Unexpected Cause of Anxiety and Parkinsonism

An elderly man presented with a gradual onset of left-sided resting tremor, bradykinesia, and rigidity, which progressed to involve the right-sided limbs over a few months, associated with symptoms of generalized anxiety disorder. He had palpitations, restlessness, sleep disturbance, worried excessively about daily events, and also complained of “poor concentration and memory.” However on examination, there was no evidence of impaired cognition, and his limb power, sensory modalities, and reflexes were normal. A formal neuropsychological assessment by a psychologist did not reveal any evidence of cognitive dysfunction. There were no atypical features such as gaze abnormalities or orthostatic hypotension to suggest secondary causes for his parkinsonism. The constellation of signs and symptoms of the motor system in our patient was compatible with clinical diagnostic criteria of “idiopathic” Parkinson’s disease. The patient was prescribed a course of Selegiline 5 mg per day for 2 months but subsequently discontinued receiving the medication despite subjective improvement. Because of his recent onset of anxiety symptoms, a brain magnetic resonance imaging (MRI) was carried out with the intention to reassure him. However, the scan unexpectedly revealed a large meningioma in the right frontal-temporal region with significant ventricular compression and midline shift of the brain ( Figure 1 ). The patient underwent a resection of the meningioma with resolution of his parkinsonism and anxiety symptoms.