Medical mystery: What caused man’s dizziness, difficulty walking?

A 63-year-old man who had recently returned from a flight to the West Coast developed dizziness the day after his trip.

He had suffered from debilitating vertigo on two previous occasions. One was after a flight, which resolved within 48 hours of the onset of the symptoms. Another time, it occurred unrelated to a flight. Both occasions were determined to be caused by small crystals of calcium that got loose in his inner ear.

This condition is known as benign paroxysmal positional vertigo (BPPV). His doctor treated the condition by performing the Epley maneuver. This is a treatment that involves turning your head 45 degrees to the left or the right. You then lie back, and after 30 seconds, turn your head 90 degrees to the other direction, and wait another 30 seconds before sitting up.

This third time, his symptoms started out similar to those he had experienced in the past, which were sudden balance problems, and some difficulty walking, in addition to some nausea and dizziness. When dizziness occurs following a flight, it typically is due to pressure fluctuations in the plane’s cabin. Flight-induced symptoms may last up to two weeks.

In his case, the symptoms had lasted close to a month, which concerned him and his regular doctor. He also started to notice some tremors of his right arm. And, his difficulty walking seemed to be worsening.

His doctor recommended X-rays, which showed some osteoarthritis in his right shoulder, and in both hips. He wasn’t in any more pain than normal in his hips and arm, and he had not had a recent injury. But he did notice pain in his toes, and they seemed to curl or cross, like a cramp, at times. He also had symptoms of a cold or possibly allergies, and noticed a decreased sense of smell.

His doctor, my colleague, consulted with me regarding his pain and the curious, possibly neurologic symptoms. We ordered a full neurologic exam and some blood tests, on a hunch that we hoped was wrong.

The blood tests revealed that the patient had abnormally low levels of dopamine. That signaled to us that he was showing early signs of Parkinson’s disease, which is caused by a lack of naturally produced dopamine.

This unusual presentation can show in patients who are typically between ages 60 and 70. They may have balance problems and difficulty walking, and the symptoms can be easily confused with vertigo. And often those with painful orthopedic symptoms are assumed to be due to osteoarthritis of the joints affected. Many patients in this age group do have osteoarthritis, and therefore are often treated for that, while the lesser-known signs of Parkinson’s are ignored, and early diagnosis and therapy is delayed.

Other atypical symptoms include pain in the toes, with curling or crossing over of the toes. This is what tipped us off to order a blood test for the patient.

Some patients lose their sense of smell, called anosmia. This is seen with common ailments such as sinusitis, allergies, and colds. But in early Parkinson’s patients, there is a very specific change in the patient’s ability to sense smells, and it can be disturbing to them.

Also, rarely, people can notice their handwriting changing — it becomes smaller. This disorder is called micrographia. It results from the loss of strength of the muscles of the hands. During the patient’s neurologic evaluation this was noted, while subtle.

Some patients may become constipated due to the lack and loss of muscle control in the colon.

Treatment involves giving L-dopa (levo dopa), a drug that mimics dopamine action in the brain. The patient was started on L-dopa immediately, in hopes of slowing the progression of the disease. Many patients also need other medications, such as carbidopa, an enzyme that helps the L-dopa be metabolized and more available and effective.

Parkinson patients are monitored for other symptoms, such as dementia, depression and worsening tremors. In some patients, L-dopa may become less effective with time, often manifesting as involuntary muscle movements called dyskinesis.

Many trials are underway to improve the current therapies for this incurable disease, for which there is no known cause. There is considerable research and many experimental protocols, giving much hope to people like my patient.

Alfred Mauro is director emeritus of Jersey City Medical Center Anesthesia and Pain Management. He can be reached at almauro@optonline.net.