Clinical presentation of Parkinson ' s disease among Sudanese patients

Parkinson Disease (PD) is a neurodegenerative disorder affecting motor system. It is a chronic progressive disorder leading to long standing disability. Objective: To study the clinical presentation of PD among Sudanese patients seen at Elshaab Teaching Hospital during the period from May2004-April 2008. Methodology: In this descriptive prospective, cross sectional hospital based study, 94 patients were studied using standardized questionnaire including history and clinical examination. Result: The total number diagnosed to have PD was 94 patients. Male to female ratio was found to be1.5:1.Common age group affected was 70-80 years (24.47%).The common presenting symptom was found to be poverty of movement (93.6%) followed by tremor (82.98%). On neurological examination; rigidity, dyskinesia and festinate gait were the common signs. Primitive reflexes were found in significant number of patients. Idiopathic PD was found to be the common type (75.53%). Of the side effects of benzhexol, 66.67% of our patients developed dry mouth. Postural hypotension was seen in 10.42% of the patients who were taking levodopa. Conclusion: The clinical presentations of our patients does not differ from what was mentioned in the literature

arkinson disease (PD) is a neurodegenerative disorder affecting motor system.It was first described in 1817 by James Parkinson, a British physician, who published a paper in what he called it shaking palsy 1,2 .PD is a chronic progressive disease, with an incidence of 20 new cases per 100000 people and a prevalence of 200 cases per 100000 in the United States.PD seems to be running in families in some cases but 95% of cases are sporadic 3,4 .PD is age specific, it affects 1% of population over the age of 60, which is the average age of onset, and it was suggested that the disease may be time locked to certain age related changes in the nervous system.However, early onset disease below the age of 40 occurs in 5-10% of cases, suggesting that in addition to any changes related to age there are other contributory factors to the disease.PD has equal sex distribution 5,6 .There is no social, economic or geographical variation but some studies showed that African American Correspondence: Dr. Abbasher Hussien .Department of medicine, University of Khartoum -Sudan and Asian are less likely affected than Caucasians.Idiopathic PD account for 85% of cases 7,8 .In idiopathic PD there is loss of dopamine producing cells, the dead cells contain Lewy bodies 9,10  Investigations were requested to rule out other diseases if needed.Patients were treated medically and followed up monthly.Data were analyzed, then the results expressed in form of figures, tables and graphs using SPSS programme.Result: The total number diagnosed to have PD was 94 patients, 59.6% out of these were males with male to female ratio of 1.5:1.The age groups 70-79 years, 60-69years and 50-59 years represent the majority of patients (24.47%, 22.3% and 18.09% respectively), while the younger ages 40-49 years, 30-39 years, 20-29 years, 10-19 years and 1-9 years constitute smaller percentages (7.45%, 10.64%, 6.38%, 8.5% and 1.06% respectively).Very old patients (80-89 years) form 1.06% of patients.House wives constituted 34.04% of patients.Geographical distribution showed that 50% of our patients were from Khartoum region, 30.85% from central Sudan, 9.57% from western Sudan, 8.5% from northern Sudan and 1.06% from eastern Sudan.Family history of similar condition was found in 11.7%.In the past medical history 17.02% of our patients had febrile illness that preceded the Parkinsonian feature, 8.5% had jaundice, 3.19% had trauma and 1.06% had Syphilis.12.77% used to consume alcohol.The common presenting symptoms were illustrated in table (1) .

Discussion
The study showed that the vast majority of patients were from Khartoum and central Sudan (80.5%).The large population and the feasibility of diagnosis in this part of the country had probably played a central role in that.Males were affected more than females with male to female ratio of 1.5:1 this is similar to other reports 11 .The fact that males are exposed to risk factors that cause Parkinson disease more than females may partially explains that 12 .The peak incidence of PD was found to be in the age group 70 -80 years (24.47%).This is similar to the findings of Witjas et al, but it differs from others 13 .The late presentation of our patients could be behind these differences 12,14 .This also holds true for the duration of the disease before presentation, however, miss diagnosis is another contributory factor 12,13 .Most patients had idiopathic Parkinson (75.53%) and that goes with what was mentioned in the literature 15 .A considerable number of our patients had Wilson disease (12.77%).
Atherosclerosis was found in 7.45% of our patients, which is similar to literature, but it differed from a study done in Spain 15 .Drug induced PD accounted for 1.06% which is far less than the 22% reported elsewhere.There is no clear reason for that, however, non compliance to treatment especially hypertensive and psychotic patients might have contributed to that 15 .Common presenting symptoms in our study were found to be poverty of movement (93.6%) and tremors (82.98%), this is similar to the reports from Saudi Arabia and elsewhere 11,13 .Other presenting symptoms include constipation which was detected in 47.87%, this is similar to study done by Witjas and et al (40%) and differed from a study done in Sudia Arabia by Al Bunyan (63%) 11,13 .Excessive sweating, excessive salivation and dysphagia were less common than reports from Saudi Arabia and other places 11,13 .The stage, activity of the disease and the differences in daily habit, emotional support and style of life appeared to play a role in these differences 11,13 .Dysartheria was detected in (47.87%) of the patients 13 .The small number of patients in this study could explain the relatively small percentage (11.7%) of patients with family history compared to that found in Denmark 14 .There is significant number of patients who had past history of jaundice, fever, trauma, some patients were used to take alcohol and one patient had past history of syphilis, all these are well known causes of parkinsonism.The primitive reflexes, signs of brain atrophy, which has a well known recognized association with PD had appeared at the expected ages in our patients.Cog wheel rigidity and lead pipe rigidity were seen in a high percentage in our patients, similar to a report from Saudi Arabia 11 .Dyskinesia was less in our patients compared to Al Bunyan's finding 11 .Festinant gait was found in 77.66% which is different from the results reported by Witjas et al.Part of these neurological differences can be explain by the late presentation of our patients.Cranial nerves involvement in our patients is due to vascular causes, three patients had facial palsy and they had repeated attacks of CVA.Dystonia was reported in few numbers of patients unlike what was mentioned in the literature 4,5 .The small doses of Levodopa used by our patients is probably behind that, this also holds true for the decreased incidence of onoff phenomena, postural hypotension and other side effects of the drug among our patients [6][7][8][9][10] .Conclusion: PD is common among male than female.The most affected age group was found to be 70-80s.Idiopathic PD was found to be the most common type.Family history was found in a minority of our patients.There were significant numbers of patients with Wilson's disease and febrile illness preceding the parkinsonian feature.Few patients were bedridden.Primitive reflexes were found in significant number of patients.Although our findings were generally similar to literature; there are some few differences.Our patients had minimal side effects of the drugs.

Table 1 :
Presenting symptoms among 94 Sudanese patients with Parkinson disease

Table 2 :
The primitive reflexes and clinical findings among 94 Sudanese patients with Parkinson disease