Parkinson Disease: Initiating Therapy for Young-Onset PD

Anamaria Shanley, MSN, APRN-C | Nurse Practitioner, Compass Clinic, Orlando, Florida

A 51-year-old man was referred to your neurology clinic for his “right side not working correctly.” He stated that his right upper and lower extremities do not feel the same, although he could not be more specific in his report. He had previously consulted another neurologist, who completed electromyography and nerve conduction velocity tests and spinal axis imaging, results of which were unremarkable.

History. His symptoms had started about 8 months prior to presentation with subtle progression, prompting him to consult his primary care provider. The patient is healthy, with no significant medical history. He is married and has 4 grown children, all of whom are healthy. He denied any family history of neurological disorders.

The patient owns an automobile fabrication shop and has spent many years welding. The symptoms were affecting his ability to weld, although welding was not necessary for his role as a business owner.

He denied any changes with vision, hearing, sense of smell, swallowing, and weight. He denied drooling, constipation, and diarrhea. No tremors or falls were reported, although his balance was slightly off. He denied any change in cognition, sleep, or sleep behaviors and denied any psychiatric manifestations such as depression, anxiety, or psychosis.

Physical examination. Results of an initial examination revealed a healthy-appearing man with normal weight. His vital signs were within the normal range, with no orthostasis noted. His speech was clear and fluent with normal voice volume. He was alert, attentive, cooperative, and pleasant. There was a slight increase in midline tone.

His pupils were equal, round, and reactive to light; they had normal pursuit and full extraocular eye movements including vertical gaze. A slight increase in tone was noted in the right upper and lower extremities, which increased with distraction, but no increased tone on the left extremities was noted. No resting or postural tremors were noted. Finger tapping was clumsy in the right upper extremity but normal in the left. Right foot tapping was clumsy but was normal in the left. No lower extremity tremor or spasticity of the lower extremities were noted. Motor strength was intact throughout, with normal and symmetrical muscle bulk.

Results of a sensory examination were within normal limits throughout. Deep tendon reflexes were symmetrical without any hyperreflexia. He could stand without push and ambulated upright with some bradykinesia to the right extremities. No tremor was noted, and he had a normal turn. Mildly impaired postural reflexes were noted when tested.

Diagnostic testing. Based on the patient’s history, previous workup, and neurological examination, idiopathic Parkinson disease was suspected. Based on the progression of symptoms, it was decided to follow up on previous testing to evaluate other possible etiologies. Based on lack of cognitive reports from the patient or his wife, other Parkinson syndromes, such as progressive supranuclear palsy or corticobasal degeneration, were not considered.

A magnetic resonance imaging (MRI) scan of the brain without contrast was conducted to follow up on the initial MRI conducted 4 months prior to presentation. Additional laboratory studies were sent to evaluate for ceruloplasmin, urine heavy metal, vitamin B12, folate, homocysteine, thyroid-stimulating hormone, and free thyroxine levels. The results of this workup were within normal limits, and the patient was started on rasagiline, 0.5 mg, daily and was to follow up in the clinic in 4 weeks.

In addition to initiating therapy, the patient was instructed to monitor his blood pressure most days, avoid specific over-the-counter medications such as dextromethorphan and St John’s Wort, and to make providers aware of the new medication to avoid drug interactions.

After 2 weeks, the patient calls your office concerned that his blood pressure is elevated at 140/90 mm Hg, without any other symptoms. Therefore, you tell him to stop taking the rasagiline. At the follow-up office visit 2 weeks later, his neurological examination revealed continued asymmetrical rigidity and bradykinesia with impaired postural instability. At this time, because of his poor tolerance of rasagiline, other treatment options were discussed.