title: Lesson of the month 2: a case of coma in a Parkinson's patient: a combination of fatigue, dehydration and high protein diet over the New Year period?
abstract: Although motor fluctuation can often be severe in Parkinson's disease (PD), it is rare for an 'off period' to result in coma. The case presented here is of a patient with longstanding PD who was admitted to our hospital with a Glasgow Coma Scale of three after missing just one or two doses of her medication. Investigation for infective, neurovascular and metabolic causes of coma were negative and the patient recovered very rapidly following reinstitution of dopaminergic therapy via nasogastric tube. This case highlights how florid the presentation of motor fluctuations in PD can be and the importance of restarting treatment as quickly as possible. Guidance is provided on how to administer dopaminergic medications in patients who are unable to swallow.
authors.affiliation: the Great Western Hospital, Swindon, UK; previously specialist registrar, Department of Clinical Pharmacology and General Medicine, Queen Elizabeth Hospital, Birmingham, UK and honorary lecturer, Department of Clinical Pharmacology, University of Birmingham, UK nirmalan.arulanantham@doctors.org.uk.
authors.forename: Nirmalan
authors.initials: N
authors.lastname: Arulanantham
authors.affiliation: West Midlands rotation, UK.
authors.forename: Ralph Wing Fung
authors.initials: RW
authors.lastname: Lee
authors.affiliation: Department of Neurology, Queen Elizabeth Hospital, Birmingham, UK.
authors.forename: Tom
authors.initials: T
authors.lastname: Hayton
mesh_terms: D000368:Aged; D003128:Coma / Q000209:etiology*; D003681:Dehydration / Q000150:complications; D004044:Dietary Proteins / Q000009:adverse effects; D015259:Dopamine Agents / Q000008:administration & dosage*; D005221:Fatigue / Q000150:complications; D005260:Female; D006693:Holidays; D006801:Humans; D010300:Parkinson Disease / Q000150:complications / Q000188:drug therapy*
chemical_list: D004044:Dietary Proteins; D015259:Dopamine Agents
keywords: Parkinson’s disease; acute akinesia; coma; high protein diet; wearing off
references.citation: N Engl J Med. 2004 Dec 9;351(24):2498-508
references.pmid: 15590952
references.citation: BMJ. 2010 Nov 01;341:c5718
references.pmid: 21041319
references.citation: Yale J Biol Med. 1987 Mar-Apr;60(2):133-7
references.pmid: 3577210
references.citation: J Nerv Ment Dis. 1981 May;169(5):324-7
references.pmid: 6111584
references.citation: Neurology. 2005 Apr 12;64(7):1162-9
references.pmid: 15824341