Objective: To share a case report of Atypical PNES and MSA.

Background: Multiple system atrophy (MSA) is a rare neurodegenerative diagnosis that clinically presents with autonomic dysfunction, parkinsonism, and cerebellar ataxia ^Stefanova. The diagnostic criteria include autonomic failure, poor levodopa responsiveness and cerebellar syndrome ^Gilman. Psychogenic nonepileptic seizures (PNES) are characterized by sudden motor, sensory or autonomic disturbances that may imitate an epileptic seizure ^Reuber. PNES commonly affects females in their third decade of life, and most often are associated with an underlying conversion disorder ^{Meierkord, Lawton}. We present an unusual case of PNES diagnosed in an elderly male 12 years prior to the diagnosis of MSA. To our knowledge, this is the first case of PNES preceding MSA in the scientific literature.

Method: Review of literature, patient presentation.

Results: A 74-year-old right-handed male with a past medical history of COPD, laryngeal papilloma, GERD, hyperlipidemia, hypertension, diabetes mellitus type II, who initially presented to our clinic for management of seizures. Patient had previously been evaluated at two tertiary centers 12 years and 4 years prior to presenting to our clinic. Through long-term epilepsy monitoring at those facilities, patient was found to have PNES. Upon further evaluating and monitoring the patient, it had become evident that he had been and continued to exhibit progressive parkinsonian symptoms.  Due to the lack of response to carbidopa/levodopa, continued progression of his symptoms including the presence of autonomic instability, cerebellar ataxia, pseudobulbar affect, patient was diagnosed with multiple system atrophy (MSA), 12 years after the diagnosis of PNES.

Conclusion: Our case illustrates an atypical case of PNES in an elderly male. To our knowledge, PNES has not been shown to precede neurodegenerative disorders. Physicians should consider impending development of neurodegenerative disorders in atypical presentations of PNES.

References: Stefanova N, Bucke P, Duerr S, Wenning GK. Multiple system atrophy: an update. Lancet Neurol 2009; 8: 1172. Gilman S, Wenning GK, Low PA, et al. Second consensus statement on the diagnosis of multiple system atrophy. Neurology 2008; 71: 670. Reuber M, Baker GA, Gill R, et al. Failure to recognize psychogenic nonepileptic seizures may cause death. Neurology 2004; 62:834. Meierkord H, Will B, Fish D, Shorvon S. The clinical features and prognosis of pseudoseizures diagnosed using video-EEG telemetry. Neurology 1991; 41:1643 Lawton G, Baker GA, Brown RJ, Comparison of two types of dissociation in epileptic and nonepileptic seizures. Epilepy Behav 2008; 13:333.

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