Unusual kleptomania in a Parkinson’s disease patient treated with pramipexole: a case report

Case presentation: A 49-year-old male with Parkinson’s Disease (PD), diagnosed in 2017, initially presented with rigidity in the left upper limb, progressing to resting tremor in the same limb, later affecting the right upper limb and both lower limbs. He also reports chronic constipation, agitated sleep, festinating gait, difficulty swallowing, dysarthria, and various bodily pains. The patient was using Pramipexole 0.125 mg, Fluoxetine 20 mg, Clonazepam 2 mg, and Levodopa 800 mg daily. Initially, he was taking Pramipexole 0.125 mg three times a day. Due to nocturnal freezing and the short duration of Levodopa’s effect, the dose of Pramipexole was increased to 1 mg three times a day. Later, he reported taking 1.5 mg of Pramipexole three times a day, resulting in significant improvement in motor symptoms. At the most recent consultation, he was advised to reduce Pramipexole to 1.5 mg per day due to significant dyskinesias and compulsive behaviors. Other medications remained unchanged. During the evaluation, the patient reported compulsive behaviors related to Pramipexole. He mentioned an uncontrollable urge to take items from supermarkets, a behavior never exhibited before, causing concern for his wife. He reported taking multiple small items from the market that he did not need, just to satisfy this urge. He has no diagnosis of conduct disorder, bipolar disorder, or antisocial personality disorder. Discussion: Kleptomania is characterized by a recurrent failure to resist the impulse to steal objects not needed for personal use or monetary value, with tension before the act and pleasure or relief during the theft (DSM-IV TR). Dopamine agonists like pramipexole are effective in treating PD motor symptoms but can induce impulse control disorders (ICDs) such as pathological gambling, hypersexuality, and compulsive shopping. The pathogenesis of ICDs involves hyperactivation of the mesolimbic dopaminergic system associated with reward behavior and impulse control. Pramipexole, by excessively stimulating D3 dopamine receptors, can dysregulate these circuits, leading to compulsive behaviors. In this case, the patient developed an uncontrollable compulsion to take items from the market, leading to a reduction in the pramipexole dose. Studies show that ICDs induced by dopamine agonists are relatively common, with prevalence ranging from 6.1% to 14% in PD patients. However, kleptomania as a side effect of pramipexole use has been reported only three times in the international literature. Final comments: This case illustrates the complexity of managing Parkinson’s Disease, especially when medication side effects compromise the patient’s quality of life. Identifying kleptomania as a rare side effect of pramipexole is crucial for appropriate therapeutic adjustment. Continuous studies on the adverse effects of dopamine agonists and regular patient monitoring are essential to improve outcomes and quality of life for these individuals.