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Unmasking and aggravation of Parkinson’s disease in an elderly patient: case report A 74-year-old woman received flupentixol for depression and developed parkinsonism, which worsened with tardive symptoms when flupentixol was withdrawn. She began receiving tetrabenazine, which could not be down-titrated due to aggravation of tardive symptoms. The woman had been receiving flupentixol [route and dosage not stated] for 17 years, and presented with generalised slowing. Examination revealed upper extremity tremors, mild left-predominant bradykinesia, rigidity and slow gait. On suspicion of drug-induced parkinsonism, flupentixol was withdrawn, but 6 weeks later she had developed disabling facial dyskinesias and excessive salivation. Trihexyphenidyl, baclofen, clonazepam and tiapride did not alleviate her symptoms. After 2 years, tetrabenazine was initiated, which controlled her tardive symptoms at 50mg [route and frequency not stated]. Attempts to reduce her dose led to intolerably worsened oromandibular movements. About 6 years later she was referred for progression. Investigations revealed dystonias, involuntary movements and parkinsonism. EMG suggested cortical myoclonus, and CT found decreased radiomarker activity in her right posterior putamen. She was diagnosed with tardive dystonia, oral-lingual-buccal dyskinesias, myoclonus, and probable idiopathic Parkinson’s disease, developing after prodromal drug-induced parkinsonism. She received botulinum toxin injections in her masseter muscles and parotid glands, and her tetrabenazine dosage was reduced slightly. Levodopa therapy was begun, and her bradykinesia improved with no worsening in her tardive symptoms. At last follow-up her identical twin sister, who had never received neuroleptics, had developed levodoparesponsive parkinsonism. Author comment: "Clinical asymmetry and progression, congruent neuroimaging results, good response to levodopa and a positive family history for levodopa-responsive parkinsonism in an identical twin are suggestive of probable idiopathic [Parkinson’s disease], possibly unmasked by a typical neuroleptic and aggravated by continued use of a dopamine depletor." Kurtis MM, et al. Tardive syndrome and Parkinson's disease responsive to concomitant tetrabenazine and levodopa therapy. Parkinsonism and related disorders 17: 774-776, No. 10, Dec 2011. Available from: URL: http:// 803066504 dx.doi.org/10.1016/j.parkreldis.2011.05.024 - Spain

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