eMedicine Specialties > Physical Medicine and Rehabilitation > Movement Disorders

Parkinson Disease: Differential Diagnoses & Workup

Author: Jeff Blackmer, MD, FRCP(C), Associate Professor, Medical Director, Neurospinal Service, Division of Physical Medicine and Rehabilitation, The Rehabilitation Centre; Executive Director, Office of Ethics, Canadian Medical Association
Contributor Information and Disclosures

Updated: Mar 10, 2009

Differential Diagnoses

Multiple System Atrophy
Olivopontocerebellar Atrophy
Progressive Supranuclear Palsy
Subdural Hematoma
Wilson Disease

Other Problems to Be Considered

Shy-Drager syndrome7
Drug-induced parkinsonism (neuroleptics, metoclopramide, reserpine)
Toxin-induced parkinsonism (methyl-phenyl-tetrahydropyridine [MPTP], manganese, carbon monoxide, carbon disulfide, cyanide)
Metabolic causes (anoxic, hypothyroidism, hypoparathyroidism)
Multiple strokes
Basal ganglia tumor
Normal-pressure hydrocephalus
Postencephalitic Parkinson's disease
Posttraumatic brain injury Parkinson's disease
Vascular Parkinson's disease (lesions of the caudate, putamen, globus pallidus, or brain stem)
Creutzfeldt-Jakob disease
Structural Parkinson's disease (brain tumor compromising or invading the basal ganglia)

Workup

Laboratory Studies

  • The diagnosis of Parkinson's disease is based almost entirely on results of the history and physical examination.8 Initial diagnostic accuracy, based on clinicopathologic studies, is about 65% (or 76% with the benefit of follow-up). In atypical cases, lab investigations may be performed to exclude other causes of parkinsonism. These investigations may include the following:
    • Plasma ceruloplasmin and copper to exclude Wilson disease
    • Thyrotropin levels if hypothyroidism is suggested
    • Toxin screening if clinically indicated by a history of possible exposure

Imaging Studies

  • As with laboratory investigations, imaging studies and other investigations are not performed routinely for patients with clinically typical Parkinson's disease; however, they may assist in ruling out other causes of the patient's symptomatology.
  • Magnetic resonance imaging (MRI) may suggest the following:
    • Normal-pressure hydrocephalus (large ventricles)
    • Subdural hematoma
    • Tumor
    • Multiple infarcts
    • Multisystem atrophy (eg, decreased T2 signal in the striatum)
    • Progressive supranuclear palsy (eg, midbrain atrophy)

Other Tests

  • Sphincter electromyelography examination shows evidence of denervation in Shy-Drager syndrome.
  • Olfactory testing can reveal problems with olfaction, which may precede the motor complications of Parkinson's disease by several years.8 Evidence indicates that poor olfaction is correlated with the loss of dopamine receptors in the nigrostriatal region.

Procedures

  • Lumbar puncture should be performed if signs of normal-pressure hydrocephalus are observed (eg, incontinence, ataxia, dementia). The clinical picture usually improves after removal of about 20 mL of cerebrospinal fluid.

Histologic Findings

Classic pathologic findings in Parkinson's disease include degeneration of the neurons containing neuromelanin, especially in the substantia nigra and the locus ceruleus. Surviving neurons often contain eosinophilic cytoplasmic inclusions called Lewy bodies. The primary biochemical defects are loss of striatal dopamine, which results from degeneration of dopamine-producing cells in the substantia nigra, as well as hyperactivity of the cholinergic neurons in the caudate nucleus.

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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References

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  2. Stoessl AJ. Etiology of Parkinson's disease. Can J Neurol Sci. Aug 1999;26 Suppl 2:S5-12. [Medline].

  3. Lang AE, Lozano AM. Parkinson's disease. Second of two parts. N Engl J Med. Oct 15 1998;339(16):1130-43. [Medline].

  4. Driver JA, Logroscino G, Gaziano JM, et al. Incidence and remaining lifetime risk of Parkinson disease in advanced age. Neurology. Feb 3 2009;72(5):432-8. [Medline].

  5. Grimes DA, Lang AE. Treatment of early Parkinson's disease. Can J Neurol Sci. Aug 1999;26 Suppl 2:S39-44. [Medline].

  6. Thobois S, Delamarre-Damier F, Derkinderen P. Treatment of motor dysfunction in Parkinson's disease: an overview. Clin Neurol Neurosurg. Jun 2005;107(4):269-81. [Medline].

  7. Stoessl AJ, Rivest J. Differential diagnosis of parkinsonism. Can J Neurol Sci. Aug 1999;26 Suppl 2:S1-4. [Medline].

  8. Tolosa E, Gaig C, Santamaria J, et al. Diagnosis and the premotor phase of Parkinson disease. Neurology. Feb 17 2009;72(7 Suppl):S12-20. [Medline].

  9. Sliwa JA. Neuromuscular rehabilitation and electrodiagnosis. 1. Central neurologic disorders. Arch Phys Med Rehabil. Mar 2000;81(3 Suppl 1):S3-12; quiz S36-44. [Medline].

  10. Dombovy ML. Rehabilitation concerns in degenerative movement disorders of the central nervous system. In: Braddom RL, ed. Handbook of Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders; 1996:1088-99.

  11. Honey C, Gross RE, Lozano AM. New developments in the surgery for Parkinson's disease. Can J Neurol Sci. Aug 1999;26 Suppl 2:S45-52. [Medline].

  12. Chu J, Wagle-Shukla A, Gunraj C, et al. Impaired presynaptic inhibition in the motor cortex in Parkinson disease. Neurology. Mar 3 2009;72(9):842-9. [Medline].

  13. Fogelson N, Kühn AA, Silberstein P, et al. Frequency dependent effects of subthalamic nucleus stimulation in Parkinson's disease. Neurosci Lett. Jul 1-8 2005;382(1-2):5-9. [Medline].

  14. Poewe W. Treatments for Parkinson disease--past achievements and current clinical needs. Neurology. Feb 17 2009;72(7 Suppl):S65-73. [Medline].

  15. Schapira AH. Molecular and clinical pathways to neuroprotection of dopaminergic drugs in Parkinson disease. Neurology. Feb 17 2009;72(7 Suppl):S44-50. [Medline].

  16. Lim SY, Fox SH, Lang AE. Overview of the extranigral aspects of Parkinson disease. Arch Neurol. Feb 2009;66(2):167-72. [Medline].

  17. Canadian Pharmacists Association. Compendium of Pharmaceuticals and Specialties. 25th ed. Toronto, Canada: Webcom Ltd; 2000.

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Further Reading

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Keywords

Parkinson's disease, Parkinson disease, Parkinson, tremors, tremor, dopamine, Parkinson's, deep brain stimulation, motor cortex, Parkinson's symptoms, dementia, L dopa, movement disorders, Parkinson's treatment, Parkinson's disease symptoms, parkinsonism, levodopa, bradykinesia, Parkinson's disease treatment, Parkinson disease symptoms, L-dopa, idiopathic Parkinson disease

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Contributor Information and Disclosures

Author

Jeff Blackmer, MD, FRCP(C), Associate Professor, Medical Director, Neurospinal Service, Division of Physical Medicine and Rehabilitation, The Rehabilitation Centre; Executive Director, Office of Ethics, Canadian Medical Association
Jeff Blackmer, MD, FRCP(C) is a member of the following medical societies: American Paraplegia Society, Canadian Association of Physical Medicine and Rehabilitation, Canadian Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Medical Editor

Milton J Klein, DO, MBA, Consulting Physiatrist, Heritage Valley Health System-Sewickley Hospital, Allegheny General Hospital, and Ohio Valley General Hospital.
Milton J Klein, DO, MBA is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Medical Acupuncture, American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, American Pain Society, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Kat Kolaski, MD, Assistant Professor, Departments of Orthopedic Surgery and Pediatrics, Wake Forest University School of Medicine
Kat Kolaski, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine and American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Denise I Campagnolo, MD, MS, Director of Multiple Sclerosis Clinical Research and Staff Physiatrist, Barrow Neurology Clinics, St Joseph's Hospital and Medical Center; Investigator for Barrow Neurology Clinics; Director, NARCOMS Project for Consortium of MS Centers
Denise I Campagnolo, MD, MS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, and Consortium of Multiple Sclerosis Centers
Disclosure: Teva Neuroscience Honoraria Speaking and teaching; Serono-Pfizer Honoraria Speaking and teaching

 
 
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