title: Recurrent and Alternating Pisa Syndrome.
abstract: OBJECTIVE
  The aims of the study were to report the case of a male patient who developed a first episode of Pisa syndrome (PS) to the right side and a second episode to the left side and to discuss the hypothesis that states that denervation is one of the main mechanisms implicated in the development of PS.
  
  
  METHODS
  We report on the case of a 71-year-old patient with Parkinson disease who developed PS to the right side while on dopaminergic treatment with pramipexol and levodopa. The dopamine agonist was discontinued and the postural abnormality was corrected increasing the levodopa dose. Six years later, while on ropinirole and levodopa, he developed PS again but this time the lean was to the left. Even though the dopamine agonist was discontinued, this condition failed to improve.
  
  
  CONCLUSIONS
  Mechanisms other than denervation and its relationship with the more or less affected side contribute to the development of the syndrome.This is the first report of a case of recurrent alternating PS and highlights the need for research on this topic to better understand this disorder.
authors.affiliation: Parkinson's Disease and Movement Disorders Unit, Department of Neurology, Hospital de Clínicas "Jose de San Martin," Buenos Aires, Argentina.
authors.forename: Alejandro
authors.initials: A
authors.lastname: Pellene
authors.forename: Michel
authors.initials: M
authors.lastname: Saenz-Farret
authors.forename: Federico
authors.initials: F
authors.lastname: Micheli
mesh_terms: D000368:Aged; D052160:Benzothiazoles / Q000009:adverse effects*; D018491:Dopamine Agonists / Q000009:adverse effects*; D020821:Dystonic Disorders / Q000139:chemically induced*; D006801:Humans; D007980:Levodopa / Q000009:adverse effects*; D008297:Male; D010300:Parkinson Disease / Q000188:drug therapy; D004856:Postural Balance; D000077487:Pramipexole; D012678:Sensation Disorders / Q000139:chemically induced*
chemical_list: D052160:Benzothiazoles; D018491:Dopamine Agonists; D007980:Levodopa; D000077487:Pramipexole