Basal ganglia infarction as a possible cause of cervical dystonia

The functional anatomy of dystonia: Recent developments

While dystonia has traditionally been viewed as a disorder of the basal ganglia, the involvement of other key brain structures is now accepted. However, just what these structures are remains to be defined. Neuroimaging has been an especially valuable tool in dystonia, yet traditional cross-sectional designs have not been able to separate causal from compensatory brain activity. Therefore, this chapter discusses recent studies using causal brain lesions, and animal models, to converge upon the brain regions responsible for dystonia with increasing precision. This evidence strongly implicates the basal ganglia, thalamus, brainstem, cerebellum, and somatosensory cortex, yet shows that different types of dystonia involve different nodes of this brain network. Nearly all of these nodes fall within the recently identified two-way networks connecting the basal ganglia and cerebellum, suggesting dysfunction of these specific pathways. Localisation of the functional anatomy of dystonia has strong implications for targeted treatment options, such as deep brain stimulation, and non-invasive brain stimulation.

Unilateral pallidothalamic tractotomy at Forel's field H1 for cervical dystonia

Background

Neurosurgical ablation of Forel's field H1 for cervical dystonia, which is currently abandoned, was formerly used in the 1960s–1970s. Regardless of the lack of neuroimaging modalities and objective evaluation scales, the reported efficacy was significant. Although recent studies have reappraised the ablation of the pallidothalamic tract at Forel's field H1 for Parkinson's disease, the efficacy for cervical dystonia has not been investigated well.

Methods

Data of 35 patients with cervical dystonia who underwent unilateral pallidothalamic tractotomy at Forel's field H1 were retrospectively analyzed. The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) scores, the neck score of the Burke–Fahn–Marsden Dystonia Rating Scale (BFMDRS), and adverse events were evaluated preoperatively and at the last available follow‐up period.

Results

The mean clinical follow‐up period was 13.9 ± 6.5 months. The mean TWSTRS total scores were 34.3 ± 14.0 preoperatively and 18.4 ± 16.5 at the last available follow‐up period (46.4% improvement, p < 0.0001). The BFMDRS neck score also improved significantly from 6.2 ± 2.9 preoperatively to 2.8 ± 2.8 at the last available follow‐up period (55.0% improvement on the neck score, p < 0.0001). Reduced hand dexterity in seven patients, hypophonia in five patients, dysarthria in four patients, and executive dysfunction in one patient were confirmed as adverse events at the last available follow‐up evaluation. One patient had postoperative hemorrhage.

Conclusion

The current study confirmed significant improvement in TWSTRS total scores and BFMDRS neck scores at the 13.9‐month follow‐up after unilateral pallidothalamic tractotomy. The pallidothalamic tract in Forel's field H1 is expected to be an alternative treatment target for cervical dystonia.

Network localization of cervical dystonia based on causal brain lesions

Cervical dystonia is a neurological disorder characterized by sustained, involuntary movements of the head and neck. Most cases of cervical dystonia are idiopathic, with no obvious cause, yet some cases are acquired, secondary to focal brain lesions. These latter cases are valuable as they establish a causal link between neuroanatomy and resultant symptoms, lending insight into the brain regions causing cervical dystonia and possible treatment targets. However, lesions causing cervical dystonia can occur in multiple different brain locations, leaving localization unclear. Here, we use a technique termed 'lesion network mapping', which uses connectome data from a large cohort of healthy subjects (resting state functional MRI, n = 1000) to test whether lesion locations causing cervical dystonia map to a common brain network. We then test whether this network, derived from brain lesions, is abnormal in patients with idiopathic cervical dystonia (n = 39) versus matched controls (n = 37). A systematic literature search identified 25 cases of lesion-induced cervical dystonia. Lesion locations were heterogeneous, with lesions scattered throughout the cerebellum, brainstem, and basal ganglia. However, these heterogeneous lesion locations were all part of a single functionally connected brain network. Positive connectivity to the cerebellum and negative connectivity to the somatosensory cortex were specific markers for cervical dystonia compared to lesions causing other neurological symptoms. Connectivity with these two regions defined a single brain network that encompassed the heterogeneous lesion locations causing cervical dystonia. These cerebellar and somatosensory regions also showed abnormal connectivity in patients with idiopathic cervical dystonia. Finally, the most effective deep brain stimulation sites for treating dystonia were connected to these same cerebellar and somatosensory regions identified using lesion network mapping. These results lend insight into the causal neuroanatomical substrate of cervical dystonia, demonstrate convergence across idiopathic and acquired dystonia, and identify a network target for dystonia treatment.

Pedunculopontine Nucleus Cholinergic Deficiency in Cervical Dystonia

BACKGROUND

The etiology of cervical dystonia is unknown. Cholinergic abnormalities have been identified in dystonia animal models and human imaging studies. Some animal models have cholinergic neuronal loss in the striatum and increased acetylcholinesterase activity in the pedunculopontine nucleus.

OBJECTIVES

The objective of this study was to determine the presence of cholinergic abnormalities in the putamen and pedunculopontine nucleus in cervical dystonia human brain donors.

METHODS

Formalin-fixed brain tissues were obtained from 8 cervical dystonia and 7 age-matched control brains (controls). Pedunculopontine nucleus was available in only 6 cervical dystonia and 5 controls. Neurodegeneration was evaluated pathologically in the putamen, pedunculopontine nucleus, and other regions. Cholinergic neurons were detected using choline acetyltransferase immunohistochemistry in the putamen and pedunculopontine nucleus. Putaminal cholinergic neurons were quantified. A total of 6 cervical dystonia patients and 6 age-matched healthy controls underwent diffusion tensor imaging to determine if there were white matter microstructural abnormalities around the pedunculopontine nucleus.

RESULTS

Decreased or absent choline acetyltransferase staining was identified in all 6 pedunculopontine nucleus samples in cervical dystonia. In contrast, strong choline acetyltransferase staining was present in 4 of 5 pedunculopontine nucleus controls. There were no differences in pedunculopontine nucleus diffusion tensor imaging between cervical dystonia and healthy controls. There was no difference in numbers of putaminal cholinergic neurons between cervical dystonia and controls.

CONCLUSIONS

Our findings suggest that pedunculopontine nucleus choline acetyltransferase deficiency represents a functional cholinergic deficit in cervical dystonia. Structural lesions and confounding neurodegenerative processes were excluded by absence of neuronal loss, gliosis, diffusion tensor imaging abnormalities, and beta-amyloid, tau, and alpha-synuclein pathologies. © 2018 International Parkinson and Movement Disorder Society.

Cervical dystonia caused by focal putaminal ischemia

We describe a 48-year-old woman with putaminal gliosis and a sphenoid wing meningioma at the left, who developed dystonia restricted to cervical regions. We propose the following causal chain: the meningioma led to an occlusion of a lenticulo-striatal branch of the middle cerebral artery that caused ventral putaminal ischemia and finally resulting in symptomatic dystonia. The previously reported relevance of the infarcted regions to the pathophysiology of dystonia supports this assumption. Implications for the diagnostic procedure of dystonia will be discussed.

Reversible dropped head syndrome after hemispheric striatal infarction

We report a rare case of transient "dropped head syndrome" (DHS) after acute ischemic stroke. A 64-year-old man noticed a sudden onset of mild weakness in his left hand and also difficulty in preventing his head from dropping onto his chest without weakness of the neck extensor muscles. Magnetic resonance images showed acute ischemic changes at the right putamen and caudate nucleus. Surface electromyography (EMG) performed 3 days after the stroke showed that both trapeziuses were hypertonic at rest, whereas the activity of the sternocleidomastoids was gradually increased on passive head lifting, indicating dystonia of the neck muscles. His dropped head fully improved by 9 days after the stroke. Re-examination by surface EMG 30 days after the stroke showed no hypertonic activity in the neck muscles. DHS is characterized by an abnormal ante-fixed posture of the neck, usually observed in patients with neurodegenerative disorders such as multiple system atrophy and Parkinson disease. This is the first case of reversible DHS after acute ischemic stroke, and the accumulation of similar cases will be important to elucidate the mechanisms underlying the development of DHS and stroke-associated movement disorders.

Systemic diseases that cause movement disorders

The present review is aimed at providing practical assistance to the clinical neurologist in reaching a diagnosis, understanding the pathogenic mechanisms of movement disorders associated with systemic diseases, and determining appropriate therapy. Infectious disease by direct effect or as an acquired autoimmune neurological disease, stroke, hypoxia-ischemia, paraneoplastic syndromes, collagen disorders, endocrine, liver and kidney diseases that may cause hypokinetic or hyperkinetic abnormal movement are considered separately. The type and evolution of abnormal movement caused by systemic disease vary with age and underlying pathology. Therapy for abnormal movements should include a primary treatment for the systemic disease.

Post-stroke movement disorders: report of 56 patients

BACKGROUND

Although movement disorders that occur following a stroke have long been recognised in short series of patients, their frequency and clinical and imaging features have not been reported in large series of patients with stroke.

METHODS

We reviewed consecutive patients with involuntary abnormal movements (IAMs) following a stroke who were included in the Eugenio Espejo Hospital Stroke Registry and they were followed up for at least one year after the onset of the IAM. We determined the clinical features, topographical correlations, and pathophysiological implications of the IAMs.

RESULTS

Of 1500 patients with stroke 56 developed movement disorders up to one year after the stroke. Patients with chorea were older and the patients with dystonia were younger than the patients with other IAMs. In patients with isolated vascular lesions without IAMs, surface lesions prevailed but patients with deep vascular lesions showed a higher probability of developing abnormal movements. One year after onset of the IAMs, 12 patients (21.4%) completely improved their abnormal movements, 38 patients (67.8%) partially improved, four did not improve (7.1%), and two patients with chorea died. In the nested case-control analysis, the patients with IAMs displayed a higher frequency of deep lesions (63% v 33%; OR 3.38, 95% CI 1.64 to 6.99, p<0.001). Patients with deep haemorrhagic lesions showed a higher probability of developing IAMs (OR 4.8, 95% CI 0.8 to 36.6).

CONCLUSIONS

Chorea is the commonest movement disorder following stroke and appears in older patients. Involuntary movements tend to persist despite the functional recovery of motor deficit. Deep vascular lesions are more frequent in patients with movement disorders.

Dystonia in AIDS: report of four cases

Dystonia is a rare complication of acquired immune deficiency syndrome (AIDS). We report four such cases related to three different causes. Cases 1 and 2 both developed dystonia secondary to biopsy-proven progressive multifocal leukoencephalopathy. One had left arm dystonia, whereas the other had bilateral upper limb dystonia. One patient had associated akinesia and rigidity. Imaging demonstrated frontal and/or parietal white matter lesions but no basal ganglia abnormalities. Case 3 developed hemidystonia and cervical dystonia from biopsy-proven toxoplasmosis with a lesion in the thalamus. Case 4 suffered from AIDS dementia complex and developed cervical dystonia while taking risperidone therapy. We also review previously reported cases of dystonia in AIDS patients with the same causes and discuss the issue of increased vulnerability of the basal ganglia to HIV infection which, in turn, leads to increased sensitivity to neuroleptics. When dystonia is seen in AIDS patients, its pattern may be a clue to the ultimate cause.

Secondary cervical dystonia associated with structural lesions of the central nervous system

We tested the hypothesis that structural lesions of the central nervous system (CNS) associated with cervical dystonia more commonly involve the cerebellum and its primary afferent pathways than basal ganglia structures. Cervical dystonia is the most common focal dystonia, the majority of cases are idiopathic, and only a small percentage of patients have a family history of dystonia or other movement disorders. Pathophysiological mechanisms operative in solely or predominantly appendicular dystonias such as writer's cramp and Oppenheim's dystonia, respectively, may not be directly applicable to axial dystonias. The localization of structural lesions of the CNS associated with secondary cervical dystonia may provide some insight into the neural structures potentially involved in primary cervical dystonia. The National Library of Medicine Gateway (from 1960) and a clinical database maintained by the senior author (from 1999) were searched for cases of secondary cervical dystonia associated with structural lesions of the CNS. Search terms included one or more of the following: dystonia, torticollis, cervical, secondary, and symptomatic. Lesion localization and type, patient age, patient gender, head position, occurrence of sensory tricks, and associated neurological findings were tabulated for each case. Structural lesions associated with cervical dystonia were most commonly localized to the brainstem and cerebellum. The remaining cases were equally divided between the cervical spinal cord and basal ganglia. Although inconsistent, head rotation tended to be contralateral to lesion localization. Additional neurological abnormalities were present in the majority of patients with secondary cervical dystonia. The relative paucity of basal ganglia pathology and concentration of lesions in the brainstem, cerebellum, and cervical spinal cord in patients with secondary cervical dystonia suggests that dysfunction of cerebellar afferent pathways may be important to the pathophysiology of primary cervical dystonia.

[Clinico-pathomorphologic correlations in patients with symptomatic dystonias]

Symptomatic dystonia can be the result of various metabolic, degenerative diseases, the consumption of certain medications or exposure to toxic agents. However, only symptomatic dystonia with focal structural lesion provides a significant "window" for, at least indirect, perception of aetiopathogenesis and pathomorphological substratum of idiopathic dystonia. Our study included 57 patients with symptomatic dystonia, which as a base had focal or multifocal lesions, of whom 7 patients had generalized dystonia, 18 hemidystonia, 6 segmental dystonia, 7 torticollis, 6 blepharospasm, 7 hand dystonia, 3 spasmodic dysphonia, and 3 had oromandibular dystonia. Stroke was highly statistically the most frequent cause of structural lesions (33/57 or 58%). Relevant pathomorphological changes were present in 50/57 (88%) patients, of whom 25 (50%) had lesion in the lenticular nucleus (including individual damage of the putamen and globus pallidus), 12/50 (24%) had damage of the thalamus and 6/50 (12%) had damage of the brainstem. Generalized dystonia was most frequently associated with bilateral lesion of the putamen, hemidystonia with lesion of contralateral putamen, torticollis with damage of the caudate nucleus, hand dystonia with lesion of the thalamus and blepharospasm with lesion of the upper brainstem.

Meige syndrome secondary to basal ganglia injury: a potential cause of acute respiratory distress

BACKGROUND

Meige syndrome is a movement disorder that includes blepharospasm and oromandibular dystonias. Its etiology may be idiopathic (primary) or it may arise secondary to focal brain injury. Acute respiratory distress as a feature of such dystonias occurs infrequently. A review of the literature on Meige syndrome and the relationship between dystonias and respiratory compromise is presented.

METHODS

A 60-year-old woman suffered a cerebral anoxic event secondary to manual strangulation. She developed progressive blepharospasm combined with oromandibular and cervical dystonias. Neuroimaging demonstrated bilateral damage localized to the globus pallidus. Years later, she presented to the emergency department in intermittent respiratory distress associated with facial and cervical muscle spasms.

RESULTS

Increasing frequency and severity of the disorder was noted over years. The acute onset of respiratory involvement required intubation and eventual tracheotomy. A partial therapeutic benefit of tetrabenazine was demonstrated.

CONCLUSION

This case highlights two interesting aspects of Meige's syndrome: (1) Focal bilateral basal ganglia lesions appear to be responsible for this patient's movement disorder which is consistent with relative overactivity of the direct pathway from striatum to globus pallidus internal and substantia nigra pars reticularis; (2) Respiratory involvement in a primarily craniofacial dystonia to the point of acute airway compromise.

To test or not? The value of diagnostic tests in cervical dystonia

It has long been suspected that idiopathic cervical dystonia is result of a dysfunction of the brain, but the cause of the disease has been elusive. The purpose of this study was to determine the diagnostical value of different radiological and laboratory tests in cases of cervical dystonia. Cerebral computer tomography and/or cerebral magnetic imaging were carried out in all of the 149 patients who were included in this study. A total of 25 scans revealed some minor findings that did not alter patients' management. Of the 128 cervical plain x-ray examinations, 63.1% showed degenerative changes. Cerebrospinal fluid (CSF) was examined in 125 patients, and was normal in 103. Some degree of pathology was found in the remaining 22 CSF samples. All patients under the age of 50 years were tested for serum ceruloplasmin and no decreased level was found. Seven patients had elevated ANA titre; four of them also developed Botulinum toxin antibodies. We can conclude that the detection rate of pathologic findings in patients with idiopathic cervical dystonia is similar to what we can expect in the general population, provided the neurological findings are normal apart from the involuntary movements. In the adult form of typical cervical dystonia we do not recommend any standard laboratory or imaging tests if the neurological examination is normal aside from the abnormal head movements.

Lateralization of the P22/N30 precentral cortical component of the median nerve somatosensory evoked potentials is different in patients with a tonic or tremulous form of cervical dystonia

Somatosensory evoked potentials (SEPs) of the median nerve were recorded in 40 patients with the tonic and tremulous form of torticollis and in 40 healthy volunteers. Polymyographic recordings of the activity of cervical muscles were performed in all patients with cervical dystonia to determine the dystonic and antagonistic muscles. Patient SEPs were recorded during abnormal head movement. SEPs in 20 healthy volunteers were recorded with the head in the middle position. SEPs in another 20 healthy volunteers were recorded with the head rotated 60 degrees to the right. The mean peak-to-peak amplitude values of the precentral P22/N30 and the postcentral N20/P25 complexes and their mean side-to-side ratios were calculated in the F3 (F4), C3' (C4'), and C3+ (C4+) electrode positions in all four groups. In patients with the tonic form of torticollis (group I), an apparent mean P22/N30 amplitude increase was found above the hemisphere contralateral to the direction of head deviation in both precentral electrode positions, F3(4) and C3(4)'. A statistically significant difference was observed between group I and other patient and control groups. In patients with the tremulous form of torticollis (group II), an increase in the mean P22/N30 amplitude was found above both hemispheres in both precentral electrode positions F3(4) and C3(4)'; a significant difference was found between group II and both control groups. Lateralization of the P22/N30 component was found only in patients with the tonic form of torticollis. The mean side-to-side ratio of the precentral P22/N30 component amplitude was significantly different when group I was compared with either group II or control groups. No significant difference between group II and either control group was found. No significant abnormalities in the postcentral N20/P25 component were found in either the dystonic patients or in healthy control subjects. These results might indicate a different pattern of cortex excitability in patients with tonic versus tremulous forms of torticollis and therefore may implicate different underlying pathophysiological mechanisms in these two forms of disorder.

Clinical comparison of tardive and idiopathic cervical dystonia

It has been suggested that tardive cervical dystonia may be clinically indistinguishable from the idiopathic form and that the diagnosis rests solely on documenting an exposure to dopamine antagonist medications. To investigate this, we performed a retrospective evaluation of patient records on 102 patients with idiopathic and 20 patients with tardive cervical dystonia seen in our Movement Disorder Clinic over the past 8 years. Several clinical and demographic variables were compared and a number of differences were observed. The presence of extracervical involvement, retrocollis, and spasmodic head movements were individually found to be predictive of tardive cervical dystonia. Torticollis, laterocollis, and trick maneuvers were predictive of idiopathic cervical dystonia. Head tremor (42.2%) and family history of dystonia (9.8%) were present only in the idiopathic group. Cervical muscle hypertrophy was significantly more common in the idiopathic group (100% versus 75%). No difference was found between the two groups in their response to treatment with botulinum toxin A. These results indicate that clinical differences between idiopathic and tardive cervical dystonia exist. These differences may help to distinguish them in the clinical setting, improve diagnostic accuracy, and support the existence of a causal relationship between exposure to dopamine antagonist medications and chronic dystonia.

Mosaic pattern of gliosis in the neostriatum of a North American man with craniocervical dystonia and parkinsonism

We present the case of a 51-year-old patient with a 31-year history of psychiatric symptoms, craniocervical dystonia, bulbar dysfunction, and parkinsonism. His dystonic movements included blepharospasm, jaw opening and lingual dystonia, and spasmodic retrocollis. Psychiatric symptoms included psychosis and depression, with onset years before the movement disorder. After his death by aspiration, examination of his brain revealed abnormalities limited to the neostriatum. Staining of brain sections, including Holzer, glial fibrillary acidic protein, and immunohistochemical stain for calbindin D28k, revealed the presence of a mosaic pattern of gliosis with neuronal loss (sparing large neurons) within this region. The islands of tissue between stands of gliosis had a normal appearance. This patient represents only the fourth case (and first North American born) with a mosaic pattern of gliosis in the neostriatum. The clinical and pathologic features were similar in all four cases except that our patient was the first with prominent psychiatric symptoms and a more stable, less progressive course. Mosaicism has been described in the X-linked Filipino disorder Lubag. Occurrence in non-Filipino patients, such as ours, suggest that either Lubag can develop in non-Filipino families or that mosaicism is a nonspecific pathologic finding in some patients with idiopathic dystonia. Finally, our case reports the notion that craniocervical dystonia may result from neostriatal dysfunction.

Lateralization of the P22/N30 component of somatosensory evoked potentials of the median nerve in patients with cervical dystonia

Somatosensory evoked potentials (SEPs) of the median nerve were recorded in 40 patients suffering from cervical dystonia and in 40 healthy volunteers as a control. Before recording the median nerve SEPs, polymyographic recordings were performed in all patients with cervical dystonia. The activity of cervical muscles was recorded, and the leading muscle of cervical dystonia was determined. Patients were divided into two groups according to the results of polymyography. The leading muscle was sternocleidomastoid in the first group and the splenius capitis in the second group. Patient SEPs were recorded during abnormal head rotation. SEPs in 20 healthy volunteers were recorded with the head in the middle position. SEPs of another 20 healthy volunteers were recorded with the head rotated 60 degrees to the right. The mean peak-to-peak amplitude values of the precentral P22/N30 complex and the mean ratio of the P22/N30 amplitudes between both hemispheres were calculated in the F3 (F4) and C3' (C4') electrode positions in all four groups. No significant lateralization of the precentral P22/ N30 component was found in either group of healthy volunteers. In dystonic patients in whom the sternocleidomastoid was determined as the leading muscle of dystonia, a statistically significant lateralization of the P22/N30 component toward the ipsilateral side of the leading muscle was found. In the group with the splenius capitis determined as the leading muscle of dystonia, a statistically significant lateralization of the P22/N30 component toward the contralateral side of the leading muscle was found. The possibility that the precentral cortex is activated differently in cervical dystonia patients who have different muscle patterns of dystonia is discussed.

Symptomatic dystonias associated with structural brain lesions: report of 16 cases

BACKGROUND

Symptomatic (secondary) dystonias associated isolated lesions in the brain provide insight into etiopathogenesis of the idiopathic form of dystonia and are a basis for establishing the possible correlation between the anatomy of a lesion and the type of dystonia according to muscles affected.

METHODS

In 358 patients with differently distributed dystonias, a group of 16 patients (4.5%) was encountered in whom dystonia was associated with focal brain lesions.

RESULTS

Of the 16 patients, 3 patients had generalized, 3 segmental and 4 hemidystonia, while the remaining 6 patients had focal dystonia. The most frequent etiologies were infarction in 7, and tumor in 4 patients. These lesions were usually found in the lenticular and caudate nucleus, thalamus, and in the case of blepharospasm in the upper brainstem.

CONCLUSIONS

Our results support the suggestion that dystonia is caused by a dysfunction of the basal ganglia.

Infraputaminal 'lacunes'. Clinical and pathological correlations

BACKGROUND AND PURPOSE

Single, oval lesions greater than 5 mm in diameter lying inferior to the lateral putamen (infraputaminal lacunes [IPLs]) seen on CT or MR images are commonly reported as lacunar infarcts. To determine the clinical relevance and underlying pathology of IPLs, we evaluated the imaging appearances, clinical features, vascular risk factors, and histopathology in patients with IPLs.

METHODS

Consecutive MR scans were reviewed for the presence of IPLs. Serial patients seen in routine clinical practice with IPLs were also included. Vascular risk factors were obtained from a prescan questionnaire. Histology and microangiography were performed on postmortem material. A MEDLINE search for putaminal infarcts was performed to look for imaging lesions typical of IPLs.

RESULTS

Three of 100 serial MR scans had IPLs (3%). Nine other patients with in vivo (7) or postmortem (2) MR scans had IPLs. No neurological symptoms could be related to the IPLs. There were no differences in age, hypertension, diabetes, or presence of cortical enlarged perivascular spaces (EPVSs) between patients with and without IPLs. Unlike infarcts, IPLs were isointense with the cerebrospinal fluid on proton density MR sequences. Histological correlation of three MR scans showed IPLs to be a single large EPVS, situated lateral to the anterior commissure. IPLs were located at a point where multiple lenticulostriates turn sharply dorsally. An IPL was the probable cause of the apparent infarct in six publications from peer-reviewed literature that linked different clinical signs to putaminal infarct.

CONCLUSIONS

IPLs are EPVSs that can be differentiated from infarcts on proton density MR images.

Reversible parkinsonism and dystonia following probable mycoplasma pneumoniae infection

Infectious disease is a rare cause of parkinsonism. We report a 7-year-old boy who developed flu-like symptoms followed by parkinsonian features including hypophonia, hypomimia, bradykinesia, and dystonia. A T2-weighted brain magnetic resonance imaging showed high signal intensities in both basal ganglia. The results of serial serologic tests of Mycoplasma pneumonia antibody suggest that this movement disorder was associated with Mycoplasma pneumonia infection. The patient's symptoms gradually resolved, and the basal ganglionic lesions disappeared on follow-up magnetic resonance imaging.