Alzheimer's disease: with Gerstmann syndrome and dressing apraxia
Presentation
60 year old right-handed male with 2 year history of progressive difficulty dressing, completing his basic ADLs and expressive dysphasia. Further examination revealed extensive inability to calculate, write, name his/examiner's finger, differentiate left and right, and brisk reflexes of the left limbs.
Patient Data
Global cortical atrophy with thinning of grey matter. Right side (e.g. parieto-occipital sulcus and occipital lobe) showed slightly greater atrophy than the left. Mild hippocampal atrophy.
Lateral parietal hypometabolism with extension to occipital and posterior temporal lobes. Right hypometabolism is more marked than left. Mild precuneus involvement bilaterally.
Case Discussion
This is a case of Alzheimer's disease with correlating findings in the parietal lobes. The parieto-occipito-temporal pattern in both the SPECT and MRI confirm the diagnosis.
Apraxia can present as the main presenting symptom of Alzheimer's disease. Apraxia occurs in multiple forms and seems to correlate with different area of the cortex. Dressing apraxia, as in the case demonstrated, has been associated with right inferior parietal and parieto-occipital lesions. Patients with this apraxia would have a great difficulty coordinating motor action to wear their clothes (e.g. backwards, inside out) and visuoconstructional deficits.
Gerstmann's Syndrome consists of difficulty calculating, writing, right-left disorientation and finger agnosia. While the syndrome is commonly associated with the left(dominant) inferior parietal lesion, the case demonstrated right-more-than-left pathology. The case demonstrated does not have a 'pure' form of Gerstmann as he presents concurrently with dysphasia.
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