The Internet represents a huge resource for medical information and communication, available to both doctors and patients. 1 There are numerous Web sites with information relating to Parkinson's disease (PD). 2 Some concerns have been expressed about the possible misuse of these resources for self-(mis)diagnosis, inappropriate treatment, and self-harm, but these instances are probably rare. [3][4][5] I report another Internet-related hazard relevant to neurological illness.
A 42-year-old man was diagnosed with idiopathic PD, based on a 2-year history of slowing down, unilateral rest tremor, and micrographia. Examination findings included monotonic hypophonia, hypomimia, limb rigidity, and rest tremor. Past medical history included an episode of depression 3 years before symptom onset. PD was treated with the dopamine agonist pergolide (this predated concerns about possible pergolide-related valvulopathy 6 ), titrated up to 1 mg t.d.s., with unequivocal clinical benefit in speech, tremor, and walking. Over the following 2 years, gait difficulties and hypokinesia gradually progressed, which required the introduction of levodopa and escalation of the pergolide dose.
Shortly after increasing the pergolide dose to 5 mg/day, a new problem arose. According to his wife, the patient began to stay up late at night gambling on various Internet sites. This behavior was completely out of character, as previously he had never been interested in gambling. He also downloaded and subscribed to various Internet services, including a pornographic channel, which he did not then use. He charged services to both his and his wife's credit cards. When the problem first came to light, he and his wife were unwilling to stop pergolide because of its beneficial clinical effects, but were persuaded to try pramipexole; this drug was associated with limiting side effects, and he requested restarting pergolide. Echocardiographic monitoring was normal.
Gambling symptoms continued intermittently over a 3-year period, during which time all his betting activity was accessed through the Internet. The final straw was an episode when he failed to return from a shopping trip one evening; he was found "frozen" (immobile) the following morning, having spent all his money at a betting shop. It was now agreed that pergolide should be stopped. There was some decline in the patient's mobility requiring higher L-dopa dosage, but this increase was deemed acceptable as there was concurrent cessation of gambling behavior. In all, debts in the region of Β£15,000 had accrued.
Pathological gambling is a rare but recognized complication associated with dopamine agonist use in patients with Parkinson's disease. [7][8][9] Modes of gambling behavior reported include visiting casinos and betting shops, using fruit machines, or purchasing scratch cards, each patient tending to use one main mode of gambling. 8,9 As shown by this case, Internet-based gambling should be added to this list. Only one prior report of a PD patient receiving dopamine agonist therapy (pramipexole), gambling, and losing heavily on the Internet has been identified (Ref. 9, Case 5). Increasing home availability of the Internet 4 may make such cases more frequent. Vigilance may be needed in at-risk PD patients (male, young, comorbid psychiatric disorders or history thereof) commencing with, or increasing the dose of, a dopamine agonist.