Case Study 3: Dropping Cards

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Headshot of Dawn Elise DeWitt, MD, MSc, CMedEd, MACP, FRACP, FRCP-London · Senior Associate Dean, Collaboration for InterProfessional Health Education Research & Scholarship (CIPHERS)
Dawn Elise DeWitt
MD, MSc, CMedEd, MACP, FRACP, FRCP-London · Senior Associate Dean, Collaboration for InterProfessional Health Education Research & Scholarship (CIPHERS)
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Case study 3: Mac—Dropping cards

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A 64-year-old male visits your clinic for worsening Parkinson’s disease symptoms. He was diagnosed a year and a half ago. At the time, he was prescribed a dopamine agonist such as pramipexole.
He is capable of performing most ADLs without assistance, but he has difficulty buttoning his work shirt. He’s worked as a delivery driver for a large bread chain for nearly 30 years, but says it has become “nearly impossible” to do his job as of late due to an increasing right-sided resting tremor. He says he has almost fallen off the top of the loading ramp more than once, while loading his truck. He is also frustrated by dropping cards during his weekly card game with friends and he wonders if his “eyesight is going.” He is determined to remain at his job until age 65 to qualify for full retirement benefits.
On physical exam, a minor skin rash is present, and he fidgets on the exam table. It is clear that his predominantly right-sided pill-rolling tremor is worse, and he has developed mild cogwheel rigidity in this same arm since his last visit. His gait appears shuffling, with blocky turns. He has a positive five-second Romberg.

task

Identify the medications used to manage Parkinson’s disease, as well as common side effects. 

Question

Which of the following is a well-known side effect of the medication being used to manage this patient’s condition?

Compulsive gambling (correct answer):

  • Rationale: Compulsive gambling is a known side effect of dopamine agonists, including ropinirole, pramipexole, and bromocriptine. While ropinirole (Requip) is used frequently for the management of PD and achieves roughly the same goal as levodopa-carbidopa (Sinemet), it does not work by the mechanism described in the vignette. Drugs in this class work as agonists on D2 receptors in the brain. 

Blurry vision:

  • Rationale: Blurry vision is especially associated with anticholinergic medications like benztropine. These medications do not work by the mechanism described in the question stem and are generally reserved for younger patients whose primary symptom is tremor. 

Involuntary movement:

  • Rationale: Involuntary movement, or dyskinesia, is a late side effect of Sinemet (carbidopa-levodopa), which is considered a mainstay of Parkinson’s disease treatment. The movements may include lip smacking, chewing motions, frowning, or repeated blinking and eye movements, as well as others. This is more likely to occur in patients on higher doses of the drug, or with longer-term use. Sinemet is a synthetic neurotransmitter precursor that crosses the blood brain barrier and is converted to dopamine by naturally occurring enzymes in the brain. 

Livedo reticularis:

  • Rationale: Livedo reticularis is known to occur with use of Amantadine, which can be used for short-term therapy early in the course of Parkinson’s disease. Amantadine is not used as frequently in PD as other drugs, such as Sinemet (carbidopa-levodopa) or Requip (ropinirole).  

Weight loss:

  • Rationale: Weight loss can certainly occur in the setting of chronic disease, however none of the typical medications for PD are known to cause this as a primary side effect. It can occur secondary to the dyskinesias described in letter (C), which are a known side effect of long-term use of carbidopa-levodopa.

task

Describe the pathophysiology of Parkinson’s disease.

Question

What part of the patient’s brain anatomy is most involved in his symptoms?

Amygdala:

  • While the amygdala may demonstrate PD-related accumulation of Lewy bodies similar to other areas of the brain, and may be involved in the depression experienced by many PD patients, it is not the “most” involved part of the brain anatomy. 

Corpus callosum:

  • The corpus callosum can demonstrate significant volume loss in PD patients, and research has suggested an association between corpus callosum volume loss and clinical cognitive deficits in the setting of PD. However, this is not the primary zone of brain involvement in PD. 

Hippocampus:

  • The hippocampus can be involved in PD, particularly in those patients who demonstrate impaired “recognition memory.” These memories constitute the day-to-day events of life. While altered hippocampal function can lead to some of the more debilitating symptoms of PD, it is not the most highly involved area of the brain.

Midbrain (correct answer):

  • Parkinson’s disease is caused by an accumulation of Lewy bodies—and loss of dopaminergic neurons—in the substantia nigra, which is located in the midbrain. Although other structures may be secondarily implicated due to loss of dopamine, this is the source of the problem. 

 

  Keywords: Tremor, Parkinson’s disease

Resources

Question 1

  1. Thanvi, B., Lo, N., and Robinson, T. (2007). Levodopa-induced dyskinesia in Parkinson’s disease: clinical features, pathogenesis, prevention and treatment. Postgraduate medical journal, 83(980), 384–388. 
  2. Kashihara K. Weight loss in Parkinson’s disease. J Neurol. 2006 Dec;253 Suppl 7:VII38–41. 
  3. Levodopa and Carbidopa.
  4. Vollum, D. I., Parkes, J. D., and Doyle, D. (1971). Livedo reticularis during amantadine treatment. British medical journal, 2(5762), 627–628. 
  5. Pathological gambling associated with dopamine agonist therapy in Parkinson’s disease.
  6. Ahuja A, Abdijadid S. Benztropine. [Updated 2020 Nov 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. 
  7. Sinemet (Carbidopa-Levodopa) Side Effects Drug.

Question 2

  1. Abnormal amygdala function in Parkinson’s disease patients and its relationship to depression.
  2. Amygdala and emotionality in Parkinson’s disease: An integrative review of the neuropsychological evidence.
  3. Goldman, J. G., Bledsoe, I. O., Merkitch, D., Dinh, V., Bernard, B., and Stebbins, G. T. (2017). Corpus callosal atrophy and associations with cognitive impairment in Parkinson disease. Neurology, 88(13), 1265–1272. 
  4. Das, T., Hwang, J. J., and Poston, K. L. (2019). Episodic recognition memory and the hippocampus in Parkinson’s disease: A review. Cortex; a journal devoted to the study of the nervous system and behavior, 113, 191–209. 

Image credits

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