Systemic diseases that cause movement disorders

Dancing Out of Step: A Case of Tuberculous Meningitis Presenting as Childhood Chorea

Background

Acute to subacute pediatric movement disorders require prompt diagnosis to identify potentially treatable diseases.

Case Report

We present a 6-year-old male with a three-week history of generalized chorea transitioning to predominantly right-sided hemichorea and then to left hemiplegia.

Discussion

We review the mechanisms in tuberculous meningitis underlying his movement abnormalities.

Assessment and Treatment of Abnormal Involuntary Movements: A Clinically Focused Narrative Review

LEARNING OBJECTIVES

After participating in this CME activity, the psychiatrist should be better able to:• Categorize and describe different types of abnormal involuntary movements (AIMs).• Identify assessment tools and treatment options for AIMs.

ABSTRACT

Abnormal involuntary movements (AIMs) comprise a diverse group of movement disorders characterized by uncontrolled and unintended movements (e.g., tremors, tics, dystonia). AIMs can occur at any stage of life and pose significant challenges for clinicians. It is difficult to determine their underlying causes due to the complex neurobiological mechanisms involved. Therefore, it is crucial to quantify the severity and progression of AIMs using well-validated measurement scales, such as the Abnormal Involuntary Movement Scale (AIMS). By employing reliable assessment approaches, clinicians can objectively evaluate the motoric manifestations of AIMs and track them over time. Treatment of AIMs varies depending on their nature and etiology. While AIMs often respond to treatment, serious side effects can undermine treatment efficacy. In this clinically focused narrative review, we categorize different types of AIMs and discuss their neurobiological aspects. Further, we emphasize the importance of using well-validated measurement scales for accurate assessment and discuss available treatment modalities that target the specific AIMs manifestations. Additionally, we cover the need for comprehensive care to address the multifaceted nature of AIMs, accounting for their physical manifestations as well as their psychological, social, and functional toll on patients. By embracing a multidisciplinary approach, health care professionals can provide patient-centered care that promotes overall well-being and enhances the lives of patients coping with AIMs. Regular follow-up assessments are necessary to monitor treatment response, adjust medications when needed, and provide ongoing support for individuals affected by AIMs.

Overview of management of infection-related movement disorders with focus on specific-infections

Infections are important treatable causes of secondary movement disorders (MD) that can have heterogeneous presentations. According to various studies, infection-related movement disorders (IRMD) account for around 10-20% of secondary MD. Certain infections have a predilection for causing various MD, and some MD phenomenologies, such as acute cerebellar ataxia and opsoclonus-myoclonus-ataxia syndromes (OMAS), suggest a strong possibility of an underlying infectious cause. The underlying pathophysiology is multifaceted, including direct neuronal damage due to neurotropism, granulomas, abscesses causing structural damage, and inflammatory and autoimmune responses triggered by infections. Understanding the prevalence, spectrum, and pattern of these IRMD and common infections that are responsible helps in early diagnosis, and instituting appropriate, timely treatment, thereby improving the overall prognosis and avoiding unnecessary investigations. In this review, we aim to provide a brief overview of common infections associated with MD, common clinical presentations of IRMD, their underlying pathophysiology, and overall approach to their treatment, with a focus on specific treatments of prevalent and treatable IRMD.

Neurocysticercosis and movement disorders: A literature review

Neurocysticercosis (NCC) is a specific form of cysticercosis that affects the central nervous system. It is caused by the tapeworm Taenia solium, which is often found in pigs. NCC is considered one of the “great simulator/mimickers” of other diseases. In this context, movement disorders (MDs) can occur in a small percentage of individuals with NCC. This review aims to evaluate the clinicoepidemiological profile, pathological mechanisms, and historical features of NCC-associated MD. Relevant reports in six databases were identified and assessed by two reviewers without language restriction. A total of 71 reports containing 148 individuals who developed an MD related to NCC were identified. NCC-associated MD included parkinsonism (n = 47), ataxia (n = 32), chorea (n = 18), dystonia (n = 13), tremor (n = 8), myokymia (n = 6), myoclonus (n = 4), ballism (n = 1), tics (n = 1), and others (n = 18). The mean and median ages were 36.58 (standard deviation: 20.51) and 35 years (age range: 1–88 years), respectively. There was a slight predominance of female sex (52.17%). On follow-up, 58.90% of the individuals had a full recovery; two deaths were reported. We believe that the majority of cases reported were only diagnosed because patients had classical clinical manifestations generally investigated by neuroimaging, resulting in incidental findings suggestive of NCC, which were later supported by laboratory examinations. Therefore, the association between NCC and MD is probably underreported. Clinicians should be wary of this association, mainly in endemic areas for cysticercosis.

A case of bilateral thalamic infarct complicating tuberculous meningoencephalitis

Ischemic stroke can result from multiple etiologies. It can also be a complication of tuberculous meningoencephalitis and determine its outcome. stroke secondary to tuberculous meningoencephalitis, occurs in 30% cases in the basal ganglia region, unusually in the thalamus. The mechanism of stroke in this condition is vasculitis. We report an unusual case of bilateral thalamic infarcts complicating tuberculous meningoencephalitis. Ischemic stroke in tuberculous meningoencephalitis is unpredictable with poor prognosis despite antituberculous drug treatment, emphasising the importance of primary prevention, particularly in tuberculosis endemic areas.

Erratic movement disorders disclosing Graves' disease and paralleling thyroid function but not autoantibody levels

Graves’ disease (GD) is an autoimmune pathology characterized by hyperthyroidism and the presence of specific anti-thyroid antibodies. Neurological symptoms such as seizures, cognitive impairment, and tremor can be observed during the course of GD, but more complex movement disorders such as chorea and myoclonus are less frequent. The mechanisms underlying movement disorders in GD are not fully understood. While some authors relate movement disorders to thyroid dysfunction, others claim an autoimmune origin. We herein report a case involving a 60-year-old woman who presented with erratic, intricate movement disorders for which a medical workup revealed GD. During the 2-year follow-up period, her neurological symptoms evolved in parallel with her thyroid function, but not with her autoimmune anti-thyroid antibody level. Her neurological symptoms completely disappeared when she became euthyroid. We herein discuss the complicated clinicobiological relationship between thyroid function and movement disorders. This relationship involves several factors, including the impact of radioactive treatment. The present case emphasizes the importance of including thyroid function screening in the workup of unexplained movement disorders.

Parkinsonism and other movement disorders in 23 cases of neurocysticercosis

INTRODUCTION

Parkinsonism and other movement disorders have been occasionally described in neurocysticercosis (NCC) but their clinical features and pathogenesis are not well understood.

METHODS

This is a descriptive study conducted over 20 years. We studied 590 consecutive patients from the NCC Registry at Eugenio Espejo Hospital, Quito, Ecuador, and found 23 subjects who developed movement disorders. We investigated the clinical features, localization of brain lesions, severity of infection and neurological deficit as well as the outcome of the patients. Patients were treated with albendazole, dexamethasone, acetazolamide and surgery. We established the diagnosis of NCC, by absolute, imaging and clinical/exposure criteria.

RESULTS

Fifteen patients had parkinsonism, 5 tremor, 2 dystonia and 1 chorea. Patients with chorea and dystonia were young females and had cystic lesions in the thalamus and putamen, respectively. Parkinsonism was more frequent in middle aged subjects with subarachnoid and ventricular cysts, hydrocephalus, brain cysts and frequently abnormal cerebrospinal fluid. After anthelmintic treatment no patient died and all patients with chorea, dystonia and tremor fully recovered; 7 of the 15 patients with parkinsonism required treatment with steroids, surgery and long term l-DOPA therapy.

CONCLUSIONS

Chorea and dystonia in NCC are due to selective lesions of the basal ganglia. Parkinsonism, the most common movement disorder in NCC, is not related to specific localization of the lesions but the patients show widespread and large lesions, associated with inflammation and distortions of brain structures. In patients with NCC, chorea, dystonia, tremor have a better prognosis, Parkinsonism has a worse one.

Abnormal movements in critical care patients with brain injury: a diagnostic approach

Abnormal movements are frequently encountered in patients with brain injury hospitalized in intensive care units (ICUs), yet characterization of these movements and their underlying pathophysiology is difficult due to the comatose or uncooperative state of the patient. In addition, the available diagnostic approaches are largely derived from outpatients with neurodegenerative or developmental disorders frequently encountered in the outpatient setting, thereby limiting the applicability to inpatients with acute brain injuries. Thus, we reviewed the available literature regarding abnormal movements encountered in acutely ill patients with brain injuries. We classified the brain injury into the following categories: anoxic, vascular, infectious, inflammatory, traumatic, toxic-metabolic, tumor-related and seizures. Then, we identified the abnormal movements seen in each category as well as their epidemiologic, semiologic and clinicopathologic correlates. We propose a practical paradigm that can be applied at the bedside for diagnosing abnormal movements in the ICU. This model seeks to classify observed abnormal movements in light of various patient-specific factors. It begins with classifying the patient’s level of consciousness. Then, it integrates the frequency and type of each movement with the availability of ancillary diagnostic tests and the specific etiology of brain injury.

Scrub typhus mimicking Parkinson's disease

Background

Scrub typhus is a re-emerging infection in Sri Lanka. It often poses a diagnostic challenge and tends to present as a febrile illness of uncertain origin. Undiagnosed illness may progress to serious multi-systemic complications. Here we report a case of scrub typhus presenting with features of Parkinsonism.

Case presentation

A 62-year-old previously healthy Sri Lankan native male from the Western province of Sri Lanka presented with high fever with malaise, myalgia and arthralgia for 17 days. On the 5th day of illness he developed intermittent resting tremor in his right arm and leg associated with stiffness, difficulty in carrying out normal work and difficulty in smiling. He denied similar previous episodes. There were no other associated neurological manifestations. Clinical examination revealed a high amplitude low frequency resting tremor in his right hand, a mask-like face and increased muscle tone limited to the right side with normal reflexes. The rest of the system examination was normal except for an eschar over the abdomen. His investigations revealed lymphocytic leukocytosis, high erythrocyte sedimentation rate and immunofluorescence assay-IgM and IgG against Orientia tsutsugamushi Karp antigen were positive with rising titers. With oral doxycycline and azithromycin his fever settled within 48 h and a complete recovery of Parkinson’s features was observed within 2 weeks.

Conclusion

Doctors practicing in endemic regions should be familiar with delayed clinical manifestations of scrub typhus and should carefully look for an eschar in order to avoid delay in the diagnosis.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1428-x) contains supplementary material, which is available to authorized users.

Movement disorders in systemic diseases

Movement disorders, classically involving dysfunction of the basal ganglia commonly occur in neurodegenerative and structural brain disorders. At times, however, movement disorders can be the initial manifestation of a systemic disease. In this article we discuss the most common movement disorders which may present in infectious, autoimmune, paraneoplastic, metabolic and endocrine diseases. Management often has to be multidisciplinary involving primary care physicians, neurologists, allied health professionals including nurses, occupational therapists and less frequently neurosurgeons. Recognizing and treating the underlying systemic disease is important in order to improve the neurological symptoms.

Scrub typhus associated with transient parkinsonism and myoclonus

Parkinsonism with myoclonus is rarely associated with infectious disease in adults. We present a 55-year-old man experiencing acute onset bilateral limb tremor, rigidity, and myoclonus with small-stepped gait, and skin rash involving the trunk and limbs, after a fever. Serum was positive for anti-Orientia tsutsugamushi immunoglobulin M antibody. Brain MRI revealed no abnormalities. The fever improved with oral doxycycline, and the parkinsonism and myoclonus improved with amantadine and clonazepam. This is a rare case of parkinsonism with myolonus associated with scrub typhus infection.

Movement disorders in autoimmune diseases

Movement disorders have been known to be associated with a variety of autoimmune diseases, including Sydenham's chorea, pediatric autoimmune neuropsychiatric disorders associated with streptococcus, systemic lupus erythematosus, antiphospholipid syndrome, gluten sensitivity, paraneoplastic and autoimmune encephalopathies. Tremors, dystonia, chorea, ballism, myoclonus, parkinsonism, and ataxia may be the initial and even the only presentation of these autoimmune diseases. Although antibodies directed against various cellular components of the central nervous system have been implicated, the pathogenic mechanisms of these autoimmune movement disorders have not yet been fully elucidated. Clinical recognition of these autoimmune movement disorders is critically important as many improve with immunotherapy or dietary modifications, particularly when diagnosed early. We discuss here the clinical features, pathogenic mechanisms, and treatments of movement disorders associated with autoimmune diseases, based on our own experience and on a systematic review of the literature.

Benign hereditary chorea: an update

Benign hereditary chorea (BHC, MIM 118700) is a rare autosomal dominant disorder manifesting with chorea in conjunction with hypothyroidism and respiratory problems, a triad also named "brain-lung-thyroid syndrome". BHC is characterized by childhood onset with minimal or no progression into adult life and normal cognitive function. The genetic basis of BHC has been partially resolved, when mutations in the TTF1 gene on chromosome 14q13 encoding the thyroid transcription factor-1 have been identified in a number of BHC patients, suggesting that aberration of TTF1 transcriptional function or haploinsufficiency is associated with this disorder. TTF1 (also known as TITF1, TEBP or NKX2-1), belonging to the NKX2 homeodomain transcription factor family, has been implicated in several important molecular pathways essential for brain, thyroid and lung morphogenesis. Clinical evaluation of TTF1 gene mutations carrier patients exposed the involvement of each of the triad's components characterized by heterogeneity between index cases and even within families. This review highlights the current updates on expanded clinical aspects of BHC, imaging and treatment experience, its genetic markers, proposed molecular mechanisms, animal models and link to cancer.

Self-remitting and reversible parkinsonism associated with neuro-Sweet disease

We describe a 72-year-old man who developed subacute onset parkinsonism caused by neuro-Sweet disease (NSD). Magnetic resonance imaging of this patient's brain suggested inflammation of the bilateral basal ganglia and amygdalae. Clinical symptoms and MRI findings gradually improved without medication. However, his parkinsonism recurred one month after discharge from the hospital, at which time he was treated with corticosteroids, resulting in improvement again. His clinical course and human leukocyte antigen typing suggested that he was suffering from NSD. This case is the first report of NSD presenting with self-remitting and reversible parkinsonism.