Objective: Case study to review functional exam findings in an abnormal Dopaminergic transporter scan positive Lewy body dementia patient.

Background: Patient presented with known Parkinson’s disease for continued care and requested for formal confirmation to increase disability benefits from the VA. Abnormal motor exam findings: distractible tremor, promotable dyskinesia, and deliberate bradykinesia. There is extensive mental health history and unclear exposure to neuroleptics. The initial symptoms were fluctuating cognition followed by bilateral hand rest tremor (R>L). By history component the patient had a robust response to levodopa and quickly developed motor fluctuations with early wearing OFF dystonic pain and worsening of tremor and subsequently ON dyskinesia. DaTScan was read as normal. This is likely Symptoms without Evidenced of Dopaminergic Deficit/ Neuroleptic-induced Parkinsonism. Functional Movement Disorder cannot be ruled out as some of the motor exam findings were distractible and increased during assessment (Miyasaki et al., 2018). Fluctuating cognition made Lewy Body Dementia a likely consideration. This was also supported by robust response to cholinesterase inhibitor (Lam et al., 2009). Based on the DATQuant, the scan is read as borderline abnormal. This is inconsistent with the severity of the clinical exam findings and subjective reporting of motor fluctuations (more consistent with patients with 10+ years of illness) (Nissen et al., 2003).   Disabling symptoms were present on the right side while the DaTScan revealed right striatal abnormality.

Method: Clinical exam findings:Biomarkers: DaTscan analysis; DATQuant analysis, brain MRISubjective reporting of dopamine replacement therapy response: fluctuations, wearing off, severe OFF dystonia, pain, and tremor and ON dyskinesia. Severe mental health history and exposure to neuroleptics.

Results: The diagnosis revised to Lewy body dementia with functional overlay and severe behavioral disturbances.

Conclusion: In patients with inconsistent subjective history reporting as compared to clinical exam findings and biomarkers it increases the complexity of management. There is no direct approach to pharmacological intervention with poor correlation of symptoms. There are limitations to the objective findings and diagnostic conclusion versus the patient’s personal interest. Normal scan can evolve to abnormal over time, so a single test cannot be used a singled diagnosis for FMD (Miyasaki, et al., 2018).

References: Lam, B., Hollingdrake, E., Kennedy, J. L., Black, S. E., Masellis, M. (2009). Cholinesterase inhibitors in Alzheimer’s disease and Lewy body spectrum disorders: the emerging pharmacogenetic story. Human Genomics, 4(2): 91-106. doi: 10.1186/1479-7364-4-2-91 Miyasaki, J. M., Hurtig, H., Eichler, A. F. (2018). Functional movement disorders. UpToDate. Topic 14132 Version 22.0 Nissen, T., Malek, N., Grossett, K.A., Newman, E.J., Paterson, J., Hadley, D., Grossett, D.G., (2003). Baseline FP-CIT SPECT (DaTScan) severity correlates with medication use at 3 years in Parkinson’s disease. Wiley Online Library. https://doi.org/10.1111/ane.12178

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MDS Abstracts - https://www.mdsabstracts.org/abstract/functional-exam-findings-in-lewy-body-disease/