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Adjunct treatment with levodopa in a patient with dementia with Lewy bodies, delusions and severe neuroleptic hypersensitivity syndrome

Published online by Cambridge University Press:  04 March 2010

Tomislav Majic ,
Thomas Mell ,
Andreas Heinz  and
Michael A. Rapp
Tomislav Majic
Affiliation:
Department of Psychiatry, Charité – University Medicine Berlin, Campus Charité Mitte, Berlin, Germany
Thomas Mell
Affiliation:
Department of Psychiatry, Charité – University Medicine Berlin, Campus Charité Mitte, Berlin, Germany
Andreas Heinz
Affiliation:
Department of Psychiatry, Charité – University Medicine Berlin, Campus Charité Mitte, Berlin, Germany
Michael A. Rapp*
Affiliation:
Department of Psychiatry, Charité – University Medicine Berlin, Campus Charité Mitte, Berlin, Germany
*
Correspondence should be addressed to: Michael A. Rapp, MD, PhD, Department of Psychiatry and Psychotherapy, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany. Phone: +49 30 2311 2959; Fax: +49 30 2311 2952. Email: michael.rapp@charite.de.

Abstract

We report on the treatment of a patient suffering from dementia with Lewy bodies who initially presented with severe neurological and psychopathological symptoms. After treating the patient with levodopa and clozapine, these symptoms remitted.

Keywords

Lewy body dementianeuroleptic hypersensitivitylevodopa

Information

Type
Case Report
Information
International Psychogeriatrics , Volume 22 , Issue 4 , June 2010 , pp. 678 - 679
Copyright
Copyright © International Psychogeriatric Association 2010

Introduction

Neuroleptic hypersensitivity is a common feature and diagnostic criterion of dementia with Lewy bodies (DLB) (McKeith et al., Reference McKeith, Fairbairn, Perry, Thompson and Perry1992; Reference McKeith2005; Ballard et al., Reference Ballard, Grace, McKeith and Holmes1998; Burke et al., Reference Burke, Pfeiffer and McComb1998; Magnusson et al., Reference Magnusson, Keller and Burke1998). Therefore, the treatment of psychotic symptoms is still limited (e.g. Sadek and Rockwood Reference Sadek and Rockwood2003), despite promising initial evidence for treatment with cholinesterase inhibitors (McKeith et al., Reference McKeith2000).

Case report

We report a case of a 73-year-old woman suffering from DLB who was admitted to a psychiatric hospital because of anxiety, paranoia and visual hallucinations combined with psychomotor symptoms of hyperkinesia and rigidity. She had a two-year history of fluctuating cognitive impairment and psychotic symptoms. During that time, she had been repeatedly treated with quetiapine (up to 125 mg/day) and clozapine (up to 100 mg/day), having experienced several side effects such as gait disturbance and cogwheel rigidity. The patient gave written informed consent to the publication of this case report in International Psychogeriatrics.

At the time of admission, her medication had been changed to pipamperone (80 mg/day) by her family physician. Pipamperone is a low potency butyrophenone neuroleptic commonly prescribed off-label in Germany for the symptomatic treatment of delirium and psychosis in dementia; however, its use is not indicated in dementia. The patient was disoriented in terms of time and place and displayed concentration and memory deficits (her Mini-mental State Examination score was 20/30). There were asymmetric deep tendon reflexes and several pathological reflexes, such as bilateral positive Babinski, palmomental, and palmar grasp reflexes. Such primitive reflexes have been described previously in DLB (Borroni et al., Reference Borroni2006) and may be additional symptoms of the neuroleptic sensitivity syndrome. In addition, she presented with postural instability and Pisa syndrome. Blood tests and lumbar puncture results did not change significantly. A cerebral MRI scan showed moderate cortical and subcortical atrophy.

During the course of treatment, pipamperone was withdrawn and the patient received donepezil (10 mg/day). After four weeks of this treatment, however, delusions and visual hallucinations were still present and so the patient was started on clozapine, which was gradually increased. At 150 mg daily, the patient still suffered from disturbing hallucinations, which only resolved at a dosage of 200 mg daily. At this dose, no further visual hallucinations were reported, and delusions attenuated, but the patient again developed a Pisa syndrome with an increased risk of falling. Given the history of neuroleptic hypersensitivity and treatment resistance of the anxiety provoking delusions and visual hallucinations, we added levodopa to the regimen (up to 375 mg/day). The Pisa syndrome improved gradually, and the psychotic symptoms and anxiety did not re-emerge.

Discussion

This case illustrates the severity of neuroleptic sensitivity in LBD following low doses of typical and atypical antipsychotics. Improvement was only achieved when levodopa was added to the regimen and clozapine was increased, suggesting that response to atypical neuroleptics may reflect a dose-response phenomenon requiring added levodopa treatment. At the same time, we did not try a reduction of levodopa in this case and hence cannot demonstrate cause and effect empirically in this case report. Levodopa has been discussed in general treatment guidelines for LBD (McKeith et al., Reference McKeith2005; Molloy et al., Reference Molloy, McKeith, O'Brien and Burn2005), but there are few clinical case reports in the literature, which may reflect the limited overall experience with this pharmacotherapeutic approach. This case outlines possible management strategies in patients with DLB who exhibit both neuroleptic hypersensitivity syndrome and disturbing psychotic features.

Conflict of interest

None.

Description of authors’ roles

T. Majic, T. Mell and M. A. Rapp were all treating clinicians in this case; T. Majic and T. Mell drafted the paper; M. A. Rapp and A. Heinz were responsible for the design and conception of the case report and edited the final paper.

References

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