Case report Child A is a 13-year old boy with a history of poor adherence to his asthma treatment.
He was admitted to hospital with an acute severe exacerbation of asthma, which needed escalation of treatment to intravenous bronchodilators. Despite intensive treatment, he went on to have a cardio-respiratory arrest, necessitating five minutes of cardiopulmonary resuscitation and adrenaline prior to return of his circulation.
Child A spent a week on PICU, after which he underwent neurological rehabilitation on the ward, involving a multidisciplinary team. MRI of his brain confirmed severe hypoxic brain injury with infarction within the basal ganglia and occipital lobe (Figure 1). Similar to other children with acquired brain injury, he demonstrated 4-limb spasticity, as well as dystonic posturing.
In addition to this, he also displayed Parkinsonian features, which is a rare complication of brain injury. He had a resting tremor, bradykinesia, rigidity and a shuffling gait, with difficulty in turning around. He displayed hypomimic facies, along with a monotonous speech. The above symptoms responded well to co-careldopa.
Discussion Poor compliance with asthma medication in children remains a significant problem with major health implications. Our case sustained a severe brain injury as a result of this. Unlike in adults where Parkinsonism is common, this condition is rare in children and easy to miss. The commonest cause of Parkinsonism is the loss of dopaminergic neurones in the substantia niagra of the basal ganglia. Child A’s symptoms resolved with co-careldopa which increases dopamine levels in the brain.
We have not come across a similar paediatric case during our literature review. Paediatricians need to be vigilant to identify Parkinsonian features in children with brain injury. These typical signs become apparent to the clinician who is clearly looking out for them. Making this diagnosis correctly is important so that we can prescribe a specific anti-Parkinsonian medication, rather than make the child go through repeated failed trials with incorrect drugs. There are different classes of medication for Parkinsonism and treatment choices are largely based on data from adults.
Recognising this movement disorder is hence vital to support the rehabilitation process and optimise recovery.
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