Retroperitoneal fibrosis caused by treatment with pergolide in a patient with Parkinson's disease

Iliocaval Venous Obstruction in Pergolide-Induced Retroperitoneal Fibrosis

Design:

Case report.

Setting:

BMI Priory Hospital, Birmingham, UK.

Patient:

A 67-year-old man presenting with unilateral lower limb oedema. Past history included ipsilateral lower limb melanoma and Parkinson's disease, treated by pergolide.

Intervention:

Laparotomy to confirm a diagnosis of retroperitoneal fibrosis (RPF) causing iliac vein obstruction.

Conclusion:

RPF is a rare complication of pergolide therapy for Parkinson's disease. Previous reports have also described iliocaval obstruction and there may be an association between pergolide-induced RPF and venous complications.

The serotonergic system in Parkinson's disease

Although the cardinal manifestations of Parkinson's disease (PD) are attributed to a decline in dopamine levels in the striatum, a breadth of non-motor features and treatment-related complications in which the serotonergic system plays a pivotal role are increasingly recognised. Serotonin (5-HT)-mediated neurotransmission is altered in PD and the roles of the different 5-HT receptor subtypes in disease manifestations have been investigated. The aims of this article are to summarise and discuss all published preclinical and clinical studies that have investigated the serotonergic system in PD and related animal models, in order to recapitulate the state of the current knowledge and to identify areas that need further research and understanding.

Retroperitoneal fibrosis

Retroperitoneal fibrosis encompasses a range of diseases characterised by the presence of a fibro-inflammatory tissue, which usually surrounds the abdominal aorta and the iliac arteries and extends into the retroperitoneum to envelop neighbouring structures--eg, ureters. Retroperitoneal fibrosis is generally idiopathic, but can also be secondary to the use of certain drugs, malignant diseases, infections, and surgery. Idiopathic disease was thought to result from a local inflammatory reaction to antigens in the atherosclerotic plaques of the abdominal aorta, but clinicolaboratory findings--namely, the presence of constitutional symptoms and the high concentrations of acute-phase reactants--and the frequent association of the disease with autoimmune diseases that involve other organs suggest that it might be a manifestation of a systemic autoimmune or inflammatory disease. Steroids are normally used to treat idiopathic retroperitoneal fibrosis, although other options--eg, immunosuppressants, tamoxifen--are available. The outlook is usually good, but, if not appropriately diagnosed or treated, the disease can cause severe complications, such as end-stage renal failure. Here, we review the different aspects of retroperitoneal fibrosis, focusing on idiopathic retroperitoneal fibrosis and on the differential diagnosis associated with the secondary forms.

Diagnosis and management of pergolide-induced fibrosis

We report on 2 patients treated with pergolide, 1 of whom developed pleural fibrosis and the other retroperitoneal fibrosis. In both cases, an extensive diagnostic evaluation and surgical intervention were required to reach a diagnosis. Based on our experience with these patients and a review of cases of pergolide-induced fibrosis in the English-language literature, we propose guidelines for the diagnosis and management of this rare complication.

Switching from ergot to nonergot dopamine agonists in Parkinson's disease: A clinical series and five-drug dose conversion table

Of 99 patients on ergot-derived dopamine agonists informed about possible long-term side effects, switching to a nonergot was undertaken in 88 (89%). There were adverse events in 26%. After 11 months, 82% were on their switch agonist and 93% were on any agonist. Switching dopamine agonists is feasible in this population.

Primary and postoperative retroperitoneal fibrosis-experience with 18 cases

OBJECTIVES

Retroperitoneal fibrosis (RPF) is an uncommon disease complicated by ureteral entrapment. Its etiology includes several medications, periaortic inflammation, abdominal and retroperitoneal operations, radiotherapy, and malignancy. We present 18 patients, 14 of whom developed RPF after surgery and radiotherapy.

METHODS

During the past 12 years, we treated 7 women and 11 men. The diagnosis was based on intravenous urography, retrograde pyelography, and computed tomography features. Computed tomography-guided or intraoperative biopsies were taken to differentiate benign from malignant fibrosis. In all patients, percutaneous stent nephrostomies or internal stents were inserted before surgery. The operation included ureterolysis with an omental flap or ureteral reimplantation. Follow-up included renal function tests, intravenous urography, and computed tomography.

RESULTS

The mean patient age was 57.3 years (range 36 to 85). Fourteen patients developed RPF after abdominal or retroperitoneal surgery. Three had primary RPF and one malignant RPF due to metastatic disease. Six patients also underwent radiotherapy. The mean time between the insults to the diagnosis of RPF was 18.6 months (range 1 to 96). Ten patients had bilateral obstruction. Fourteen patients underwent surgery and four were treated with stenting only. Of the 14 patients who underwent surgery, 10 had a normal intravenous urogram postoperatively and 4 had decreased function of the formerly obstructed kidney. In 1 patient, re-entrapment of the ureter appeared owing to pelvic recurrence of tumor. At last follow-up, 1 patient waits with stents. The mean follow-up time was 22 months (range 4 to 52).

CONCLUSIONS

The etiology of RPF varies. The unique feature of our series was the high incidence of patients who developed RPF after surgery and radiotherapy to the retroperitoneum. Nephrostomy drainage and ureteral stenting facilitated surgery. Ureterolysis combined with wrapping the ureter with an omental flap or re-implantation ensured good anatomic and functional results.

Pergolide-induced pleuropulmonary fibrosis

Pleuropulmonary fibrosis is a rare, but well-recognized adverse effect of ergot alkaloids. We report on four patients who developed pleural and/or pulmonary fibrosis during treatment with pergolide and give characteristics of 87 cases with one or more symptoms of serosal fibrosis. Retroperitoneal and pleuropulmonary fibrosis are serious conditions, which are often irreversible after drug withdrawal. Increased awareness may help to diagnose these complications at an earlier stage and to minimize any permanent damage to the patient.

Choosing the right dopamine agonist for patients with Parkinson's disease

Dopamine receptor agonists (DA) are assuming an increasing importance in the treatment of both early and advanced symptoms of Parkinson's disease (PD). However, choosing the right DA for patients with PD unfortunately remains more a pragmatic medical art than a science. The aim of this review is to provide a realistic point of view on the strengths and weaknesses of five DAs: bromocriptine, ropinirole, pergolide, pramipexole and piribedil. This has been done by analysing their respective: (1) flexibility in PD, i.e. in monotherapy, in early and in late combination with levodopa; (2) safety profile and (3) titration schedule. These five DAs are not evenly matched regarding these three criteria. The differences observed highlight the therapeutic value of piribedil, which has a flexible indication, adapted to all stages of PD, a safer profile and the most simple initiation schedule.

Pergolide in the treatment of patients with early and advanced Parkinson's disease

Introduced on the market in 1989, pergolide, a D1/D2 dopamine receptor agonist, is still widely prescribed for the treatment of patients with early and advanced Parkinson's disease (PD). Initially, pergolide was introduced as an adjunct therapy to levodopa treatment in patients exhibiting fluctuating motor responses and dyskinesias. Results of recent randomized controlled clinical trials in de novo patients with PD show that pergolide is able to improve parkinsonian symptoms when used as monotherapy. Moreover, preliminary results of a long-term monotherapy study in early PD suggest that pergolide is as effective as levodopa, and that a significant delay in the time of the onset of levodopa-induced motor complications can be obtained. A number of randomized studies have shown that pergolide is more effective than bromocriptine as adjunct therapy to levodopa in patients with advanced PD; the greater benefit found with pergolide could be ascribed to its action on both D1 and D2 dopamine receptors. However, controlled comparative studies with new dopamine agonists, such as ropinirole, cabergoline, and pramipexole, have not been performed yet. Interestingly, few open studies in patients with complicated PD have shown that high doses of pergolide (> 6 mg/d) are able to improve motor fluctuations and dyskinesias through a dramatic reduction of levodopa dosage. The side-effect profile of pergolide is similar to that of other dopamine agonists, and complications such as sleep attack and serosal fibrosis have been rarely reported.

Dopamine agonists: the treatment for Parkinson's disease in the XXI century?

Levodopa combined with a peripheral dopa-decarboxylase inhibitor (DCI) has been considered the therapy of choice for Parkinson's disease (PD). Levodopa is nearly always effective, but has a high incidence of adverse effects with long term use, including response fluctuations (on/off phenomena) and dyskinesias. Dopaminergic agonists, acting directly at the receptor level, would be able to decrease the incidence of these motor complications.In progressive neurodegenerative diseases, such as PD, modification of the rate of disease progression (often referred to as neuroprotection) is currently a highly debated topic. Increased oxidative stress is thought to be involved in nigral cell death, that is characteristic of PD. This oxidative stress may be further exacerbated by levodopa therapy. These mechanisms have been proven in vitro and animal models, but it's relevance in humans remains speculative.Based on the considerations above, the emerging therapeutic strategies for PD advocate early use of dopamine agonists in the treatment of PD. A number of recent well-controlled studies have proven the efficacy of dopamine agonists used as monotherapy. Moreover, as predicted by animal studies, on the long term, dopaminergic agonists induce significantly less motor complications than levodopa.In the last 2years, three new dopamine agonists have been launched, including ropinirole, pramipexole and cabergoline. These new agonists have been added, as therapeutical options to well-established drugs, like pergolide, bromocriptine or talipexole. The recently launched compounds have proven efficacy in monotherapy and as adjunctive therapy to levodopa. Unfortunately, only a very limited amount of comparative data among the different agonists is available. Pergolide has proven to be a superior drug to bromocriptine as adjunctive therapy to levodopa in a significant number of studies and is considered the gold standard dopamine agonist. Nevertheless, none of the recently launched compounds has compared itself against pergolide.A comparison of monotherapy trials is difficult, because of differences in design and populations. In a recently completed trial pergolide was statistically significantly better than placebo in all the efficacy parameters tested, with 57% of pergolide treated patients improving over 30% in the motor section of the UPDRS, as compared to 17% in the placebo arm. Interestingly, these results were obtained in the absence of any other antiparkinsonian drug during the trial. Recent monotherapy trials done with ropinirole and pramipexole achieved also significant improvements as monotherapy, but in these cases selegeline, a drug that causes a symptomatic improvement in PD, was allowed as co-medications during the trial. Not all trials used the same efficacy measures, i.e. monotherapy trials with pergolide and ropinirole used a "responder" based analysis (responder were all patients that improved 30% or more on the motor section of UPDRS), as well as a baseline to endpoint improvement in motor scores. Pramipexole monotherapy trials used only the latter approach, which is clinically less powerful than a responder analysis.Even with the difficulties mentioned above, all the recent trials with dopamine agonists have proven that these drugs are a useful symptomatic long term treatment for PD with or without levodopa and that the early use of dopamine agonists reduces the incidence of motor complications as compared to levodopa.

Treatment of Parkinson's disease with ropinirole after pergolide-induced retroperitoneal fibrosis

Pergolide is a dopaminergic agonist used to treat Parkinson's disease but is associated with the development of retroperitoneal fibrosis (RPF). Newer nonergot agents (pramipexole, ropinirole) may not carry this same risk. A patient with a history of pergolide-induced RPF was treated successfully with ropinirole for 1 year without complications.

Chronic constrictive pericarditis induced by long-term bromocriptine therapy: report of two cases

OBJECTIVE

To report two cases of chronic constrictive pericarditis that appear to be related to the intake of bromocriptine for Parkinson's disease.

CASE SUMMARY

Two white men (aged 63 and 69 y) were treated with bromocriptine for four (40 mg/d) and two years (30 mg/d), respectively, with a cumulative dose intake of 58.4 and 21.9 g, respectively. The patients experienced dyspnea with bilateral lower-limb edema and pleural effusion, suggesting right cardiac dysfunction. Echocardiography, computed tomography, and cardiac catheterization results were compatible with a diagnosis of constrictive pericarditis, so pericardectomy was performed on both patients. The anatomic pathology examination showed a fibrous pericardium; cultures were sterile. In the first case, pleural effusion recurred seven months after the pericarditis; bromocriptine was suspected and treatment was discontinued. In the second case, just prior to the pericardectomy, an episode of mental confusion occurred and prompted the cessation of bromocriptine therapy.

DISCUSSION

To the best of our knowledge, only one case of constrictive pericarditis induced by bromocriptine therapy has previously been described in the literature.

CONCLUSIONS

Our cases call attention to a possible association between bromocriptine use in patients who have Parkinson's disease and constrictive pericarditis.