Menkes disease: case report of an uncommon presentation with white matter lesions

Menkes kinky hair syndrome: a rare neurodegenerative disease

Menkes kinky hair disease is a rare X-linked recessive disease nearly exclusively affecting males who present at 2-3 months of age due to abnormal functioning of copper-dependent enzymes due to deficiency of copper. Here, we describe a completely worked-up case of a 4-month-old male infant with very typical history and radiological features confirmed by biochemical and trichoanalysis. The initially seen asymmetric cortical and subcortical T2 hyperintensities in cerebral and cerebellar hemispheres converted into symmetrical diffuse cerebral and predominantly cerebellar atrophy with uniform loss of both white and grey matter on follow-up MRI. Also, subdural hemorrhages of various sizes and different stages and tortuosity of larger proximal intracranial vessels with distal narrowing were identified. Ours is a completely worked-up proven case of Menkes kinky hair disease (MKHD) with history, electroencephalography, biochemical, trichoanalysis, and MRI findings. This is a good teaching case and shows importance of clinical examination and biochemistry as complimentary to MRI. Tortuous intracranial arteries with blocked major vessels are found only in this disease, thus stressing the value of MR Angiography in these patients.

Apparent diffusion coefficient restriction in the white matter: going beyond acute brain territorial ischemia

Background

Reduction of apparent diffusion coefficient (ADC) values in white matter is not always ischaemic in nature.

Methods

We retrospectively analysed our MRI records featuring reduced ADC values in the centrum semiovale without grey matter involvement or significant vasogenic oedema.

Results

Several conditions showed the aforementioned MR findings: moose-horn lesions on coronal images in X-linked Charcot-Marie-Tooth disease; small fronto-parietal lesions in Menkes disease; marked signal abnormalities in the myelinised regions in the acute neonatal form of maple syrup urine disease; strip-like involvement of the corpus callosum in glutaric aciduria type 1; persistent periventricular parieto-occipital abnormalities in phenylketonuria; diffuse signal abnormalities with necrotic evolution in global cerebral anoxia or after heroin vapour inhalation; almost completely reversible symmetric fronto-parietal lesions in methotrexate neurotoxicity; chain-like lesions in watershed ischaemia; splenium involvement that normalises in reversible splenial lesions or leads to gliosis in diffuse axonal injury.

Conclusion

Neuroradiologists must be familiar with these features, thereby preventing misdiagnosis and inappropriate management.

Unusual magnetic resonance imaging features in Menkes disease

We present a case of an inherited disorder of copper metabolism, Menkes disease in which MRI studies revealed the coexistence of T2 hypersignal in the temporal white matter with an increase of apparent diffusion coefficient indicative of vasogenic oedema combined with T2 hypersignal of the putamen and head of the caudate and decreased apparent diffusion coefficient indicative of cytotoxic oedema. These unusual MRI features emphasize the interest of newly developed techniques in early diagnosis in Menkes disease. The acute cerebral damage might result from the combined effects of acute metabolic stress due to infectious disease and prolonged status epilepticus, acting on a highly susceptible developing brain. Vasogenic oedema in the temporal white matter could be related to prolonged status epilepticus and vascular abnormalities. Cytotoxic oedema of the putamen and head caudate could result from energetic failure.

Menkes' disease: case report

Menkes’ disease is a rare neurodegenerative disorder due to an intracellular defect of a copper transport protein. We describe a 7 months male patient who presented with seizures, hypoactivity and absence of visual contact. The investigation disclosed pilli torti and thrycorrexis nodosa in the hair, low serum levels of both copper and ceruloplasmin, brain magnetic resonance study showed atrophy and white matter hypointensities on T1-weighted images, electroencephalogram reveals moderate background activity disorganization and epileptiform activity, and muscle biopsy with type 2 fiber atrophy. The clinical, laboratorial, genetic, muscle biopsy and neurophysiological findings in Menkes’ disease are discussed.

"From sheep to babe"--Menkes disease

A four-month-old boy presented with a new onset focal seizure lasting 18 minutes. During the seizure, his head and eyes were deviated to the left, and he assumed a fencing posture to the left with pursing of his lips. He had been unwell for one week, with episodes of poor feeding, during which he would become unresponsive, limp and stare for a few seconds. Developmentally he was delayed. He was not yet rolling, and he had only just begun to lift his head in prone position. He could grasp but was not reaching or bringing his hands together at the midline. He was cooing but not laughing. His past medical history was significant for term delivery with fetal distress and meconium staining. He was flat and blue at birth, with birth weight of 3.5 kg, and Apgar scores of 1 at one minute, 4 at 5 minutes, and 8 at 10 minutes. He required resuscitation with positive pressure ventilation for two minutes, and then had no further postnatal complications. Family history was remarkable for a paternal cousin with cortical malformation, epilepsy, and developmental delay. His mother and maternal grandmother had migraine headaches and fibromyalgia.