A new clinical tool for gait evaluation in Parkinson's disease.

This study was devised to check the feasibility and validity of a rating scale specifically designed to evaluate gait impairment in Parkinson's disease (RSGE). Demographic data, a brief questionnaire on general aspects influencing gait and mobility, a battery of scales (Barthel Index; Hoehn and Yahr staging; and Northwestern University Disability, Schwab and England, and Unified Parkinson's Disease Rating Scale [UPDRS]), and timed tests ("Up and Go" and "Steps x Seconds" tests) were recorded under protocol, as was the RSGE-Version 1.0 (23 items in four subscales). Fifty patients enrolled at two centers were included. Twenty-five (50%) were simultaneously (though independently) evaluated by three examiners, in order to determine the interrater reliability. The mean age of the patients was 67.6 +/- 11.16 years, with a mean 8.18 +/- 5.58 years of disease duration. Motor fluctuations were present in 48% of patients. The RSGE Cronbach's alpha was 0.94. Only the item "Dyskinesias" was not correlated with the RSGE total sum. The item "Axial rigidity" showed a fair interrater reliability (kappa = 0.30). However, most of the RSGE items (16/23, 70%) had kappa > or = 0.65. The convergent validity with the applied scales was very high (Spearman r = 0.74-0.90, p < 0.001). The highest correlation (0.90) was obtained with the UPDRS. Also, the RSGE correlation with timed tests was very satisfactory ("Up and Go" = 0.81; "Steps x Seconds" = 0.70; both, p < 0.001). Factor analysis of the RSGE disclosed four dimensions explaining 68% of the variance. The RSGE-Version 1.0 proved to be a valid instrument. The reliability of some items has to be improved, however.

Acute cerebellopathy as a probable toxic effect of flucytosine.

Cryptococcosis is the commonest fungal infection of the CNS and it is an important cause of morbidity and mortality in immunodeficient patients [1]. It has been occasionally described in immunocompetent patients [2]. We report a patient with no predisposing factors who was treated with flucytosine and amphotericin B for cryptococcal meningitis. Following treatment, she developed a reversible acute cerebellar syndrome that was probably secondary to the administration of flucytosine, an adverse effect that has not previously been described [3, 4]. An 87-year old women with no relevant personal or family history was admitted to the hospital for headache, fever, and confusion over the past week. The vital signs, general and neurological examination were normal. In laboratory tests, the urine, urea nitrogen, glucose, bilirubin, electrolytes, aspartate aminotransferase, creatine kinase, alkaline phosphatase, haematocrit, white-cell count, and platelet were also normal. A lumbar puncture was performed which showed: 60 typical lymphocytes per ml, adenosine deaminase (ADA) activity 6 U.l-1 (normal under 4 U.l-1), proteins 75.7 mg.dl-1, and glucose 13 mg.dl-1 with a glycaemia of 120 mg.dl-1. The microbiology study showed staining and a positive culture for Cryptococcus neoformans, and an antigen titre of 1/2080. The serology for HIV infection was negative, and other predisposing factors for this fungal infection, such as immunological defects, a lymphoreticular malignancy and sarcoidosis were excluded. A CT scan of the cranial-thoracic-abdominal regions was normal and tumour markers were absent.

[Meningoencephalitis due to Rickettsia conorii. Etiopathological, clinical and diagnostic aspects]. / Meningoencefalitis por Rickettsia conorii. Aspectos etiopatogénicos, clínicos y diagnósticos.

Boutonneuse fever (BF) is usually considered to be a benign rickettsiosis. However, severe presentations, resembling Rocky Mountain spotted fever, have been reported. There are few neurological complications, except in serious forms of the disease. We present a case of meningoencephalitis in a male adult suffering from BF, and we review the clinical, etiopathogenic and diagnostic aspects among the cases previously reported. We conclude that BF encephalitis would have the following characteristics: a) they mostly affect elderly males; b) they cause altered consciousness level, headaches and low rate of meningeal signs; c) absence of "tâche noir"; d) cerebrospinal fluid with slight pleocytosis and/or increased level of proteins, and normal glucose values; e) computerized tomography without significative changes, and f) high rate of morbidity and mortality. We emphasize that we should consider BF in the differential diagnosis of our environmental encephalitis.

Serum levels of ascorbic acid (vitamin C) in patients with Parkinson's disease.

To elucidate the possible role of vitamin C in the risk for developing Parkinson's disease (PD), we compared serum levels of ascorbic acid (vitamin C), measured by a fluorometric method, of 63 PD patients using their spouses as the control group. The serum levels of vitamin C did not differ significantly between the groups (47.13 +/- 0.89 micrograms/ml for PD and 47.60 +/- 0.60 micrograms/ml for controls). There was no influence of antiparkinsonian therapy on vitamin C. Serum levels of vitamin C did not correlate with age, age at onset and duration of the disease, scores of the Unified PD Rating Scale or the Hoehn and Yahr staging in the PD group. These results suggest that serum vitamin C concentrations are apparently unrelated to the risk of developing PD.

"Panic attacks" in Parkinson's disease. A long-term complication of levodopa therapy.

A series of 31 Parkinson's disease (PD) patients suffering from panic attacks (PA), late in the evolution of their disease, was analyzed from a group of 131 levodopa-treated PD patients. We found that many of motor, sensory, and vegetative symptoms, previously described as complicating phenomena in PD, constituted some of the symptoms of panic disorders. Comparing PA series with the series of PD patients who did not complain of PA, we discovered a clear-cut relationship of PA with the presence of standing/gait troubles (p < 0.001), depression (p < 0.001), and dyskinesias/fluctuations (p < 0.001). The patients of the PA series also presented a more precocious age of PD onset, were put on levodopa therapy earlier, and needed to be treated with higher doses of levodopa than the patients without PA. Finally, we hypothesize that PA could be considered to be a sort of abstinence syndrome from levodopa, because they appears mostly (90.3%) in the OFF phase of fluctuations, and are relieved administering new doses of levodopa or dopaminergic agonists. Nevertheless, we suggest PA are not directly related to the pharmacological properties of levodopa, but to alterations of the noradrenergic systems in the CNS.

Parkinsonism associated with calcium channel blockers: a prospective follow-up study.

Parkinsonism is a well-known side effect of some calcium channel blockers (CCB). Its long-term evolution, however, is unknown. To clarify this issue, we performed a prospective follow-up study involving 32 patients diagnosed with CCB-induced parkinsonism. After the baseline examination, the CCB were discontinued and serial evaluations were carried out according to the same protocol. Despite a global improvement, cognitive and mood disturbances subsided slowly, and tremor persisted in most patients. After 18 months of CCB withdrawal, 44% of patients had depression, 88% had tremor, and 33% still had criteria for diagnosis of parkinsonism. During the survey, only three patients were found to be fully recovered. The improvement of some clinical symptoms was related to age: Patients younger than 73 years recovered better than older patients did. Our data indicate that CCB-induced parkinsonism is not the benign condition previously thought, and suggest an age-related prognosis of this entity.

[Complicated migraine: a study of 7 cases]. / Migraña complicada: estudio de siete casos.

The association between migraine and stroke is well known. It is assumed that 15% of strokes in patients below 45 years are due to migraine. To evaluate the features of this association, we have reviewed seven cases of patients with migraine and established neurological deficits. All patients fulfilled the following criteria: 1) past history of migraine, defined on the basis of the classification by the International Committee for the Classification of Headache; 2) temporal association between a migraine episode, similar to previous ones, and the ischemic episode, and 3) absence of other concomitant diseases that might result in stroke. We evaluated the age at the onset of migraine, its type, familial history of migraine (particularly of migrainous accompaniments), vascular risk factors, mode of onset, and type and duration of neurological deficit. In all cases, cranial CT, EEG, echocardiogram, serologic tests for syphilis, autoantibody investigation, routine laboratory tests and nuclear magnetic resonance (in four patients). In five cases cerebral arteriography was carried out, and arterial occlusion was demonstrated in one. We conclude that, in spite of its low frequency, migraine may result in cerebral ischemic episodes, although the relevant pathogenetic mechanisms are not yet well understood.

[Toxoplasmosis of the central nervous system in immunodepressed patients. Our experience]. / Toxoplasmosis del sistema nervioso central en enfermos inmunodeprimidos. Nuestra experiencia.

Seven patients carriers of a disease capable of provoking immunodeficiency (six of them suffering AIDS and one case of Hodgkin type lymphoma) are reported. All of them presented neurological complications consisting of toxoplasma Gondii infection of the Central Nervous System. We summarize their evolution and the diagnostic and therapeutical approaches.

[Calcification of the basal ganglia and hypoparathyroidism: Fahr disease. Study of a family]. / Calcificación de los ganglios basales e hipoparatiroidismo: enfermedad de Fahr. Estudio de una familia.

We studied three members of a single family who had basal ganglia calcifications (BGC): two with BGC alone and one associated with parkinsonism and hypoparathyroidism (H). This family links together BGC and H and may help resolve the apparent controversy about relationship of both.

[Lupus anticoagulant and recurrent transient ischemic attacks]. / Anticoagulante lúpico y accidentes isquémicos transitorios de repetición.

Lupus anticoagulant (LA) is an immunoglobulin that has been found in association with many diseases and shows an in vitro anticoagulant activity but is clinically associated with thrombosis. We report a patient with a diagnosis of autoimmune disease who developed recurrent transient ischemic attacks; after through investigation of other possible conditions and pathogenetical mechanisms, LA was the only causative factor that was found. We feel that LA should be systematically investigated in cerebrovascular disease, particularly in young patients without other known risk factors, to determine its true incidence and the correct therapeutic approach.

Cerebral mucormycosis in two cases of acquired immunodeficiency syndrome.

We describe two patients with isolated cerebral mucormycosis and acquired immunodeficiency syndrome (AIDS). Their clinical course was rapid and fatal; early diagnosis and treatment with amphotericin B did not prevent a fatal outcome in both cases. Isolated cerebral mucormycosis has not (to our knowledge) been reported previously in patients with AIDS. Mucormycosis should be included in the differential diagnosis of central nervous system infections in intravenous drug abusers with AIDS. A brain biopsy is needed for the diagnosis of mucormycosis.