Acute parkinsonism and bilateral basal ganglia lesions

Parkinsonismo agudo e lesão bilateral nos núcleos da base

A 58-year-old man with arterial hypertension and poorly controlled type 2 diabetes using glyburide/metformin presented a history of sudden slurred speech and gait disturbance eight days before clinical evaluation. Neurological examination disclosed dysarthria, postural instability and bradykinesia. Laboratory investigations demonstrated low glucose (24 mg/dL), elevated urea nitrogen (168 mg/dL) and creatinine (8 mg/dL) levels. Cranial computerized tomography revealed lentiform “fork sign” (Figures 1A and 1C).

Figure 1.
Axial and coronal cranial computerized tomography (A/C) - decreased density in bilateral lentiform nuclei surrounded by a more hypodense rim delineating them - fork-like structure. Cranial computerized tomography (B/D) - regression of lentiform nucleus lesions after three months.

Acute bilateral basal ganglia lesions syndrome is a rare complication of uremia, occurring typically in diabetic patients and characterized by acute parkinsonism and/or involuntary movements¹. The pathogenesis is unclear and potential causes include metabolic acidosis^1,2,3, uremic toxins^1,3, hemodynamic changes (hypotension/heart failure)³ and diabetes¹. In the case reported, hypoglycemia may be implicated as a triggering factor. The patient’s symptoms improved after hemodialysis.

References

• ¹
  Juryńczyk M, Rożniecki J, Zaleski K, Selmaj K. Hypoglicemia as a trigger for the syndrome of acute bilateral basal ganglia lesion in uremia. J Neurol Sci. 2010 Oct; 297(1-2):74-5. https://doi.org/10.1016/j.jns.2010.07.016
  » https://doi.org/https://doi.org/10.1016/j.jns.2010.07.016
• ²
  Fabiani G, Teive HA, Munhoz RP. Lentiform fork sign and fluctuating, reversible parkinsonism in a patient with uremic encephalopathy. Mov Disord 2013 Jul; 28(8):1053. https://doi.org/10.1002/mds.25503
  » https://doi.org/https://doi.org/10.1002/mds.25503
• ³
  Moreira RF, Barsottini OG, Pedroso JL. Lentiform “fork sign” and parkinsonism after acute myocardial infarction and cardiac failure. Mov Disord Clin Pract 2017 Feb; 4(4):646. https://doi.org/10.1002/mdc3.12482
  » https://doi.org/https://doi.org/10.1002/mdc3.12482

Publication Dates

• Publication in this collection
  25 Nov 2020
• Date of issue
  Dec 2020

History

• Reviewed
  05 Apr 2020
• Received
  13 June 2020
• Accepted
  16 June 2020