a 42 year old gentleman presented with rest tremors , bradykinesia and rigidity for 10 years .
he responded very well to the treatment [ updrs scale ( off 40 , on 24 ) ] .
after three years of onset of the disease , family members noticed that while walking he was having lateral flexion of trunk and was leaning on left side ( see video ) .
along with this he also developed striatal hand ( figure 1 ) . during supine position
x - rays whole spine , mri brain and paraspinal electromyography ( emg ) were normal .
this patient of pd was diagnosed to have pisa syndrome due to lateral flexion and axial dystonia on standing which used to completely improve in supine position .
pisa syndrome is a combination of lateral deviation of spine and corresponding tendency to lean on one side.3 exact pathogenesis of ps is still not known .
it is believed that cholinergic excess in patients of ad receiving cholinesterase inhibitor cause ps . in patients of pd
it may be possible that striatal dopamine deficiency or imbalance in dopaminergic - cholinergic level is responsible for ps.4 this imbalance seems to be asymmetrical and is responsible for the lateral flexion on one side .
our patient also had significant improvement in lateral flexion on standing during on period , however striatal hand symptoms showed no response to levodopa / carbidopa .
it has been described that pd subjects in advanced stage of disease ( hy iii & iv ) have more postural abnormality and striatal deformities while our patient manifested in early part of disease ( hy iib).3 dopa agonists and amantidine has been tried with variable response .
neurosurgical interventions like pallidotomy and deep brain stimulation has also been tried in 13 subjects with good results.5
 pisa syndrome is ( ps ) usually seen in patients receiving antipsychotic drugs and characterised by lateral flexion of trunk and axial dystonia . 
 it is believed that antipsychotic drugs lead to dopamine blockage causing ps . 
 we describe a parkinson s disease patient who was doing well with levodopa / carbidopa for 3 years and developed lateral flexion of trunk . his abnormal posture used to completely improve upon lying down position . 
 he also had striatal hand deformity suggestive of focal dystonia . 
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Discussion