Worsened postural deformity in multiple-system atrophy patients with excessive dopaminergic treatment

Postural deformities like dropped head, camptocormia, and Pisa syndrome are seen in both Parkinson's disease and multiple-system atrophy (MSA). However, these features are relatively more common in MSA. These deformities may worsen during treatment and cause the patient distress. We report here two MSA patients. The first patient was a 53-year-old woman with severe bradykinesia, rigidity, and orthostatic hypotension developed dropped head after increasing her levodopa dose from 400 to 600 mg/day. This symptom improved when we reduced the levodopa dose back to 400 mg/day. The second was a 59-year-old woman with severe bradykinesia, rigidity, and urinary incontinence who showed putaminal atrophy on magnetic resonance imaging. After Pisa syndrome was observed at her last follow-up visit, we decreased the pramipexole dose from 4.5 to 3 mg, and she improved. In conclusion, postural deformities in MSA patients may worsen with higher doses of dopaminergic treatment, and decreasing the dose may be the treatment of choice in these patients