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PARKINSON’S DISEASE (PD)
Presented by – pankaj singh
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History In western medical litreture it was discovered by the
physician Golen as shaking palsy in 175 A.D IN 1817 A detailed medical essay was published on the
subject by london doctor James parkinson Jean martin charcot was the first to truely recognise the
importance of docter james parkinson and renamed the disease which was formerly known paralysis agitans or shaking palsy after him
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DEFINITION
Involuntary tremulous motion, with
lessened muscular power, in parts not
in action and even when supported;
with a propensity to bend the trunk
forward, and to pass from a walking to
a running pace: the senses and intellect
being uninvolved (1817)
3Adam victor principle of neurology 10 e
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Parkinsonism and parkinsons disease(idiopathic)
Parkinsonism is a clinical syndrome charecterised primarly by bradinesia with associated increased tone (rigidity)tremors and loss of postural reflexes .there are many causes but most common is parkinsons disease
When parkinsonism feature are present in a person without any established etiology it is called parkinsons disease
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Harrisons priciple of internal medicine 19
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Genetics
Mutation in parkin (a ubiquitin ligase that attaches ubiquitin to misfolded protein to promotes their transport to the proteasome for degradation and UCH-L1(which cleaves ubiquitin from misfolded protein to permit theri entry into the proteosome) are causative in other cause of familial PD
Mitochondrial dysfunction has also been implicated in familial PD.gene involed (parkin,PNKI,and DJ)
Having first degree are relative with PD Confers on a 2-3 times increased risk of developing parkinsonsim disease
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Genetics Genetic abnormalites resulting in protein misealding and
accumulation and mitochodrial dysfunction are found to be responsible for causing
Protein accumaltion can be due to increased formation or impaired clearance
Mutation in the park I gene encoding the protin alpha synuclein a main component of lewy body ,on the chromosome 4q are seen in early onset (mean age 46 year )parkinsons
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10Bradley neurology 6th edition
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NATURAL HISTORY
Begin between 40-70 years of age Peak age of onset 6th decade Infrequent before30 years of age More common in men Trauma,emotinal upset overwork exposure to cold,rigid
personality etc are suggested to be predisposing factors to disease but none have evidence
Disease observed in all countries and all races
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Harrisons priciple of inernal medicine 19
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14Robins pathological basis of disease 9th edition
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15Bradley neurology 6th
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Bradley neurology 6thedition
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TREMORS Often involves the hand Pin-rolling tremors(four per second)involing thumb and
fingersand charectestic Typically present when hand is at rest(hence the term resting
tremor) Voluntary movements dampens the tremors momentrly Complete relaxation (sleeping greatly reduces or abolishes
the tremor Also known as alternating tremors due to alternating burst of
activity in agonist and antagonist muscles in EMG
17Adam and victor principle of neurology10th
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Second common type is
A fine (seven to eight per sec ) tremors of the outstreched hands and fingers
Persists through out voluntary moments Not evident in resting position More easilly supressed by relaxation Lacks the alternating burst of action potential unlikeresting
tremors and resemble essential tremor Parkinsons disease patients may have either type of tremor
or both
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neurology 19 ed
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26Adamvictor principle of neurology 10
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28Adam and victor priciple of
neurology 10 th
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29Harrisons principle of internl
medicine 19th ed
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D Dx OF PARKINSONIAN SYNDROME
Idiopathic Parkinson’s disease
Drug induced – phenothiazines
Multiple cerebral infarct state.
Trauma – pugilistic encephalopathy
Toxin induced- MPTP, CO, Mn, Cu,
Parkinson’s plus syndromes
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ESSENTIAL TREMOR
Most common diagnostic error
10 times more common than PD
Postural or action tremor.
Titubation
Family history
B – Blockers help
Adamvictor principle of neuroloy 10 ed
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DRUG INDUCED PARKINSONISM Predictable
Neuroleptic Drugs (Both Typical And Atypical)
Hidden Neuroleptics – Metoclopromide
Prochlorperazine
Combination With Antidepressants (Fluphenazine )
Calcium Antagonist
Idiosyncratic› Lithium
› Sodium Valproate
› Amiodarone
› Mainly Tremor But Parkinsonism Reported. Adam and victor principle of neurology 10 ed
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MULTIPLE INFARCT STATE
Related to Hypertension and other risk factors
Common mis-diagnosis.
Poor prognosis
Aspirin and Dipyridamole may be effective and safe
Adam victor principle of neurlogy 10 th ed
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VASCULAR PARKINSONISM
Binswanger’s encephalopathy
Insidious Onset
Gradual progression
Diffuse sub cortical white matter ischaemia.
2-3 % incidence of ‘pure’ vascular causes
No Acute or abrupt onset basal ganglia infarct
No lewy bodies or nigral degeneration
Confirmation: PM studies only
Adam victor principle of neurology 10 ed
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DEMENTIA WITH LEWY BODIES Dementia
Fluctuating alertness
Hallucinations
Myoclonus more common
Tremor less common
More symmetrical
More rigid
Mild parkinsonism
Neuroleptic sensitivity
Less bradykinetic
Lewy bodies are abnormal dense core eosinophilic cytoplasmic inclusion aggregates of protein -alpha-synuclein of spherical masses surrounded by a halo of 10-nm-wide radiating fibrils that displace other cell components Adam victor principle of
neurology 10 ed
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42Kd tripathi 6 edition
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47Harrisons priciple of
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49Harrisons priciple of internal
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56Harrisons principle of internal medicine
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57Harrisons principle of internal medicine
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58Harisons principle of internal medicine 19th
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SURGERY
Deep Brain Stimulation
› Brain pacemaker, sends electrical impulses to brain to stimulate the subthalamic nucleus.
› Improves motor functions and reduce motor complications.
› Complications include: brain hemorrhage, seizures, death.
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TAKE HOME MESSAGES
Diagnosis of PD is clinical and can be difficult.
Every patient should be referred to secondary care
› to confirm the diagnosis and initiate treatment
Tt should only be started if there is functional impairment
Ldopa is the gold standard but DA cause much less dyskinesia
Follow up should be life long
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Thank you
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