ABSTRACT
CASE PRESENTATION A 51-year-old man presented at age 37 years with slowness in his left hand. He was diagnosed with idiopathic Parkinson’s disease (PD) and started on levodopa with excellent benefit. Within 4 years, however, he started to complain of left foot inversion upon awakening. This was relieved by taking his morning dose of levodopa but would return before his next dose was due. In fact, the left foot inversion became the first sign of the levodopa effect wearing off at each dose. The abnormal postures gradually spread to other parts of the body, including the right leg, upper extremities, neck, and face. They also became increasingly painful and distressing. The intervals between individual doses of levodopa had to be progressively shortened in order to abort the pain and functional disability resulting from these abnormal fixed involuntary movements. Around the same time, he also developed peak-dose dyskinesias. At age 46, because of unsatisfactory control of his parkinsonian symptoms, despite optimal medical therapy, as well as levodopa-induced dyskinesias and increasingly painful abnormal postures, the patient underwent staged bilateral deep brain stimulation of the subthalamic nucleus (STN DBS). This resulted in marked improvement that has been sustained over the ensuing 4 years.
