Fifty‐eight‐year‐old man presented with difficulty in speech and handwriting for 2 years. History and neurological examination (Video 1) revealed dysarthric accelerated production of syllables and illegible handwriting (Fig. 1). Additionally, he had global bradykinesia and predominantly axial rigidity. Parkinsonism was unresponsive to levodopa 1 g/day.
Video 1.
Video showing abnormal speech, handwriting, partial supranuclear gaze palsy, and impaired postural reflexes.
Figure 1.
The patient was asked to copy the sentence “The sun is shining” in successive lines without removing the hand from the page (as one would write a letter). Line 1 is the examiner's sample sentence. Lines 2 through nine are the patient's successive attempts to replicate the sentence. The patient's handwriting demonstrates poor legibility and small letter size from writing onset.
Question
What is the most fitting phenomenology of his speech and handwriting?
Tachymicrographia, tachyphemia and oral festination.
Micrographia and hypomimia.
Apraxia of speech and handwriting.
Strained speech and micrographia.
Answer
Tachymicrographia, tachyphemia and oral festination.
Question
What is the most likely diagnosis?
Corticobasal degeneration.
Parkinson's disease.
Multiple system atrophy.
Progressive supranuclear palsy.
Answer
Progressive supranuclear palsy.
The patient's free speech (not recorded in this video) exceeded the complexity of simple strain. During the encounter his speech was fluent, hypophonic, and accelerated, suggestive of tachyphemia. Repetition of syllables (Pa, Ta, Ka, La) revealed accelerated rate with clear consonant production consistent with oral festination. He performs vocal and handwriting tasks without groping for sounds or movements as one might see with apraxia. Similar to his speech, the letters in the patient's handwriting sample were small from onset, remained small, and his handwriting was fast. This is consistent with tachymicrographia. The words became progressively cramped and many were omitted and illegible toward the end. Tachymicrographia was initially reported with tachyphemia in a patient with “striate syndrome.” 1
“Fast micrographia” has been reported with multiple pallidal pathologies, for example, progressive supranuclear palsy (PSP). 2 This characteristic handwriting differs from classic micrographia of Parkinson's disease (PD) whereby size is relatively normal initially but becomes progressively smaller and may fatigue. 3 Dysgraphic errors like letter and word omissions, and cramped handwriting have also been described in the past with PSP. 1 , 2 The lack of myoclonus, rigidity, and apraxia make corticobasal degeneration less likely. The speech pattern of some atypical parkinsonisms (MSA and PSP) can be like PD; however, MSA tends to cause more scanning and ataxic qualities while spastic speech is more common in PSP. This patient met criteria for a diagnosis of probable PSP with predominant parkinsonism based upon slowed and incomplete vertical saccades, levodopa non‐responsive parkinsonism, and postural instability. 4 Tachymicrographia may help clinicians distinguish PSP from other parkinsonisms during early disease stages.
Author Roles
(1) Research project: A. Conception, B. Organization, C. Execution. (2) Statistical Analysis: A. Design, B. Execution, C. Review and Critique. (3) Manuscript: A. Writing of the First Draft, B. Review and Critique.
S.B.: 1A, 1B, 1C, 3A.
P.T.: 1A, 1B, 1C, 3A, 3B.
J.V.G.: 1A, 1B, 1C, 3A, 3B.
Disclosures
Ethical Compliance Statement: The authors confirm that the approval of an institutional review board was not required for this work. The informed consent was obtained from the patient. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines.
Funding Sources and Conflicts of Interest: No specific funding was received for this work. The authors declare that there are no conflicts of interest relevant to this work.
Financial Disclosures for the Previous 12 Months: The authors declare that there are no additional disclosures to report.
REFERENCES
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