Folsom Street, Room 230, 94103, USA.
| | | | | | | | | | | | | | | |
Collapse
|
10
|
Abstract
Parkinsonism and dystonia may coexist in a number of neurodegenerative, genetic, toxic, and metabolic disorders and as a result of structural lesions in the basal ganglia. Parkinson's disease (PD) and the 'Parkinson-plus' syndromes (PPS) account for the majority of patients with the parkinsonism-dystonia combination. Dystonia, particularly when it involves the foot, may be the presenting sign of PD or PPS and these disorders should be suspected when adults present with isolated foot dystonia. Young age, female gender, and long disease duration are risk factors for PD-related dystonia, but dystonia in patients with PD is usually related to levodopa therapy. The mechanism of dystonia in PD is not well understood and the management is often challenging because levodopa and other dopaminergic agents may either improve or worsen dystonia. Other therapeutic strategies include oral medications (baclofen, anticholinergics and benzodiazepines), local injections of botulinum toxin, intrathecal baclofen, and surgical lesions or high frequency stimulation of the thalamus, globus pallidus, or subthalamus.
Collapse
Affiliation(s)
- J Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA.
| | | |
Collapse
|
11
|
Contin M, Riva R, Albani F, Baruzzi A. Pharmacokinetic optimisation in the treatment of Parkinson's disease. Clin Pharmacokinet 1996; 30:463-81. [PMID: 8792058 DOI: 10.2165/00003088-199630060-00004] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The current symptomatic treatment of Parkinson's disease mainly relies on agents which are able to restore dopaminergic transmission in the nigrostriatal pathway, such as the dopamine precursor levodopa or direct agonists of dopamine receptors. Ancillary strategies include the use of anticholinergic and antiglutamatergic agents or inhibitors of cerebral dopamine catabolism, such as monoamine oxidase type B inhibitors. Levodopa is the most widely used and effective drug. Its peculiar pharmacokinetics are characterised by an extensive presystemic metabolism, overcome by the combined use of extracerebral inhibitors of the enzyme aromatic-amino acid decarboxylase and rapid adsorption in the proximal small bowel by a saturable facilitated transport system shared with other large neutral amino acids. Drug transport from plasma to the brain is mediated by the same carriers operating in the intestinal mucosa. The main strategies to assure reproducibility of both drug intestinal absorption and delivery to the brain and clinical effect include standardisation of levodopa administration with respect to meal times and a controlled dietary protein intake. The levodopa plasma half-life is very short, resulting in marked plasma drug concentration fluctuations which are matched, as the disease progresses, with swings in the therapeutic response ('wearing-off' phenomena). 'Wearing-off' phenomena can be also associated, at the more advanced disease stages with a 'negative', both parkinsonism-exacerbating and dyskinetic effect of levodopa at subtherapeutic plasma concentrations. Dyskinesias may be also related to high-levodopa, excessive plasma concentrations. Recognition of the different levodopa toxic response patterns can be difficult on a clinical basis alone, and simultaneous monitoring of levodopa concentration-effect relationships may prove useful to disclose the underlying mechanism and in planning the correct pharmacokinetic management. Controlled-release levodopa formulations have been developed in an attempt to smooth out fluctuations in plasma profiles and matched therapeutic responses. The delayed levodopa absorption and lower plasma concentrations which characterise controlled-release formulations compared with standard forms must be taken into account when prescribing dosage regimens and can be complicating factors in the management of the advanced disease stages. The pharmacokinetic and pharmacodynamic characterisation of the other antiparkinsonian agents is hampered by the lack of sensitive and specific analytical methods to measure their very low plasma drug concentrations and by the difficulty in quantitatively assessing overall moderate drug clinical effects. In clinical practice an optimal dosage schedule is still generally found for each patient on an empirical basis. Future strategies should focus on the search for pharmacological agents with a better kinetic profile, particularly a higher and reproducible bioavailability and a predictable relationship between plasma drug concentration and clinical response. Treatments aimed not only at controlling the symptoms, but also at slowing the neurodegenerative process, are currently under intensive investigation.
Collapse
Affiliation(s)
- M Contin
- Laboratory of Neuropharmacology, University of Bologna, Italy
| | | | | | | |
Collapse
|
12
|
Sage JI, Mark MH. Drenching sweats as an off phenomenon in Parkinson's disease: treatment and relation to plasma levodopa profile. Ann Neurol 1995; 37:120-2. [PMID: 7818245 DOI: 10.1002/ana.410370124] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
We followed 4 patients with Parkinson's disease and severe, intermittent, drenching sweats. One patient was studied with serial plasma levodopa levels and simultaneous clinical examinations. She was observed during a severe sweating episode; this was associated with subtherapeutic plasma levodopa levels (low dopa state). All 4 patients' sweats responded favorably to the institution of agonist therapy. Drenching sweats should be considered part of the spectrum of off-period levodopa-related fluctuations in Parkinson's disease.
Collapse
Affiliation(s)
- J I Sage
- Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick 08903
| | | |
Collapse
|