title: Parkinsonian syndromes presenting with circadian rhythm sleep disorder- advanced sleep-phase type.
abstract: BACKGROUND
  Circadian rhythm sleep disorder-advanced sleep-phase type is a relatively uncommon disorder, mostly seen among the elderly population. Impaired circadian rhythms have been reported in neurodegenerative conditions; however, there are no reports of any circadian rhythm sleep disorder among patients with Parkinsonian syndromes. We report two patients who presented with this circadian rhythm disorder, and were then diagnosed with a Parkinsonian syndrome. The cases. A 65-year-old retired man presented with history of abrupt change in sleep schedules, sleeping around 6.30-7 p.m. and waking up around 3-4 a.m. for the last 2 months. On detailed examination, the patient was observed to have symmetrical bradykinesia and cogwheel rigidity of limbs. A diagnosis of multiple system atrophy was made, supported by MRI findings and evidence of autonomic dysfunction. Symptoms of change in sleep-wake cycles resolved over the next 1 year, while the patient was treated with dopaminergic therapy. A 47-year-old man, who was being evaluated for presurgical investigation for refractory temporal lobe epilepsy, presented with complaints suggestive of dysarthria, bradykinesia of limbs and frequent falls for 5 months. Simultaneously, he began to sleep around 7 p.m. and wake up at about 2-3 a.m. Examination revealed severe axial rigidity, restricted vertical gaze and bradykinesia of limbs. A diagnosis of progressive supranuclear palsy was made.
  
  
  CONCLUSIONS
  This is the first report of Parkinson's plus syndromes presenting with a circadian rhythm sleep disorder-advanced sleep-phase type. More prospective assessment for circadian sleep disorders may introduce useful insights into similar associations.
authors.affiliation: Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Garima
authors.initials: G
authors.lastname: Shukla
authors.affiliation: Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Bhavna
authors.initials: B
authors.lastname: Kaul
authors.affiliation: Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Anupama
authors.initials: A
authors.lastname: Gupta
authors.affiliation: Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Vinay
authors.initials: V
authors.lastname: Goyal
authors.affiliation: Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Madhuri
authors.initials: M
authors.lastname: Behari
mesh_terms: D000058:Accidental Falls / Q000517:prevention & control; D000368:Aged; D001342:Autonomic Nervous System Diseases / Q000175:diagnosis; D015259:Dopamine Agents / Q000627:therapeutic use; D004401:Dysarthria / Q000175:diagnosis; D004833:Epilepsy, Temporal Lobe / Q000175:diagnosis; D006801:Humans; D018476:Hypokinesia / Q000175:diagnosis; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009127:Muscle Rigidity / Q000175:diagnosis; D020734:Parkinsonian Disorders / Q000150:complications* / Q000175:diagnosis* / Q000188:drug therapy; D020178:Sleep Disorders, Circadian Rhythm / Q000175:diagnosis* / Q000188:drug therapy / Q000209:etiology*; D013494:Supranuclear Palsy, Progressive / Q000175:diagnosis; D016896:Treatment Outcome
chemical_list: D015259:Dopamine Agents