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Worsening of dysarthria and parkinsonian symptoms (rebound effect), lack of efficacy, and suicide attempt in the setting of overdose of levodopa/carbidopa: case report A 42-year-old man attempted suicide with overdose of levodopa/carbidopa. Additionally, he exhibited lack of effect of levodopa/ carbidopa and rotigotine, and developed worsening of dysarthria and parkinsonism due to the rebound effect of pramipexole. The man had type 1 von Willebrand disease. He underwent nasal septoplasty in the setting of epistaxis. He was discharged on desmopressin, following nasal septoplasty. Thereafter, he presented to hospital with seizure. A diagnosis of osmotic demyelinating syndrome (ODS) was made. His hospital course was complicated by a seizure, dysarthria, dysphaga, locked-in syndrome for approximately 3 weeks and difficulty with bilateral hand coordination. He was shifted to rehabilitation centre following partial improvement of these symptoms. Approximately after 11 months of first hospitalisation, he was re-admitted with worsening of dysphagia, dysarthria and bilateral hand discoordination. Additionally, he had bradykinesia, dystonia of bilateral hands and rigidity. Therefore, he started receiving oral levodopa/carbidopa, levodopa 100mg/carbidopa 25mg, one tablet three times daily to treat his neurological symptoms. Consequently, the dose of levodopa/carbidopa increased to 1.5 tablet three times daily. However, his symptoms did not improve with levodopa/carbidopa therapy. Owing to worsening depression in the setting of his deteriorating health, he attempted suicide by ingesting 20–30 tablets of levodopa/carbidopa. Despite the overdose, his neurological symptoms did not improve. After 1.5 years from the diagnosis of ODS, his neurological evaluation revealed severe dysarthria, mild cranial masking, facial dystonia and a risus sardonicus, mild square wave jerks, mild dystonic flexion posturing of the left metacarpophalangeal joints, mild bradykinesia of overall movements, moderately bradykinetic finger movements and moderate bilateral cogwheeling. He had no difficulty sitting up from the chair with arms crossed and demonstrated ability to walk with good stride length but with reduced left arm swing. In the following months, amantadine was added in the treatment regimen. Due to minimal benefit from amantadine therapy, he started receiving trihexyphenidyl and pramipexole 0.5mg three times/day (later titrated to 1 mg thrice daily) [route not stated]. He showed a gradual response to these regimens with an improvement in his facial masking and pseudobulbar palsy. Additionally, the dysarthria, risus sardonicus, speech and movements improved dramatically with an increased dose of pramipexole 1mg three times daily. However, after 3 months of initiation of pramipexole, he developed compulsive shopping behaviour and sexual disinhibition [aetiology not stated], which led to discontinuation of pramipexole. After the discontinuation, dysarthria and parkinsonism deteriorated, which was considered as a rebound effect of pramipexo