Amyotrophic lateral sclerosis associated with parkinsonism: an atypical manifestation

Context: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease, characterized by progressive muscle weakness. The diagnosis is not always easy, and may have atypical initial manifestations. Case report: O.S.M, female, 62 years old, started in 2016 with bradykinesia and left lower limb tremor, associated with frequent falls. Iniciated research for parkinsonism in 2017, SPECT demonstrated decreased dopamine transporter binding potential density in both striatum. Levodopa was started, with partial improvement of symptoms. In 2018, she developed dysphagia, associated with slight alterations in phonation. In 2019, in addition to the left lower limb tremor and bradykinesia, the patient developed limb paresis, also affecting the right upper limb, with proximal atrophy and fasciculations. Added to the therapeutic regimen pramipexole, without improvement in symptoms. Over the months the case progressed with axial weakness, the need for a wheelchair for walking. Patient hospitalized in April 2020, electroneuromyography performed which showed signs of active disinvervation in the bulbar, cervical, thoracic and lumbosacral segments and signs of chronic disinervation in the cervical and lumbosacral segments, with no signs of sensory or motor polyneuropathy. Such findings suggest impairment of the Lower motor neuron, and can be found in the Diseases of the Motor Neuron. With the diagnosis of ALS, Riluzole was started, with a reduction in the speed of disease progression. Conclusions: the reported case draws attention to the importance of always thinking about differential diagnoses in neurological diseases. We should always look for new symptoms, so that more rare diseases do not go unnoticed.