GENERAL PARALYSIS OF INSANE

GENERAL PARALYSIS OF INSANE

(Dementia Paralytica, GPI)

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This disease occurs ten to fifteen years after the primary syphilitic infection although it may occur earlier. It is mostly seen in males. First symptom usually appears near about 50 years.

PATHOLOGY

The anterior two-third of the cerebral cortex becomes atrophic. There may be compensatory hydrocephalus, glial proliferation, degeneration of neurons and lymphocytic infiltration. Spirochaete may be present.

CLINICAL FEATURES

Onset-Insidious

Defect of emotional control is the earliest manifestation. The patient becomes moody, excitable and is easily moved by sense of sorrow. Change of personality is most striking. He gives up his old interests and adheres to new ones.Gradually progressive dementia of various types develops. There may be delusion of grandeur (grandiose form). Patient boasts of his physical power and wealth or social position but classical delusions of grandeur are uncommon now-a-days. In simple dementing type he gradually becomes forgetful, inattentive and careless to the surrounding, personal appearance and money. Depressive, agitated and maniacal symptoms may also develop. Ultimately patient becomes bed-ridden, incontinent and dirty.

The first physical sign along with mental changes is fine tremor. This is very characteristic of this disease and consists of irregular fine wavy movements of lips, tongue and fingers. The typical tongue tremor consists of forward and backward movements of the organ which is called trombone tremor. Gradually tremor is so much pronounced that patient can neither speak nor write. Irregularity of articulation (dysarthria) is pronounced and a slurring or spastic speech develops. There may be difficulty in naming objects and echolalia may be seen.

Epileptiform convulsion occurs in about 50 per cent of cases, when the patient becomes unconscious and hemiparesis develops. Apart from transitory hemiplegia, aphasia, apraxia and hemianopia are also seen. This is called congestive attack of GPI.

Pupilary abnormalities are found even at an early stage and of the nature of Argyll-Robertson’s pupil though not in its complete form. Optic atophy may develop. Gradually signs of pyramidal mischief, e.g. extensor plantar response and exaggerated tendon jerks also develop. Incontinence of urine and faeces may be seen. In course of time patient becomes impotent. When GPI is associated with tabes, tendon reflexes may be lost and the condition is called Taboparesis.

INVESTIGATIONS

Blood and CSF show positive VDRL test, in 100 per cent of cases. FTA-ABS Test is also positive. CSF in addition shows increased lymphocytes, increased protein particularly globulin. Lange’s colloidal gold test shows paretic curve.

DIFFERENTIAL DIAGNOSIS

This disease should be differentiated from cerebral tumour, cerebral meningovascular syphilis, cerebral arteriosclerosis, alcoholism, presenile and senile dementias.