White-haired Sisters

Tuesday morning hours are allocated for new Parkinson’s patients, but secretarial staff performs scheduling and their understanding of the illness is basic, tremors. For hints, the doctor peruses the patient’s history. Sometimes the nursing staff scans the paperwork the previous day; in this case, the history is online shortly before the patient enters the room. The physician has several moments to form an opinion about what he might see. He knows the patient’s history is atypical for someone with a diagnosis of Parkinson’s disease, and when he meets the patient and her sister, he has further doubts. The woman who has come for a second opinion speaks, emphasizing certain words with hand gestures. At times, she pulls her body to the front of her chair and speaks as she sits on the edge of her seat. Her face is animated and worried. She explains her sister is present because she frequently forgets things.

In efforts to find out what the true cause of her discomfort is, she has sought the help of an alternative type of doctor. He has told her that she suffers from Candida, a fungal infection. He has restricted her diet eliminating sugars, fruit and white bread. She has lost weight on the diet, and some strength.

At the moment, she feels fine though there may be hours in her day when her body aches. The doctor asks whether the pain she feels is worse on one side of her body. Some people with PD experience deep aching pain, akin to what one would experience after having performed a grueling workout on untrained muscles. The pain stems from having muscles in contraction for prolonged spans of time. The patient’s painful episodes engulf all of her body. She mentions the burning sensation she feels in her feet, her precarious sense of balance, double vision and that she has always been a nervous type of person. She has suffered with depression for years, and sees a psychiatrist regularly to adjust her medications.

The doctor scans the past blood test results and notes her rheumatoid factor was within normal limits. On physical examination of the patient, he notes her neck is supple, as is her right side. On the left side, she has the slightest hint of rigidity in the muscles surrounding her arm joint. Her eye movements to the left are difficult due to a weak lateral rectus in the left eye; the muscle pulls the left eye away from the nose and towards the temple, and accounts for her double vision and lack of depth perception. Brisk reflexes of her arms and legs hint her nerve roots may be compressed in her neck. Yet, having reflexes indicates she lacks a neuropathy, and having sensation to vibration and pinprick means her peripheral nerve fibers are also working adequately, so she should have position sense. The patient admits she has had problems with her neck, in the past.

She asks, what will account for her decreased sense of balance? Her troubles with vision? She knows the answer to her own question. Three things give us our location in space: the vestibular system, feedback from muscles, and our eyes. Summarizing his findings the doctor feels she might have some subtle signs of PD, but she lacks sufficient evidence to suggest she needs dopamine replacement. He feels she may suffer from a parkinsonian syndrome, such as lower body PD, caused by microvascular disease; a condition commonly caused by diabetes, high cholesterol and high blood pressure. An MRI of the brain will confirm whether there is evidence for this diagnosis. Meanwhile, he suggests she gradually discontinue taking the Stalevo, eat a balanced diet rich in vegetables and fruits to provide food-based antioxidants and fiber, exercise daily to increase circulation to the brain, and take 300mg of coenzyme Q10 to keep her mitochondria happy.

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