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Neurology

Volume 54 . Number 9 . May 09, 2000

Copyright © 2000 American Academy of Neurology

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Correspondence

Cardiac uptake of [123 I]MIBG separates PD from multiple system atrophy

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To the Editor:

I read with interest the article by Braune et al. [1] reporting on the

usefulness of myocardial MIBG scintigraphy for diagnosing PD. We studied the

cardiac uptake of MIBG in multiple system atrophy (MSA), [2] and have

reported on the usefulness of myocardial MIBG scintigraphy in

differentiating PD from other akinetic rigid syndromes. [3] [4]

I am concerned about the relatively small number of patients on which Braune

et al. base their conclusions. Sisson et al. [5] and Yoshita et al. [2] [3]

[4] reported a reduced cardiac accumulation of MIBG in patients with MSA. In

our study, some MSA patients with orthostatic hypotension (OH) were observed

to have reduced cardiac MIBG accumulation, especially in the delayed phase

(3-4 hours after MIBG injection), with no correlation between the heart to

mediastinum ratio and the disease duration. [2] Braune et al. studied only

five patients with MSA, upon which they based their conclusions that cardiac

MIBG scintigraphy is useful in the differentiation of PD from MSA. [1] We

believe that it is inappropriate to draw such a conclusion from the

observation of so few MSA patients. Although we agree that cardiac MIBG

scintigraphy is useful in differentiating PD from MSA, based on our own

experience, [2] [3] [4] Braune et al. should explain the discrepancy between

their results and ours. When patients with parkinsonism and OH have reduced

cardiac MIBG accumulation, we must take great care to diagnose those

patients with PD.

Mitsuhiro Yoshita MD,

Fukui, Japan

References

1. Braune S, Reinhardt M, Schnitzer R, Riedel A, Lucking CH. Cardiac uptake

of [123 I]MIBG separates Parkinson's disease from multiple system atrophy.

Neurology 1999; 53: 1020-1025. full text

2. Yoshita M, Hayashi M, Hirai S. Iodine 123-labeled

meta-iodobenzylguanidine myocardial scintigraphy in the cases of idiopathic

Parkinson's disease, multiple system atrophy, and progressive supranuclear

palsy. Clin Neurol 1997; 37: 476-482.

3. Yoshita M, Hayashi M, Hirai S. Differential diagnosis of akinetic rigid

syndromes using iodine-123 meta-iodobenzylguanidine myocardial scintigraphy.

Mov Disord 1997; 12 (suppl 1):54.

4. Yoshita M. Differentiation of idiopathic Parkinson's disease from

striatonigral degeneration and progressive supranuclear palsy using

iodine-123 metaiodobenzylguanidine myocardial scintigraphy. J Neurol Sci

1998; 155: 60-67. abstract

5. Sisson JC, Shapiro B, Meyers I, et al. Metaiodobenzylguanidine to map

scintigraphically the adrenergic nervous system in man. J Nucl Med 1987; 28:

1625-1636. abstract

6. Yoshita M, Hayashi M, Hirai S. Decreased myocardial accumulation of 123

I-meta-iodobenzyl guanidine in Parkinson's disease. Nucl Med Commun 1998;

19: 137-142. abstract

7. Braune S, Reinhardt M, Bathmann J, Krause T, Lehmann M, Lucking CH.

Impaired cardiac uptake of meta[123 I]iodobenzylguanidine in Parkinson's

disease and autonomic failure. Acta Neurol Scand 1998; 97: 307-314.

abstract

8. Satoh A, Serita T, Seto M, et al. Loss of 123 I-MIBG uptake by the heart

in Parkinson's disease: assessment of cardiac denervation and diagnostic

value. J Nucl Med 1999; 40: 371-375. abstract

9. Brefel-Courbon C, Courbon F, Thalamas C, et al. Myocardial

meta-[123I]iodobenzylguanidine (MIBG) uptake is different in Parkinson's

disease and multiple system atrophy with autonomic failure. Clin Autonom Res

1999; 9: 285.

10. Sobue I, Senda Y, Hirayama K, et al. Clinical pharmacological evaluation

of L-threo-3,4-dihydroxyphenylserine (L-DOPS) in Shy-Drager's syndrome and

related diseases. A nation-wide double-blind comparative study. Jpn J Clin

Exp Med 1987; 141: 353-378.

11. Gasiner B, Roisin MP, Scherman D, et al. Uptake of

metaiodobenzylguanidine by bovine chromaffin granules membranes. Mol

Pharmacol 1985; 29: 275-280.

12. Solanki KK, Bomanji J, Moyes J, et al. A pharmacological guide to

medicines which interfere with the biodistribution of radiolabelled

meta-iodobenzylguanidine (MIBG). Nucl Med Commun 1992; 13: 513-521.

abstract

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Neurology

Volume 54 . Number 9 . May 09, 2000

Copyright © 2000 American Academy of Neurology

----------------------------------------------------------------------------

----

Correspondence

Cardiac uptake of [123 I]MIBG separates PD from multiple system atrophy

----------------------------------------------------------------------------

----

Reply from the Authors:

We appreciate Dr. Yoshita's comments regarding our article on the different

cardiac MIBG uptake in patients with idiopathic PD (IPD) and MSA, [1]

because they provide the opportunity to highlight some of the problems and

pitfalls in this field. Unequivocal evidence has accumulated from several

groups with a total of more than 100 patients that cardiac MIBG uptake is

grossly reduced in IPD independent of parkinsonian medication, duration of

disease, and clinical evidence of autonomic failure. [1] [2] [3] [4] [6] [7]

[8] [9] From what we observe in the literature, between 45 and 50 patients

with MSA have been investigated with MIBG scintigraphy. [1] [2] [3] [4] [5]

[9] The definite number is difficult to obtain because there is probably an

overlap between some of the populations. [2] [3] [4] In addition to one

patient in an early article by Sisson et al., [5] Yoshita et al. [2] [3] [4]

reported a small subgroup of patients diagnosed with MSA who showed a

reduced cardiac uptake of MIBG. All of these patients were classified as

having MSA subtype of striatonigral degeneration or of Shy-Drager-syndrome.

Both entities are clinically characterized by predominant parkinsonian

features and are frequently difficult to separate from IPD in vivo. Most

reports did not include information about the diagnostic criteria, disease

course, and medication, [3] [5] or they were published in Japanese, [2]

which we are unfortunately not able to understand.

The three well-documented cases referred to by Yoshita [4] with probable MSA

and impaired cardiac MIBG uptake were taking droxidopa. This substance is

also known as L-threo-3,4-dihydroxyphenylserine, which is a precursor of

norepinephrine and therefore increases norepinephrine plasma levels. [10]

Norepinephrine and MIBG compete for the same active transport mechanism

across the neurosecretory vesicle membrane. [11] To avoid falsely reduced

MIBG uptake it is mandatory to withdraw sympathomimetics at least 24 hours

before MIBG administration. [12] The small number of patients with MSA and

reduced cardiac MIBG uptake is most likely explained by the inevitable

uncertainty in the differential diagnosis of parkinsonian syndromes and by

methodologic pitfalls when performing MIBG scintigraphy.

S. Braune MD, M. Reinhardt, MD,

Freiburg, Germany

References

1. Braune S, Reinhardt M, Schnitzer R, Riedel A, Lucking CH. Cardiac uptake

of [123 I]MIBG separates Parkinson's disease from multiple system atrophy.

Neurology 1999; 53: 1020-1025. full text

2. Yoshita M, Hayashi M, Hirai S. Iodine 123-labeled

meta-iodobenzylguanidine myocardial scintigraphy in the cases of idiopathic

Parkinson's disease, multiple system atrophy, and progressive supranuclear

palsy. Clin Neurol 1997; 37: 476-482.

3. Yoshita M, Hayashi M, Hirai S. Differential diagnosis of akinetic rigid

syndromes using iodine-123 meta-iodobenzylguanidine myocardial scintigraphy.

Mov Disord 1997; 12 (suppl 1):54.

4. Yoshita M. Differentiation of idiopathic Parkinson's disease from

striatonigral degeneration and progressive supranuclear palsy using

iodine-123 metaiodobenzylguanidine myocardial scintigraphy. J Neurol Sci

1998; 155: 60-67. abstract

5. Sisson JC, Shapiro B, Meyers I, et al. Metaiodobenzylguanidine to map

scintigraphically the adrenergic nervous system in man. J Nucl Med 1987; 28:

1625-1636. abstract

6. Yoshita M, Hayashi M, Hirai S. Decreased myocardial accumulation of 123

I-meta-iodobenzyl guanidine in Parkinson's disease. Nucl Med Commun 1998;

19: 137-142. abstract

7. Braune S, Reinhardt M, Bathmann J, Krause T, Lehmann M, Lucking CH.

Impaired cardiac uptake of meta[123 I]iodobenzylguanidine in Parkinson's

disease and autonomic failure. Acta Neurol Scand 1998; 97: 307-314.

abstract

8. Satoh A, Serita T, Seto M, et al. Loss of 123 I-MIBG uptake by the heart

in Parkinson's disease: assessment of cardiac denervation and diagnostic

value. J Nucl Med 1999; 40: 371-375. abstract

9. Brefel-Courbon C, Courbon F, Thalamas C, et al. Myocardial

meta-[123I]iodobenzylguanidine (MIBG) uptake is different in Parkinson's

disease and multiple system atrophy with autonomic failure. Clin Autonom Res

1999; 9: 285.

10. Sobue I, Senda Y, Hirayama K, et al. Clinical pharmacological evaluation

of L-threo-3,4-dihydroxyphenylserine (L-DOPS) in Shy-Drager's syndrome and

related diseases. A nation-wide double-blind comparative study. Jpn J Clin

Exp Med 1987; 141: 353-378.

11. Gasiner B, Roisin MP, Scherman D, et al. Uptake of

metaiodobenzylguanidine by bovine chromaffin granules membranes. Mol

Pharmacol 1985; 29: 275-280.

12. Solanki KK, Bomanji J, Moyes J, et al. A pharmacological guide to

medicines which interfere with the biodistribution of radiolabelled

meta-iodobenzylguanidine (MIBG). Nucl Med Commun 1992; 13: 513-521.

abstract

----------------------------------------------------------------------------

----

MD Consult L.L.C. http://www.mdconsult.com

Bookmark URL:

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