Lower-Body Parkinsonism

A 71-year-old gentleman presented with progressive difficulty walking of 2 years duration. The gait abnormality was insidious in onset and gradually progressive in nature. Initially, his walking became slow and developed short steps. Subsequently, he noticed an imbalance while walking, with a tendency to fall and difficulty turning. For 6 months he developed freezing of gait and feels as if his feet are glued to the ground and has difficulty initiating gait. For the past 1 month, he requires support to walk with frequent falls if unassisted. He also complains of urinary urgency and frequency with urge incontinence for the past 1 month. There is no cognitive impairment. There is no history of tremors, weakness of limbs, speech disturbance, orthostatic giddiness, or stiffness of limbs. He is hypertensive and diabetic for more than 10 years and is on medications. He has a past history of stroke 2.5 years back with right hemiparesis that recovered nearly completely over a period of 6 months. He is a smoker and smokes about 2–3 cigarettes per day. No history of alcohol consumption or other substance abuse. No history of coronary artery disease or any other cardiac illness. There is a family history of diabetes mellitus and hypertension in his father. On examination, the patient was conscious and oriented. Pulse rate was 78/min, regular, and BP was 164/98 mm of Hg. His cardiovascular and respiratory system examination was normal. His speech was normal. MMSE was 28/30. He had reduced facial expression with normal blink rate. His eye movement examination revealed impaired up-gaze with preserved oculocephalic movements. There was no neck or upper limb rigidity and no upper limb bradykinesia. There were mild postural tremors of both hands but no rest tremors. There was mild-to-moderate rigidity of both lower limbs and moderate bradykinesia. The deep tendon reflexes were exaggerated in both upper and lower limbs (right > left). The right plantar was extensor and the left was flexor. There was mild knee-heel in-coordination. He had difficulty in initiating gait, which improved with the sensory cue, required the support of one person to walk with short steps, reduced arm swing and en-bloc turning. His routine hemogram and biochemical investigations were normal. HbA1c was 9.9%, and his LDL cholesterol was 224 mg%. His MRI brain showed diffuse cerebral atrophy, and mild dilatation of the lateral ventricles with periventricular and subcortical white matter hyperintensities on T2W and FLAIR images. There were multiple infarcts in the basal ganglia and thalamus. MR angiography was normal. Cardiac evaluation using 2D echocardiography showed concentric left ventricular hypertrophy. Based on the history, examination and neuroimaging, the patient was diagnosed as a case of vascular parkinsonism (lower-body parkinsonism). The patient was started on antiplatelet agents (aspirin and clopidogrel), atorvastatin along with antihypertensives and oral hypoglycaemic agents. He was initiated on levodopa + carbidopa (100 + 25 mg) with a gradual increase in the drug dosage finally reaching one tablet four times a day. After about a month of treatment, the patient noticed an improvement in his symptoms and was able to walk independently with a mild increase in the walking speed. In addition to levodopa, he was advised physiotherapy and balance and gait training.