Objective: Describe a PD patient with obsessive-compulsive disorder (OCD) and paranoid symptoms in whom treatment with LCIG was started in the ICU due to severe dysphagia  after SARS-COV2 infection.

Background: Pharyngeal dysphagia is frequent in PD and aspiration pneumonia is the most common cause of death in these patients. Studies suggest that LCIG may improve swallowing difficulties in PD.  Regarding use of LCIG in patients with  neuropsychiatric symptoms, available safety data suggest that LCIG, compared with other device-aided therapies, may be better tolerated in patients with a history of psychosis.  Initiation is usually carried out in stable patients, with no available data about therapy initiation in critically ill patients.

Method: We present a 63-year-old patient diagnosed with PD at age 57 with a two year progressive rigid-akinetic syndrome. He had severe OCD since the age of 38 with persistent auditory hallucinations. He was under treatment with 5 doses levodopa/benserazida (LD/BSZ) LEDD=720, UPDRS IV=6. Previous intolerance to opicapone and rotigotine due to impulsivity, worsening of hallucinations and severe dyskinesia. He was offered LCIG treatment in July 2022 but rejected it. 

In October 2022 he was admitted due to SarsCov2 pneumonia, complicated with respiratory failure and a bilateral aspiration pneumonia secondary to worsening of his  dysphagia. He presented motor and general worsening despite high LD doses through a nasogastric tube and rotigotine td, requiring ICU admission and orotracheal intubation. One month later due to torpid evolution a tracheostomy was performed. After a multidisciplinary meeting between the ICU, movement disorders unit, and patients family, a mixed gastric J-tube was decided for treatment with LCIG and enteral nutrition.

Results: PEG-J tube placement was performed and LCIG started (2,5 ml/h, Morning D 6+3 ml, Extra D 2 ml, LEDD 920 mg). He presented immediate motor improvement with no hallucinations or adverse effects. Mechanical ventilation was withdrawn in 48 hours and was discharged 15 days later with physiotherapy and speech therapy. Progressive motor improvement continued and a month later he was walking with a crutch (MDS UPDRS III= 13, IV=2) and had begun oral tolerance.

Conclusion: LCIG could be a therapeutic option for rescue in PD patients with critical illness that prevent correct swallowing.

References: Bhidayasiri R, Phuenpathom W, Tan AH, Leta V, Phumphid S, Chaudhuri KR and Pal PK (2022) Management of dysphagia and gastroparesis in Parkinson’s disease in real-world clinical practice – Balancing pharmacological and non-pharmacological approaches.
Front. Aging Neurosci. 14:979826. doi: 10.3389/fnagi.2022.979826
Labeit B, Claus I, Muhle P, Suntrup-Krueger S, Dziewas R, Warnecke T. Effect of Intestinal Levodopa-Carbidopa Infusion on Pharyngeal Dysphagia: Results from a Retrospective Pilot Study in Patients with Parkinson’s Disease. Parkinsons Dis. 2020 Mar 11;2020:4260501. doi: 10.1155/2020/4260501. PMID: 32257098; PMCID: PMC7086436.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/safety-in-levodopa-carbidopa-intestinal-gel-lcgi-titration-in-the-intensive-care-unit-icu-setting-for-parkinsons-disease-pd-patient-with-severe-dysphagia/