Parkinson's disease (PD) and parkinsonism are very common neurological diseases that generally affects older individuals [1]. Some studies suggest that patients with PD exhibit increased susceptibility to bacterial and viral infections and an excess of pneumonia is reported as a cause of death in patients with Parkinson's disease [2]. Therefore, PD could influence the course and the result of COVID-19; however, this association remains unknown.
We describe five parkinsonian patients who tested positive for COVID-19 from 8 March to 18 April 2020, at the Fondazione Policlinico Universitario“Agostino Gemelli”, IRCCS (Table 1 ).
Table 1.
Patient characteristics and treatment response.
| Patient No. | Age, y/Sex | Other diagnoses than COVID-19 | Treatment | Adverse effects |
|---|---|---|---|---|
| Case 1 | 82/F | Vascular parkinsonism and epileptic syndrome (partial epilepsy) | Levetiracetam 1000 mg and clonazepam in small doses | None |
| Split of dosage of levodopa (same dosage in four administrations instead of two) | ||||
| Hydroxychloroquine and lopinavir/ritonavir | ||||
| Case 2 | 72/M | Anxiety, depression, alcohol dependence, attempted suicide, and self-injurious behaviors | Hydroxychloroquine and tocilizumab | None |
| Drug-induced parkinsonism in the last years | Reduction of olanzapine | |||
| Suspension of trihexyphenidyl | ||||
| Case 3 | 66/M | Parkinson's disease | Hydroxychloroquine and lopinavir/ritonavir | None |
| Superimposed pneumonia | Broad-spectrum antibiotics | |||
| Halving the dosage of levodopa | ||||
| Melevodopa through a nasogastric tube | ||||
| Case 4 | 95/F | Parkinson's disease complicated by severe cognitive impairment | Broad-spectrum antibiotics | None |
| Sacral pressure ulcer | Comfort care | |||
| Atrial fibrillation | ||||
| Chronic renal failure | ||||
| Klebsiella pneumonia urinary infection | ||||
| Case 5 | 56/M | Juvenile parkinsonism Diabetes mellitus hypertension |
Followed-up one month later | None |
All cases were positive by the reverse-transcriptase polymerase chain reaction of nasopharyngeal swabs.
1. Case 1
An 82-year-old woman with vascular parkinsonism and epileptic syndrome treated with levodopa 200 mg and carbamazepine 1000 mg presented to the Emergency Department with three days of severe diarrhea, vomiting, and myalgias. She was normotensive, afebrile, with room-air oxygen saturation (SpO2) of 98%. Blood chemistry tests showed hyponatremia and hypokalemia. During hospitalization, she presented myoclonus in the limbs and trunk, which have been treated with levetiracetam and clonazepam. The dosage of levodopa was split.
She also started a course of hydroxychloroquine and lopinavir/ritonavir per institutional protocol and correction of hydro-electrolytic imbalance. Her hospitalization was uncomplicated; gastrointestinal disorders improved, and she was discharged to a rehabilitation facility after a 16-day hospitalization.
2. Case 2
A 72-year-old man with drug-induced parkinsonism. He was taking olanzapine 15 mg, escitalopram 20 mg, and trihexyphenidyl 4 mg. He was referred to the Emergency Department with altered mental status and lethargy noted a few hours prior and six days of dry cough and malaise. He was normotensive, febrile (38 °C), with room-air SpO2 at 80%, which corrected to 96% on nasal cannula (4 L/min). His chest radiograph revealed multifocal bilateral infiltrates. The serum glucose was 182 mg/dL. He received hydroxychloroquine and tocilizumab (a monoclonal antibody against the IL-6 receptor) per institutional protocol. Olanzapine was reduced and, trihexyphenidyl was suspended. His confusion gradually resolved, oxygen requirements improved, and was discharged to home after an 11-day hospitalization.
3. Case 3
A 66-year-old man with a 10-year history of PD presented to the Emergency Department with three days of dry cough and dyspnea. He was hypertensive (181/78 mmHg), febrile (38 °C), with room-air SpO2 at 96%. The chest radiograph showed bibasilar infiltrates. He was hospitalized and started a course of hydroxychloroquine and lopinavir/ritonavir per institutional protocol. He was also started on broad-spectrum antibiotics for presumed superimposed pneumonia. Because there are drug interactions between levodopa and antiretrovirals, the dosage of levodopa was halved. After two days, he developed acute generalized dystonia; antiretrovirals were suspended and melevodopa through a nasogastric tube was administered at the prior dosage. He gradually improved and was discharged to a rehabilitation facility after a 21-day hospitalization.
4. Case 4
A 95-year-old woman, nursing home resident with PD complicated by severe cognitive impairment presented to the Emergency Department with lethargy noticed one day before the presentation. She was hypotensive (80/60 mmHg), afebrile, with room-air SpO2 at 92%. On examination, she was using accessory respiratory muscles. The chest radiograph showed left mid-lower lobe infiltrates. She was admitted, started on broad-spectrum antibiotics, and additionally treated with support oxygen therapy. Later she developed a Klebsiella pneumonia urinary infection in the hospital ward. Finally, her family opted for comfort care, and she expired on hospital day 9.
5. Case 5
A 56-year-old man with juvenile parkinsonism, presented to the Emergency Department with three days of dry cough, subjective fever, and myalgias. He was normotensive, afebrile, with room-air oxygen saturation (SpO2) at 98%. He did not require hospital admission, was followed-up one month later and his symptoms had resolved.
6. Discussion
COVID-19 is a heterogeneous disease that varies from asymptomatic in some patients to fatal in others. Advanced age, male gender, and comorbidity have been identified as risk factors for adverse prognosis [3], [4].
We wanted to report studying the effects that parkinsonian syndrome could have on patients with COVID-19.
Our patients were older adults aged 56 to 95 years. All had underlying conditions, identified as high-risk comorbidities. Still, none of the patients needed mechanical ventilation or intensive care management, and with the exception of one fatality, they all eventually recovered (Table 1). The only fatality was a patient with multiple risk factors, including advanced age, nursing home residence and multiple comorbidities.
This small case series raises the possibility that COVID-19 infection may not necessarily be associated with poor outcome in patients with parkinsonism. This must be confirmed in a larger study.
Disclosure of interest
The authors declare that they have no competing interest.
References
- 1.de Lau L.M., Giesbergen P.C., de Rijk M.C., Hofman A., Koudstaal P.J., Breteler M.M. Incidence of parkinsonism and Parkinson disease in a general population: the Rotterdam Study. Neurology. 2004;63:1240–1244. doi: 10.1212/01.wnl.0000140706.52798.be. [DOI] [PubMed] [Google Scholar]
- 2.Ebmeier K.P., Calder S.A., Crawford J.R., Stewart L., Besson J.A., Mutch W.J. Mortality and causes of death in idiopathic Parkinson's disease: results from the Aberdeen whole population study. Scott Med J. 1990;35(6):173–175. doi: 10.1177/003693309003500605. [DOI] [PubMed] [Google Scholar]
- 3.Zhou F., Yu T., Du R. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054–1062. doi: 10.1016/S0140-6736(20)30566-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Richardson S., Hirsch J.S., Narasimhan M. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA. 2020;323:2052–2059. doi: 10.1001/jama.2020.6775. [published correction appears in doi: 10.1001/jama.2020.7681] [DOI] [PMC free article] [PubMed] [Google Scholar]