Objective: N/A

Background: Levodopa-responsive muscular rigidity is one of the hallmarks of Parkinson’s disease (PD). Many rheumatological conditions can present with stiffness^1-4. For example, polymyalgia rheumatica (PMR) with shoulder and pelvic girdle pain and stiffness can be mistaken for akinetic-rigid type PD^5-6. To date, calcium pyrophosphate crystal deposition disease (pseudogout) has not been reported as a PD mimic in medical literature.

Method: N/A

Results: This is a 69-year-old right-handed gentleman with a history of PD since 2005 who presented to the movement disorders clinic for evaluation of DBS candidacy. The patient was on a total of 1400 mg of levodopa and amantadine. During the encounter, he complained of increased stiffness for six months. MDS-UDPRS motor score during the OFF condition was 61 which improved to 35 with supra-therapeutic dose of levodopa. However, patient’s axial and appendicular rigidity did not respond to levodopa adequately. 

One week later, the patient presented to our emergency department with acutely worsening rigidity and muscle pain in his hips and shoulders. Exam revealed axial and appendicular rigidity and reduced range of motion of his joints. Lab work demonstrated elevated inflammatory markers with ESR of 57 mm/hr and CRP 102.2 mg/L with normal CK, rheumatoid factor and CCP antibodies. Rheumatology was consulted and PMR was initially suspected, although the acuity was deemed atypical. X-ray of the left knee demonstrated tibiofemoral chondrocalcinosis. Given concern for crystal arthropathy, ankle arthrocentesis was performed and revealed rhomboid crystals consistent with pseudogout. Increased rigidity was attributed to polyarticular pseudogout flare. The patient was started on 30 mg of prednisone daily with marked improvement of his stiffness and gait, allowing independent ambulation.

Conclusion: This is the first report of a patient with PD with pseudogout mimicking rigidity. In the setting of levodopa-unresponsive rigidity in PD, alternative explanations should be sought.

References: 1.Wantaneeyawong C, Kasitanon N, Kumchana K, Louthrenoo W. Acute parkinsonism in patients with systemic lupus erythematosus: a case report and review of the literature. Int J Neurosci. 2022 Sep;132(9):868-873. doi: 10.1080/00207454.2020.1847106. Epub 2020 Nov 29. PMID: 33153349.
2.Williams DR, Lees AJ. How do patients with parkinsonism present? A clinicopathological study. Intern Med J. 2009 Jan;39(1):7-12. doi: 10.1111/j.1445-5994.2008.01635.x. Epub 2008 Apr 14. PMID: 18422568.
3. Papalia R, Torre G, Papalia G, Baums MH, Narbona P, Di Lazzaro V, Denaro V. Frozen shoulder or shoulder stiffness from Parkinson disease? Musculoskelet Surg. 2019 Aug;103(2):115-119. doi: 10.1007/s12306-018-0567-3. Epub 2018 Oct 1. PMID: 30276531.
4. Ertan S, Fresko I, Apaydin H, Ozekmekçi S, Yazici H. Extrapyramidal type rigidity in rheumatoid arthritis. Rheumatology (Oxford). 1999 Jul;38(7):627-30. doi: 10.1093/rheumatology/38.7.627. PMID: 10461475.
5. Fietta P, Manganelli P. Steroid-reversible parkinsonism as presentation of polymyalgia rheumatica. Clin Rheumatol. 2006 Jul;25(4):564-5. doi: 10.1007/s10067-005-0151-8. Epub 2005 Dec 23. PMID: 16374574.
6. Jones O, Birrell F. Diagnosis and management of polymyalgia rheumatica. Practitioner. 2016 Dec;260(1799):13-6. PMID: 29020715.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/pseudogout-mimicking-stiffness-in-parkinsons-disease-a-case-report/