Clinical Reasoning: A 57-year-old man with subacute gait difficulty and hand tremor

Paliwal, Vimal Kumar; Uniyal, Ravi; Neyaz, Zafar; Agarwal, Vikas

doi:10.1212/wnl.0000000000003102

Cited by 1 publication

(4 citation statements)

References 6 publications

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“…There is also a lack of clear understanding of the mechanism of parkinsonism in HP. Intracranial calcifications, hypocalcaemia and ischaemia to the basal ganglia (speculated to be a result of vascular calcification) are all potential causes of parkinsonism in HP 10 15 19. Walter reported a case similar to ours in which the patient had chronic HP with basal ganglia calcification and presented with neuromuscular irritability and parkinsonism.…”

Section: Discussionsupporting

confidence: 66%

“…The most common causes of early-onset subacute to chronic parkinsonism include drugs (dopamine receptor blockers); encephalitides such as Japanese encephalitis and West Nile encephalitis; toxins (methanol poisoning, 1-methyl-4-phenyl-1,2,3,6-terahydropyridine, ethylene oxide or organophosphates); major alcohol withdrawal; pontine and extra pontine myelinolysis; metabolic disorders (Wilson disease, haemochromatosis, endocrinopathies such as HP); neurodegenerative disorders such as neurodegeneration with brain iron accumulation, mitochondrial disorders and Huntington chorea. Also, neuroleptic malignant syndrome and catatonia can have rigidity 10. Our patient had no history of exposure to harmful toxins or drugs, and he has chronic psychiatric issues requiring dopamine receptor blockers.…”

Section: Differential Diagnosismentioning

confidence: 84%

“…His exercise-induced extrapyramidal motor symptoms improved when he corrected his hypocalcaemia 15. In addition, parkinsonism due to striatal calcification is rare and is linked to a poor response to levodopa treatment 10 15 19…”

Section: Discussionmentioning

confidence: 99%

“…Elevated CPK in our patient may have been caused by hypocalcaemia-related seizures and increased muscular activity, which was alleviated by normocalcaemia. Few case reports have noted comparable clinical situations in which individuals with idiopathic HP presented with neuromuscular irritability and increased CPK, which resolved on treatment of hypocalcaemia 10 15…”

Section: Differential Diagnosismentioning

confidence: 99%

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Severe hypocalcaemia episodes in a patient of primary hypoparathyroidism precipitated by underlying stress due to haemophagocytic lymphohistiocytosis (HLH) secondary to pulmonary tuberculosis

et al. 2023

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A man in his 20s who had previously experienced multiple episodes of transient loss of consciousness, majorly attributable to the seizures, presented with a 1-month history of increased seizure frequency, high-grade fever and weight loss. Clinically, he had postural instability, bradykinesia and symmetrical cogwheel rigidity. His investigations revealed hypocalcaemia, hyperphosphataemia, inappropriately normal intact parathyroid hormone, metabolic alkalosis, normomagnesemic magnesium depletion, and increased plasma renin activity and serum aldosterone concentration. CT scan of the brain revealed symmetrical calcification of the basal ganglia. The patient had primary hypoparathyroidism (HP). A similar presentation of his brother indicated a genetic cause, most likely autosomal dominant hypocalcaemia with Bartter’s syndrome type 5. The patient’s fever was caused by underlying haemophagocytic lymphohistiocytosis secondary to pulmonary tuberculosis, which triggered acute episodes of hypocalcaemia. This case represents a complex interplay of a multifaceted relationship between primary HP, vitamin D deficiency and an acute stressor.

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Section: Discussionsupporting

confidence: 66%

Section: Differential Diagnosismentioning

confidence: 84%