eMedicine Specialties > Neurology > Movement and Neurodegenerative Diseases

Parkinson Disease: Differential Diagnoses & Workup

Author: Robert A Hauser, MD, MBA, Professor of Neurology, Molecular Pharmacology and Physiology, Director, Parkinson's Disease and Movement Disorders Center, University of South Florida; Clinical Chair, Signature Interdisciplinary Program in Neuroscience
Coauthor(s): Rajesh Pahwa, MD, Professor of Neurology, Director, Parkinson Disease and Movement Disorder Center, Department of Neurology, University of Kansas Medical Center; Kelly E Lyons, PhD, Research Associate Professor of Neurology, Director of Research and Education, Parkinson's Disease and Movement Disorder Center, University of Kansas Medical Center; Theresa McClain, MSN, ARNP, Parkinson's Disease and Movement Disorders Center, University of South Florida
Contributor Information and Disclosures

Updated: Oct 29, 2009

Differential Diagnoses

Alzheimer Disease
Normal Pressure Hydrocephalus
Cardioembolic Stroke
Parkinson-Plus Syndromes
Cortical Basal Ganglionic Degeneration
Progressive Supranuclear Palsy
Essential Tremor
Striatonigral Degeneration
Hallervorden-Spatz Disease
Lacunar Syndromes
Multiple System Atrophy

Other Problems to Be Considered

Jakob-Creutzfeldt and other prion diseases

Parkinsonism can be caused by a variety of degenerative disorders, as well as toxins, infections, and vascular or structural lesions.

Parkinsonism also can be induced by medications that block dopamine receptors (eg, neuroleptics, antiemetics) or deplete intraneuronal dopamine stores (eg, reserpine, tetrabenazine).

Workup

Laboratory Studies

  • No laboratory biomarkers exist for Parkinson disease.
  • Serum ceruloplasmin concentration is obtained as a screening test for Wilson disease. It should be obtained in patients who present with parkinsonian symptoms when younger than 40 years. In cases in which Wilson disease is suspected, 24-hour urinary copper and slit lamp examination of the eyes also should be obtained.

Imaging Studies

  • Magnetic resonance imaging (MRI) and computed tomography (CT) scan are unremarkable in Parkinson disease.
    • No imaging study is required in patients with a typical presentation. Such patients are aged 55 years or older; have a slowly progressive, asymmetric parkinsonism with resting tremor and bradykinesia or rigidity; and demonstrate a good response to dopamine replacement therapy.
    • MRI is useful to exclude multi-infarct state, hydrocephalus, and the lesions of Wilson disease.
    • MRI should be obtained in patients whose clinical presentation does not allow a high degree of diagnostic certainty, including those who lack tremor, have an acute or stepwise progression, or are younger than 55 years.
  • Positron emission tomography (PET) and single photon emission CT (SPECT) are useful diagnostic imaging studies. They are not widely available and may not be covered by insurance. Moreover, they are not needed for routine clinical diagnosis in patients with a typical presentation.
    • At the onset of symptoms, patients with Parkinson disease show approximately 30% decrease in 18F-dopa uptake in the contralateral putamen.
    • 18F-dopa is taken up by the terminals of dopamine neurons and converted to 18F-dopamine. The rate of striatal 18F accumulation reflects transport of 18F-dopa into dopamine neurons and its decarboxylation to 18F-dopamine.
    • 11C-Nomifensine and cocaine analogues such as 123I-Beta-CIT bind to dopamine reuptake sites on nigrostriatal terminals and provide an index of the integrity of nigrostriatal projections.
    • Deficits on fluorodopa PET or β-CIT SPECT indicate a dopamine deficiency syndrome but do not necessarily differentiate Parkinson disease from atypical parkinsonisms including multiple system atrophy and progressive supranuclear palsy.

More on Parkinson Disease

Overview: Parkinson Disease
Differential Diagnoses & Workup: Parkinson Disease
Treatment & Medication: Parkinson Disease
Follow-up: Parkinson Disease
Multimedia: Parkinson Disease
References
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Further Reading

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Keywords

Parkinson disease, Parkinson's disease, parkinsonism, Parkinson syndrome, basal ganglia disease, movement disorder, shaking palsy, Parkinson disease treatment, Parkinson disease symptoms

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Contributor Information and Disclosures

Author

Robert A Hauser, MD, MBA, Professor of Neurology, Molecular Pharmacology and Physiology, Director, Parkinson's Disease and Movement Disorders Center, University of South Florida; Clinical Chair, Signature Interdisciplinary Program in Neuroscience
Robert A Hauser, MD, MBA is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Society of Neuroimaging, and Movement Disorders Society
Disclosure: Allergan Sales, LLC Honoraria Speaking and teaching; Boehringer Ingelheim  Honoraria Consulting; Genzyme Corporation Honoraria Consulting; GlaxoSmithKline Honoraria Consulting; IMPAX Laboratories, Inc. Honoraria Consulting; Novartis Pharmaceuticals Corp. Honoraria Consulting; Schering Plough  Consulting; Solvay Pharmeceuticals Honoraria Consulting; Teva Neuroscience Honoraria Speaking and teaching

Coauthor(s)

Rajesh Pahwa, MD, Professor of Neurology, Director, Parkinson Disease and Movement Disorder Center, Department of Neurology, University of Kansas Medical Center
Rajesh Pahwa, MD is a member of the following medical societies: American Academy of Neurology and Movement Disorders Society
Disclosure: Nothing to disclose.

Kelly E Lyons, PhD, Research Associate Professor of Neurology, Director of Research and Education, Parkinson's Disease and Movement Disorder Center, University of Kansas Medical Center
Kelly E Lyons, PhD is a member of the following medical societies: American Academy of Neurology and Movement Disorders Society
Disclosure: Novartis Honoraria Speaking and teaching; Teva Neuroscience Honoraria Speaking and teaching; St Jude Medical Honoraria Board membership; GlaxoSmithKline Consulting fee Consulting; Medtronic Honoraria Speaking and teaching

Theresa McClain, MSN, ARNP, Parkinson's Disease and Movement Disorders Center, University of South Florida
Theresa McClain, MSN, ARNP is a member of the following medical societies: Sigma Theta Tau International
Disclosure: Teva Consulting fee Consulting; GSK Consulting fee Consulting; Valeant Pharm Consulting fee Consulting; Solvay Consulting fee Consulting; Shering Plough Consulting fee Consulting

Medical Editor

Rodrigo O Kuljis, MD, Esther Lichtenstein Professor of Psychiatry and Neurology, Director, Division of Cognitive and Behavioral Neurology, Department of Neurology, University of Miami School of Medicine
Rodrigo O Kuljis, MD is a member of the following medical societies: American Academy of Neurology and Society for Neuroscience
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Nestor Galvez-Jimenez, MD, MSc, MHA, Chairman, Department of Neurology, Program Director, Movement Disorders, Department of Neurology, Division of Medicine, Cleveland Clinic Florida
Nestor Galvez-Jimenez, MD, MSc, MHA is a member of the following medical societies: American Academy of Neurology, American College of Physicians, and Movement Disorders Society
Disclosure: Nothing to disclose.

Chief Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

 
 
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