Response of the Parkinsonian Symptoms of Multiple System Atrophy to ECT
To the Editor: Multiple system atrophy is a sporadic degenerative disorder characterized by parkinsonism, dysautonomia, and ataxia in any combination (1). The parkinsonian symptoms of multiple system atrophy are poorly responsive to levodopa therapy (2), unlike Parkinson"s disease in which the motoric symptoms respond to dopaminergic agents and ECT. We present a case report of a patient with multiple system atrophy and comorbid major depression whose parkinsonian symptoms responded to ECT.
Mr. A was a 78-year-old man who at the age of 72 had developed bradykinesia, rigidity, resting tremor, ataxia, orthostatic hypotension, and urinary incontinence. His parkinsonian symptoms were poorly responsive to carbidopa and levodopa; Mr. A was unable to transfer (i.e., move from his bed to a chair) or walk independently. At the age of 75, he had developed antidepressant-refractory major depression.
Following outpatient neurology and psychiatric evaluations, Mr. A was referred for inpatient psychiatric treatment. Upon admission, he reported a depressed mood, anhedonia, anergia, frequent nocturnal awakenings, decreased appetite, feelings of guilt, and a fixed belief that “people were plotting” against him. His score on the Mini-Mental State examination) was 27 of 30; on the Hamilton Rating Scale for Depression, his score was 41. Mr. A’s diagnosis was major depression with psychotic features; following informed consent, he received eight bilateral ECT treatments (EEG seizure duration=409 seconds) without complication. Carbidopa and levodopa (25 and 100 mg, respectively; two and one-half tablets q.i.d) were continued throughout the ECT course. Following the second treatment, improvement in bradykinesia was noted. After the fifth treatment, Mr. A was reevaluated by the neurology service, and the degree of rigidity, resting tremor, and gait instability was improved. Specifically, Mr. A was able to transfer himself from one position or station to another and walk with minimal assistance. Improvement in his parkinsonian symptoms occurred before the antidepressant effects of ECT were clinically evident. His post-ECT scores on the Mini-Mental State and the Hamilton depression scale were 24 of 30 and 7, respectively. Six bilateral maintenance ECT treatments were administered during the 4 months following discharge. Improvement in parkinsonian symptoms was sustained, and Mr. A was able to transfer himself from one position or station to another and walk independently.
To our knowledge, this represents the first case report where the parkinsonian symptoms of multiple system atrophy responded to treatment with ECT. In a MEDLINE search, one previous case report was identified in which ECT was used to treat combined multiple system atrophy and major depression (3). In this report, the patient "s depression responded to 10 right unilateral (nondominant) ECT treatments (EEG seizure duration=462 seconds), but there was no improvement in his parkinsonian symptoms. It was speculated that bilateral ECT may have been more effective and further postulated that putaminal postsynaptic dopaminergic dysfunction renders the parkinsonian symptoms of multiple system atrophy refractory to treatment with ECT.
1. Consensus statement on the definition of orthostatic hypotension, pure autonomic failure and multiple system atrophy. J Neurol Sci 1996; 144:218–219Crossref, Medline, Google Scholar
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3. Ruxin RJ, Ruedrich S: Case report and review: ECT in combined multiple system atrophy and major depression. Convuls Ther 1994; 10:298–300Medline, Google Scholar
