Clinical Reasoning: A 69-Year-Old Female Patient With Rapid-Onset Levodopa-Responsive Rest Tremor, Parkinsonism, and Gait Freezing

The evaluation of rapid-onset parkinsonism can be challenging, and the differential diagnosis encompasses a broad spectrum of etiology, management, and prognosis. We present a 69-year-old patient who developed rapid-onset resting tremor and parkinsonism with gait freezing. Her upper limb resting tremor began unilaterally but rapidly progressed to involve the contralateral limb and subsequently the lower limbs. This evolved within 3 months to also include generalized parkinsonism and a shuffling gait with prominent freezing and frequent falls. Her tremor was levodopa responsive; however, other symptoms were resistant to treatment. Through this case, we will demonstrate the diagnostic approach to rapid-onset parkinsonism, summarizing a comprehensive evaluation of history, examination, and investigations. Readers will consider atypical features revealed by examination and investigations, ultimately arriving at a conclusive and critical diagnosis not to be missed in the presentation of parkinsonism.