Parkinsonism with a bovine cough: an unusual presentation.

Abstract

Published reports on the value of sodium valproate (Epilim) as an anticonvulsant drug have been encouraging.' Acquired platelet function defects ofdoubtful significance have been found and attributed to this drug,2 and there have been two reports of haemorrhages, prolonged bleeding times, and thrombocytopenia in patients on sodium valproate with other anticonvulsant drugs.3 4 The patient we report here developed thrombocytopenia when taking sodium valproate alone, and the investigations are recorded.Case report A 6-year-old boy weighing 20 kg had been having major and minor seizures for two years and had failed to respond to other anticonvulsant drugs. On treatment with sodium valproate 400 mg four times a day, all other drugs having been stopped, he was rendered fit-free for eight months. His mother then reported that he had developed hair loss and multiple spontaneous bruises. The DiscussionIn a further 32 of our patients on sodium valproate, including several who were on large doses and had high serum levels of the drug, and five who also complained ofhair loss, no other cases ofhaemorrhage or platelet counts below 100 x 109/l were detected.Apart from the sodium valproate with the very high serum level in our patient we found no other cause for the thrombocytopenia, which we therefore considered was probably due to the drug. The finding of increased numbers of megakaryocytes in the bone marrow, together with the rate ofplatelet recovery on discontinuing the drug, is suggestive of an immunological mechanism, though circulating platelet antibodies could not be detected in vitro. The negative results obtained during the thrombocytopenic phase may be explained by consumption of the antibody in vivo, though this mechanism cannot account for the negative findings in the recovery phase. A further possibility for the negative in-vitro results is that the circulating antibody is developed to a metabolic product of sodium valproate and not to the drug itself. It was considered unjustifiable to subject our patient to a further test dose of the drug, but it is of interest that in one of the previously reported cases of thrombocytopenia3 the platelet count recovered on stopping the sodium valproate but immediately fell on recommencing the drug.As a result of these findings we recommend that any excessive or unexplained bruising or bleeding in a patient on sodium valproate is an indication for immediate platelet assessment.We are grateful to the Regional Blood Transfusion Centre, Sheffield, for the platelet antibody studies. In April 1976 he developed an acute exacerbation of his bronchlitis accompanied by cor pulmonale. He failed to respond to treatment and died four days after admission to hospital. Necropsy examination was not performed. DiscussionIn view of the disappearance of this man's bovine cough at the same time as the improvement in his other Parkinsonian features during treatment with levodopa and benserazide, it is difficult to come to any other conclusion than that the bovine cough was the presenting featu...

Stridor and parkinsonism

“…Laryngeal spasm in post-encephalitic parkinsonism and oesophageal spasm in the idiopathic form have been reported. Bendall (1976) described parkinsonian bovine cough and a man with typical parkinsonian features 'whose breathing is of a Urge incontinence and postural hypotension do occur in some patients with idiopathic parkinsonism and our patient had no other features of olivo-pontocerebellar degeneration or the Shy-Drager syndrome in both of which stridor occurs (Williams, Hanson and Calne, 1979). Of particular interest, however, are the laryngeal electromyographic studies of Guindi et al (1981) on 5 patients with multiple system atrophy and a further 9 patients with Parkinson's disease, 2 of whom had autonomic failure in addition.…”

A Case of Familial Creutzfeldt-Jakob Disease Presenting with Dry Cough

“…Instead, hyperintensities were seen in the caudate and putamen nuclei. Prodromal cough has already been reported in patients with neurological diseases such as Parkinson's disease, 17 Wilson's disease 18 and Tourette's syndrome. 19 Interestingly, all these disorders are known to localize to those same subcortical regions.…”