Smoking-induced transient motor deterioration in a levodopa-treated patient with Parkinson's disease

We report a 53-year-old patient with Parkinson's disease who complained of transient worsening of motor symptoms after smoking a tobacco cigarette. She had been a chronic smoker of one packet of cigarettes a day for over 20 years. We objectively assessed her motor performance including repetitive finger tapping (RFT) speed using 3D kinematic recordings, timed finger tapping test (TFT) and Unified Parkinson's Disease Rating Scale (UPDRS) III before and after the administration of nicotine, and with and without levodopa. Nicotine was delivered by either smoking a cigarette or by intranasal nicotine spray. Without levodopa, acute deterioration in RFT speed was observed 10 min after both routes of nicotine administration. With levodopa, there was acute deterioration in RFT speed after smoking cigarette, followed by a delayed rebound improvement. However, the administration of nicotine spray led to immediate and sustained motor improvement without initial deterioration. UPDRS III and TFT showed similar trends of acute motor deterioration after either smoking or use of the spray without intake of levodopa. Transient motor worsening after smoking tobacco has been previously reported in only one patient with Parkinson's disease. The objective findings of acute motor deterioration following both cigarette smoking and nicotine spray administration suggest that nicotine might be the cause of the negative motor effects in this patient. Similar changes were not observed after the administration of placebo intranasal spray. At low dose or beginning of dose, nicotine induces sub-threshold stimulation of dopamine release, which selectively activates the pre-synaptic D2 autoreceptors, leading to transient motor worsening. The potential mechanisms of the additive effect of levodopa and nicotine and paradoxical motor improvement after administration of high-dose nicotine via intranasal nicotine spray are also discussed.