Cirrhosis presenting as Parkinsonism

Noone, Mohan Leslie; Kumar, VG Pradeep; Ummer, K; Achambat, Laila; Salam, KA

doi:10.4103/0972-2327.42938

Cited by 11 publications

(6 citation statements)

References 7 publications

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“…The symptoms include hypermanganesemia, polycythemia, dystonia, chronic hepatic disease, cirrhosis, motor neuropathy, and behavioral disturbances with differing severity (70). These symptoms have a large overlap with patients with PD; some studies have even found an increased occurrence of Parkinsonism with sufferers of cirrhosis (up to 21%) (35, 201). Consistent with this idea, patients presenting with Parkinsonian symptoms who have decreased ability to excrete biliary Mn 2+ suffer from Mn 2+ -induced neurotoxicity (1, 35).…”

Section: Manganese Neuronal Healthmentioning

confidence: 99%

Manganese Is Essential for Neuronal Health

et al. 2015

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The understanding of manganese (Mn) biology, in particular its cellular regulation and role in neurological disease, is an area of expanding interest. Mn is an essential micronutrient that is required for the activity of a diverse set of enzymatic proteins (e.g., arginase and glutamine synthase). Although necessary for life, Mn is toxic in excess. Thus, maintaining appropriate levels of intracellular Mn is critical. Unlike other essential metals, cell-level homeostatic mechanisms of Mn have not been identified. In this review, we discuss common forms of Mn exposure, absorption, and transport via regulated uptake/exchange at the gut and blood-brain barrier and via biliary excretion. We present the current understanding of cellular uptake and efflux as well as subcellular storage and transport of Mn. In addition, we highlight the Mn-dependent and Mn-responsive pathways implicated in the growing evidence of its role in Parkinson's disease and Huntington's disease. We conclude with suggestions for future focuses of Mn health-related research.

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Section: Manganese Neuronal Healthmentioning

confidence: 99%

Manganese Is Essential for Neuronal Health

et al. 2015

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“…In a case report by Noone et al ., two patients who presented with slowly progressive Parkinsonism were subsequently diagnosed to have cirrhosis based on subtle abnormalities in liver function tests and MRI findings. [ 5 ] In all reports of Parkinsonism in liver disease, except one, Parkinsonism was slowly progressive. In a case report by Pendlebury et al ., a similar stroke-like presentation with dysarthria, dysphagia and difficulty in walking was reported in a 17-year-old boy who was subsequently diagnosed to have Wilson's disease.…”

Section: Discussionmentioning

confidence: 99%

Acute stroke-like presentation of acquired hepatocerebral degeneration

Smita

Gafoor

Saifudheen

et al. 2014

Ann Indian Acad Neurol

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Neurological manifestations in liver diseases have been well-described. Parkinsonism developing in cirrhotic patients is a unique clinical, neuroradiological, and biological entity. The symptoms are often insidious in onset and occur after liver disease has made its presentation. Acute dysarthria as the presenting manifestation of cirrhosis is rare. Here we report three cases where liver disease made an unusual presentation as acute dysarthria. In all cases the abruptness of the onset prompted the treating physicians to make a diagnosis of stroke. The computed tomography (CT) scans of all these patients did not show any evidence of stroke. This was followed by magnetic resonance imaging (MRI) which showed the characteristic symmetric high-signal intensities in globus pallidus and substantia nigra in T1-weighted images, a reflection of increased tissue concentrations of manganese that helped in making a retrospective diagnosis of liver disease, confirmed later by altered serum albumin to globulin ratios and altered liver echo texture in ultra sonogram.

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“…It is associated with poor survival and a high recurrence rate unless the underlying cause is successfully treated (Vilstrup et al, 2014). In a middle-aged patient with a rapid onset of symmetric Parkinsonism, hepato-cerebral Parkinsonism should be suspected (Noone et al, 2008). In the literature, the reported prevalence rate ranges from as low as 3.5 -4.2% to as high as 21.6% (Burkhard et al, 2003;Tryc et al, 2013;Kang et al, 2011).…”

Section: Case Presentationmentioning

confidence: 99%

“…In the literature, the reported prevalence rate ranges from as low as 3.5 -4.2% to as high as 21.6% (Burkhard et al, 2003;Tryc et al, 2013;Kang et al, 2011). Global hypokinesia and gait impairment are early Parkinsonian symptoms in cirrhosis, whereas dementia and resting tremors are uncommon symptoms (Noone et al, 2008).…”

Section: Case Presentationmentioning

confidence: 99%

“…Excess manganese within the brain is believed to be the cause of T1 weighted image (T1WI) hyperintensity on magnetic resonance imaging (MRI), which can be seen affecting bilateral globus pallidi and substantia nigra, which explains Parkinsonian manifestation (Noone et al, 2008;Rovira et al, 2008;McPhail et al, 2012). It coincided with autopsied brain tissue, where it affects the post-synaptic dopamine D2 binding sites, associated with high levels of manganese (Spahr et al, 1996).…”

Section: Case Presentationmentioning

confidence: 99%

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Parkinson’s mimicker in Acute and Chronic Hepatic Encephalopathy

Mohamad Shahrunizam Awang Setia,

Mohamad Izzat Arslan Che Ros,

Nurul Hafidzah Rahim

et al. 2023

BJMS

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Hepatic encephalopathy (HE) is a neuropsychiatric spectrum mainly caused by cirrhosis, portosystemic shunt, or portal hypertension. It may also mimic the presentation of Parkinson’s disease, which can make clinical diagnosis a challenge. A 42-year-old man with underlying chronic hepatitis C with liver cirrhosis was initially admitted for chronic lower back pain. During admission, he appeared drowsy but was able to answer questions appropriately albeit with delayed and slow speech. He had bradykinesia without stigmata of chronic liver disease. Differentials at the time were hypoactive delirium and Parkinson’s disease. Blood results were normal. Magnetic resonance imaging (MRI) of the brain showed bilateral symmetrical hyperintensities at the inferior temporal lobes, medial thalamus, cingulate gyri, head of caudate nuclei, posterior limbs of internal capsules and insula on fluid-attenuated inversion recovery (FLAIR) sequence. On the T1 weighted imaging (T1WI) sequence, bilateral symmetrical hyperintensities were seen at globus pallidi, cerebral peduncles and periaqueductal regions extending to superior cerebellar peduncles. Based on imaging, a diagnosis of acute chronic hepatic encephalopathy was made. The patient was treated conservatively in the ward and was discharged with persistent Parkinsonism. In patients with neurological abnormalities where hepatic encephalopathy (HE) is least expected due to subtle symptoms, MRI could play an important role in eliciting the underlying cause, and extent of disease and for prognostication.

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Cirrhosis presenting as Parkinsonism

Cited by 11 publications

References 7 publications

Manganese Is Essential for Neuronal Health

Manganese Is Essential for Neuronal Health

Acute stroke-like presentation of acquired hepatocerebral degeneration

Parkinson’s mimicker in Acute and Chronic Hepatic Encephalopathy

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