Objective: Our aim was to show an interesting case report with a diagnostic dilemma of a patient with well controlled Parkinson’s disease who first developed progressive neck flexion and after 2 weeks symptoms of myasthenic crisis.

Background: Head drop is very rare present in Parkinson’s disease (PD) especially in early stage. Its development or exacerbation has been found with dopamine agonists. More often it is a part of multiple system atrophy. It can also have neuromuscular and myopathic origin. Isolated head drop is an unusual presenting symptom of myasthenia gravis.

Methods: We describe a 70-year-old patient with a 4-year history of PD with very well controlled symptoms (bradykinesia, rigor, tremor of the right hand) and on a small doses of levodopa and dopamine agonist. On his first exam, in our outpatient clinic, he complained of progressive neck flexion for the past 2 months. There were no other changes in his status and symptoms. We ordered some tests including antiacetylcholine receptor antibodies. Two weeks after that he came again with general weakness, bilateral ptosis, dysphagia, nasal speaking and respiratory insufficiency.

Results: He got, by mail, antiacetylcholine receptor antibodies, which were positive, but did not, before, bring them to us. We found tooth abscess as an origin for septic reaction and a trigger for myasthenic crisis. We treated him with 5 plasma exchanges and proper antibiotics. All myastenic symptoms, including head drop, alleviated fully after treatment.

Conclusions: We have to consider myasthenia gravis as a differential diagnosis in suddenly onset head drop in patients with PD and so avoid possible life-threatening conditions like myashtenic crisis.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/head-drop-in-patient-with-parkinsons-disease-as-an-alert-of-upcoming-myasthenic-chrisis/