Case Report: Parkinsonian Syndrome in Rheumatic Disease Isn’t Always Parkinson’s Disease

Patients with rheumatic disease can have movement and other neurodegenerative disorders that may look like Parkinson’s disease, but looks can be deceiving. Sometimes these disorders are an unrelated primary neurodegenerative disorder, but in other cases, they are as a result of an autoimmune process of the original rheumatic disease, a new case report shows. 

 When Parkinsonism doesn’t respond to levodopa, it may respond to immunomodular therapy.  Neurodegenerative diseases in rheumatology patients were autoimmune diseases, not vascular diseases.  Tumor necrosis factor inhibitors may cause an atypical amyotrophic lateral sclerosis. The case report, published in the August 2015 issue of Medicine, is based on a review of 67 studies describing neurodegenerative disorders in different rheumatological diseases. The authors highlighted eight cases:  Five cases of patients with Sjögren’s syndrome; two on patients with undifferentiated connective tissue disease patients and one on a patient with psoriatic arthritis. The patients were referred to a neurologist with symptoms that looked like Parkinson’s disease, but in reality, had features inconsistent with Parkinson’s disease. They were ultimately diagnosed with other movement or neurodegenerative diseases, and sometimes unusual combinations of those diseases, including cerebellar degeneration, dystonia with alien-limb phenomenon and nonfluent aphasias, reported a group that was led by Julius Birnbaum, MD, of the Johns Hopkins University School of Medicine in Baltimore.  The medical literature reported similar clinical patterns with magnetic resonance imaging findings suggestive of widespread vasculopathy in other patients, but the Johns Hopkins patients didn’t have vasculopathy. Some did have central nervous system damage similar to vasculopathy – but without the vasculopathy. This suggests that an autoimmune process does damage similar to a thrombic or vascular inflammatory process. The authors suspect the presence of antineuronal antibodies.  Patients had syndromes which resembled paraneoplastic syndromes associated with anti-neural antibodies, but these patients didn’t have cancer either. The authors also suspect that rheumatological diseases may produce similar antibodies.  The patient with psoriatic arthritis was treated with infliximab and developed a syndrome which the authors described as atypical amyotrophic lateral sclerosis. The researchers cite three prior studies of amyotrophic lateral sclerosis developing after treatment with tumor necrosis factor inhibitors, and conclude that the tumor necrosis factor inhibitors caused the atypical amyotrophic lateral sclerosis.  The researchers distinguish between Parkinson’s disease, which is a clinical diagnosis, and Parkinsonism, which is a clinical designation based on the examination findings that includes bradykinesia, rigidity, tremor and postural instability with a tendency to fall. Patients with Parkinison’s disease usually have Lewy bodies, and respond to levodopa, which patients with Parkinsonism may not. [[{"type":"media","view_mode":"media_crop","fid":"40309","attributes":{"alt":"","class":"media-image media-image-left","id":"media_crop_6364878541789","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4107","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.0080003738403px; line-height: 1.538em; float: left;","title":" ","typeof":"foaf:Image"}}]] Rheumatic disease patients with movement disorders almost never present with Parkinson’s disease, but they could present with multiple, coexisting movement disorders, researchers found.  The case report includes two patients with rheumatoid arthritis who showed symptoms of Parkinsonism, but neither presented with findings consistent with idiopathic Parkinson’s disease. One rheumatoid arthritis patient showed signs inconsistent with idiopathic Parkinson’s disease. “The second patient developed rapidly progressive Parkinsonism over a 12-month course of TNF-inhibitor therapy (infliximab), culminating with inability to ambulate, severe bulbar dysfunction, and dyspnea. Given that infliximab otherwise induced remission of her rheumatoid arthritis, it was suggested that the rapidity of Parkinsonism might be mediated by infliximab,” the researchers wrote. 

References:

Menezes R, Pantelyat A, Izbudak I, Birnbaum J. Movement and Other Neurodegenerative Syndromes in Patients with Systemic Rheumatic Diseases: A Case Series of 8 Patients and Review of the Literature. Medicine. August 2015 94(31):e0971. doi: 10.1097/MD.0000000000000971.