Practical pearls to improve the efficacy and tolerability of levodopa in Parkinson's disease.

INTRODUCTION: Levodopa is the most effective medication for the treatment of motor symptoms of Parkinson's disease (PD). Several factors may affect the efficacy and tolerability of levodopa. These include the timing, dosage and administration of levodopa, concomitant drugs, food, PD-associated non-motor symptoms, and various neurologic and non-neurologic comorbidities. If not appropriately addressed, these issues may limit levodopa efficacy, tolerability, and compliance. AREAS COVERED: This article reviews the basics of the metabolism of orally administered levodopa, its side effects, and the factors that may affect its tolerability and efficacy. We provide several practical pearls to improve the tolerability and efficacy of levodopa. EXPERT OPINION: Protein-rich food delays and reduces levodopa absorption. Hence, levodopa should preferably be administered in a relatively empty stomach. Carbidopa dosing is crucial as it not only enhances the entry of levodopa into the central nervous system but also reduces levodopa's peripheral adverse effects. Patients experiencing the early side effects such as nausea/vomiting should be prescribed with anti-nausea medications that do not block dopamine receptors. Non-oral routes of administration can be used to obviate persistent gastrointestinal side effects. Implementation of these and other tips may help improve the tolerability and efficacy of levodopa.

Treatment Challenges in a Severe Case of Syphilitic Myelitis With a Longitudinally Extensive Spinal Cord Lesion.

Syphilitic myelitis is an unusual manifestation of neurosyphilis, rarely reported in the literature. The best management approach remains unclear in severe cases with longitudinally extensive spinal cord lesions. We describe a 29-year-old man with a history of incompletely treated syphilis after a high-risk sexual encounter, who presented two years later with several weeks of progressive numbness and weakness in both legs. MRI spine showed significant cord expansion from the craniocervical junction to T6 with patchy cord enhancement. He was diagnosed with syphilitic myelitis given his history of inadequately treated syphilis, positive serum rapid plasma reagin at a high titer, and CSF pleocytosis with elevated protein along with a reactive CSF Venereal Disease Research Laboratory test. Alternative infectious or immunological etiologies were excluded. He was treated with IV penicillin and pulse steroid therapy with IV methylprednisolone 1 g daily for 3 days with improvement. However, he was soon readmitted with recurrent weakness requiring an additional course of pulse steroid therapy followed by a short prednisone taper. Afterward, his symptoms recurred with worsened cord expansion on imaging. He was re-treated with IV penicillin and pulse steroid therapy with a more prolonged prednisone taper. The patient subsequently improved and had no further recurrent symptoms on extended outpatient follow-up. This report illustrates the importance of keeping syphilitic myelitis on the differential as a treatable cause of longitudinally extensive myelopathy. The patient may have benefited from high-dose IV steroids with a prolonged taper while waiting for the full treatment effect of antibiotics.

Healthcare Worker With Large Vessel Acute Ischemic Stroke Likely Related to Mild SARS-CoV-2 Infection.

We report the case of a healthcare worker who presented with a large vessel acute ischemic stroke in setting of a mild SARS-CoV-2 infection and provide a review of the emerging literature on COVID-related stroke. A 43-year-old female presented with right-sided hemiparesis, aphasia and dysarthria. She had a nonproductive of cough for 1 week without fever, fatigue or dyspnea. A CT Head, CT angiography and CT perfusion imaging revealed a M1 segment occlusion of the left middle cerebral artery requiring transfer from a primary to a comprehensive stroke center. A nasopharyngeal swab confirmed SARS-CoV-2 infection prior to arrival at the accepting center. During the thrombectomy a 3 cm thrombus was removed. Thrombus was also evident in the 8 French short sheath during closure device placement so a hypercoagulable state was suspected. Stroke work-up revealed a glycosylated hemoglobin of 8.7%, elevation of inflammatory markers and an indeterminate level of lupus anticoagulant IgM. On discharge home, she had near complete neurological recovery. This case highlights suspected mechanisms of hypercoagulability in SARS-CoV-2 infection and the importance of optimizing stroke care systems during the COVID-19 pandemic.

Electrodiagnostic Testing for Disorders of Peripheral Nerves.

Nerve conduction studies and electromyography are useful diagnostic tools that neurologists use to diagnose diseases of the peripheral nerves, neuromuscular junction, and muscles. These tests are considered an extension of clinical history and examination, and their results should always be interpreted with the clinical context. Neuromuscular diseases are common and affect a large proportion of the elderly population. With an aging population in expansion, these diseases are expected to become even more prevalent. It is important to highlight the basics of electrophysiology and provide a reference for providers who are planning to send their patients to electromyographers for these studies.V.