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Algahtani H, Algahtani O, Shirah B, Ahmed R, Ahmad A. Uremic parkinsonism with bilateral basal ganglia lesions: a puzzling syndrome with good outcome. Acta Neurol Belg 2024:10.1007/s13760-024-02475-3. [PMID: 38214882 DOI: 10.1007/s13760-024-02475-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/03/2024] [Indexed: 01/13/2024]
Affiliation(s)
| | - Omar Algahtani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Bader Shirah
- Department of Neuroscience, King Faisal Specialist Hospital & Research Centre, Jeddah, Saudi Arabia
| | - Raafat Ahmed
- Faculty of Medicine, Suez Canal University, Suez, Egypt
| | - Abdullah Ahmad
- College of Medicine, King Khalid University, Abha, Saudi Arabia
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Garcia Ruiz PJ, Feliz LD, Feliz CE, Sanchez IL, Fernandez AA, Kelly FB, Tiebas MJT, del Val J, Vinagre IN. The enduring enigma of sporadic chorea: A single center case series. Tremor Other Hyperkinet Mov (N Y) 2023; 13:33. [PMID: 37692071 PMCID: PMC10487123 DOI: 10.5334/tohm.800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 08/24/2023] [Indexed: 09/12/2023] Open
Abstract
Chorea can have a wide variety of causes including neurodegenerative, pharmacological, structural, metabolic, infectious, immunologic and paraneoplastic processes. We reviewed the clinical records of patients with apparently sporadic choreic movements and no relevant family history, who presented to our neurology department (Hospital Fundación Jimenez Diaz) between 1991 and 2022. We detected 38 cases of apparent sporadic chorea (ASC); Our analysis revealed 5 cases of genetic chorea (including 3 cases with Huntington's disease) while 6 cases were autoimmune/hematological; 6 drug-related chorea, 5 metabolic-vascular, 5 due to miscellaneous conditions and 4 were of mixed etiology. No clear etiology was identified in 8 cases. The differential diagnosis of ASC is extensive and challenging. Highlights Chorea can have a wide variety of genetic and sporadic causesWe reviewed the clinical records of patients with apparently sporadic chorea (ASC), who presented to our neurology department over the last 30 yearsWe detected 38 cases of apparent ASC; Our analysis revealed a wide array of different sporadic conditions and 5 cases of genetic choreaThe differential diagnosis of ASC is extensive and challenging.
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Affiliation(s)
| | - Lola Diaz Feliz
- Department of Neurology, Fundacion Jimenez Diaz, Madrid, Spain
| | - Cici E. Feliz
- Department of Neurology, Fundacion Jimenez Diaz, Madrid, Spain
| | | | | | | | | | - Javier del Val
- Department of Neurology, Fundacion Jimenez Diaz, Madrid, Spain
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Arora N, Mehdi Z, D’Cruz S, Sharma I. Orofacial Dyskinesia in Uremia in Polycystic Kidney Disease. J Emerg Trauma Shock 2023; 16:130-132. [PMID: 38025501 PMCID: PMC10661570 DOI: 10.4103/jets.jets_8_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/18/2023] [Accepted: 03/09/2023] [Indexed: 12/01/2023] Open
Abstract
Uremic encephalopathy presenting as involuntary movements of the orofacial region is important to recognize because of reversibility seen with resolution of azotaemia though residual neurological dysfunction might persist. Neuroimaging is important part of diagnosis with typical lesions involving basal ganglia seen mostly in diabetic patients. Our case highlights a patient with non-diabetic uremic encephalopathy with facial dyskinesia which is rare with a lesion in unilateral lentiform nucleus and small white matter hyperintensities. Resolution following dialysis pointed to uraemia as aetiology.
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Affiliation(s)
- Nidhi Arora
- Department of General Medicine, Government Medical College and Hospital, Chandigarh, India
| | - Zainab Mehdi
- Department of General Medicine, Government Medical College and Hospital, Chandigarh, India
| | - Sanjay D’Cruz
- Department of General Medicine, Government Medical College and Hospital, Chandigarh, India
| | - Isha Sharma
- Department of General Medicine, Government Medical College and Hospital, Chandigarh, India
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Ghoshal S. Renal and Electrolyte Disorders and the Nervous System. Continuum (Minneap Minn) 2023; 29:797-825. [PMID: 37341331 DOI: 10.1212/con.0000000000001286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE Neurologic complications are a major contributor to death and disability in patients with renal disease. Oxidative stress, endothelial dysfunction, accelerated arteriosclerosis, and uremic inflammatory milieu affect both the central and peripheral nervous systems. This article reviews the unique contributions of renal impairment to neurologic disorders and their common clinical manifestations as the prevalence of renal disease increases in a globally aging population. LATEST DEVELOPMENT Advances in the understanding of the pathophysiologic interplay between the kidneys and brain, also referred to as the kidney-brain axis, have led to more widespread recognition of associated changes in neurovascular dynamics, central nervous system acidification, and uremia-associated endothelial dysfunction and inflammation in the central and peripheral nervous systems. Acute kidney injury increases mortality in acute brain injury to nearly 5 times that seen in matched controls. Renal impairment and its associated increased risks of intracerebral hemorrhage and accelerated cognitive decline are developing fields. Dialysis-associated neurovascular injury is increasingly recognized in both continuous and intermittent forms of renal replacement therapy, and treatment strategies for its prevention are evolving. ESSENTIAL POINTS This article summarizes the effects of renal impairment on the central and peripheral nervous systems with special considerations in acute kidney injury, patients requiring dialysis, and conditions that affect both the renal and nervous systems.
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Zheng J, Sliem A, Magana S, Kapoor A. Hypoglycemia as a Cause of Reversible Recurrent Chorea in a Diabetic Uremic Patient: A Rare Presentation. Cureus 2023; 15:e39292. [PMID: 37346222 PMCID: PMC10281080 DOI: 10.7759/cureus.39292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2023] [Indexed: 06/23/2023] Open
Abstract
Chorea is characterized by involuntary, fidgety, dance-like movements caused by basal ganglia lesions. It has frequently been reported with hyperglycemia in diabetic patients, but not in association with hypoglycemia. We report on a diabetic male on hemodialysis who developed recurrent, acute, reversible choreiform movements associated with repeat episodes of hypoglycemia. Imaging was able to capture brain lesions corresponding to the acute episodes and the resolution of lesions between acute episodes.
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Affiliation(s)
- Jin Zheng
- Internal Medicine, Flushing Hospital Medical Center, New York, USA
| | - Ashraf Sliem
- Internal Medicine, Flushing Hospital Medical Center, New York, USA
| | - Sergio Magana
- Internal Medicine, Flushing Hospital Medical Center, New York, USA
| | - Anil Kapoor
- Neurology, Flushing Hospital Medical Center, New York, USA
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Cincotta MC, Walker RH. Diagnostic Uncertainties: Chorea. Semin Neurol 2023; 43:65-80. [PMID: 36882120 DOI: 10.1055/s-0043-1763506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Chorea is a hyperkinetic movement disorder with a multitude of potential etiologies, both acquired and inherited. Although the differential diagnosis for new-onset chorea is extensive, there are often clues in the history, exam, and basic testing that can help to narrow the options. Evaluation for treatable or reversible causes should take priority, as rapid diagnosis can lead to more favorable outcomes. While Huntington's disease is most common genetic cause of chorea, multiple phenocopies also exist and should be considered if Huntington gene testing is negative. The decision of what additional genetic testing to pursue should be based on both clinical and epidemiological factors. The following review provides an overview of the many possible etiologies as well as a practical approach for a patient presenting with new-onset chorea.
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Affiliation(s)
- Molly C Cincotta
- Department of Neurology, Temple University, Philadelphia, Pennsylvania
| | - Ruth H Walker
- Department of Neurology, James J. Peters Veterans Affairs Medical Center and Mount Sinai School of Medicine, Bronx, New York
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Sakurai T, Nishida H. Extrapyramidal syndromes of chronic kidney disease and dialysis (diabetic uremic syndrome) with reversible parkinsonism and lentiform fork sign: A case report and literature review including metformin-induced encephalopathy. Heliyon 2023; 9:e14255. [PMID: 36923829 PMCID: PMC10009720 DOI: 10.1016/j.heliyon.2023.e14255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 01/05/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Diabetic uremic syndrome has been rarely reported in patients on maintenance dialysis for diabetic nephropathy who present subacutely with neurological symptoms and bilateral basal ganglia lesions. There are also a few reports on metformin-induced encephalopathy, which is clinically similar to diabetic uremic syndrome. Because some patients with each of these diseases also have metabolic acidosis, it is speculated that these two diseases may have the same pathology. Recently, the term "extrapyramidal syndromes of chronic kidney disease and dialysis" (EPS-CKDD), with associated diagnostic criteria, has been proposed to describe these conditions, and metformin use is considered a risk factor for developing these syndromes. We report a case of a patient on maintenance hemodialysis for diabetic nephropathy who was taking metformin and developed subacute parkinsonism and bilateral basal ganglia lesions that rapidly improved after discontinuation of metformin with continued maintenance hemodialysis. We should ascertain whether patients with EPS-CKDD are taking metformin because it may be inappropriately prescribed for end-stage renal disease. If metformin has been prescribed, it should be discontinued immediately; its discontinuation may lead to rapid symptom recovery and improved prognosis.
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Affiliation(s)
- Takeo Sakurai
- Department of Neurology, Gifu Prefectural General Medical Center, Gifu 500-8717, Japan
| | - Hiroshi Nishida
- Department of Neurology, Gifu Prefectural General Medical Center, Gifu 500-8717, Japan
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Mahmood OA, Aliraqi MG, Ali AA. Movement Disorders in Chronic Kidney Disease Patients on Hemodialysis in Mosul City. Open Access Maced J Med Sci 2023. [DOI: 10.3889/oamjms.2023.11278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND: Movement disorders are not rare in patients with chronic kidney disease (CKD) on hemodialysis (HD). The prevalence and the exact mechanism of these disorders are unknown. Iron deficiency and dopamine dysregulation are implicated from one perspective, whereas chronic inflammation and calcium dysmetabolism may be involved from another perspective.
AIM: We studied the prevalence, delay in the diagnosis and the role of iron deficiency, inflammation, and bone abnormalities on some movement disorders in patients with CKD on HD.
METHODS: A cross-sectional study examined the prevalence, among patients with CKD on HD in Mosul city, of restless leg syndrome (RLS), periodic limb movement syndrome (PLMS), Parkinsonism, asterixis, and myoclonus. Delay in diagnosis of these disorders was also studied. Validated questionnaires and specified neurological examination were applied to define patients with these disorders. Using IBM® SPSS® v. 23 statistical software, we compared between the different groups of patients by different parameters (case–control design).
RESULTS: Among 281 enrolled CKD patients on HD in Mosul city, the prevalence of RLS, PLMS, Parkinsonism, asterixis, and myoclonus was 28.72%, 17.02%, 2.84%, 20.92%, and 24.11% respectively. Average delay in diagnoses was 2.6 (±3.09) years, 3.02 (±3.13) years, 1 (±0.78) year, 1.23 (±1.51) years, and 2.28 (±2.34) years, respectively. Median duration of dialysis in patients with PLMS and Parkinsonism tended to be higher than in those without PLMS or Parkinsonism. Neither inflammation, ferritin level nor bone dysmetabolism discriminated patients with CKD on HD with and without these movement disorders.
CONCLUSIONS: Movement disorders are prevalent in patients with CKD on HD. In Mosul city, there would be still delay in diagnosis and treatment of these movement disorders. The longer the duration on HD, the more frequent the PLMS and Parkinsonism cases.
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Yap KH, Baharudin NH, Gafor AHA, Remli R, Lim SY, Zaidi WAW, Azmin S, Mukari SAM, Khalid RA, Ibrahim NM. Movement Disorders Resulting From Bilateral Basal Ganglia Lesions in End-Stage Kidney Disease: A Systematic Review. J Mov Disord 2022; 15:258-263. [PMID: 35614016 PMCID: PMC9536908 DOI: 10.14802/jmd.21185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/19/2022] [Indexed: 12/02/2022] Open
Abstract
Objective The basal ganglia (BG) are susceptible to fluctuations in blood urea levels, sometimes resulting in movement disorders. We described patients with end-stage kidney disease (ESKD) presenting with movement disorders associated with bilateral BG lesions on imaging. Methods We report four patients and systematically reviewed all published cases of ESKD presenting with movement disorders and bilateral BG lesions (EBSCOhost and Ovid). Results Of the 72 patients identified, 55 (76.4%) were on regular dialysis. Parkinsonism was the most common movement disorder (n = 39; 54.2%), followed by chorea (n = 24; 33.3%). Diabetes mellitus (n = 51; 70.8%) and hypertension (n = 16; 22.2%) were the most common risk factors. Forty-three (59.7%) were of Asian ethnicity. Complete clinical resolution was reported in 17 (30.9%) patients, while 38 (69.1%) had incomplete clinical resolution with relapse. Complete radiological resolution occurred in 14 (34.1%) patients. Conclusion Movement disorders associated with BG lesions should be recognized as a rare and potentially reversible metabolic movement disorder in patients with ESKD.
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Affiliation(s)
- Kah Hui Yap
- Department of Medicine, UKM Medical Center, Kuala Lumpur, Malaysia
| | | | | | - Rabani Remli
- Department of Medicine, UKM Medical Center, Kuala Lumpur, Malaysia
| | - Shen-Yang Lim
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Shahrul Azmin
- Department of Medicine, UKM Medical Center, Kuala Lumpur, Malaysia
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Kroeff B, Hummelgen E, Fabiani G, Martins Cervellini AR. Teaching Video NeuroImage: Aurora and Dusk of the Lentiform Fork Sign in a Patient With Reversible Dystonia. Neurology 2021; 98:e561-e562. [PMID: 34716253 DOI: 10.1212/wnl.0000000000013020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Bruna Kroeff
- Department of Neurology, Hospital Angelina Caron, CG do Sul, PR
| | | | - Giorgio Fabiani
- Department of Neurology, Hospital Angelina Caron, CG do Sul, PR. .,Department of Neurology, CHC-UFPR - Hospital de Clinicas da UFPR, Curitiba, PR
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Safarpour Y, Vaziri ND, Jabbari B. Movement Disorders in Chronic Kidney Disease - A Descriptive Review. J Stroke Cerebrovasc Dis 2020; 30:105408. [PMID: 33139171 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105408] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/19/2020] [Accepted: 10/12/2020] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES The objective of this study is to describe the mechanism of damage to subcortical structures in chronic kidney disease (CKD) and to describe the range of movement disorders associated with CKD. MATERIALS AND METHODS We have reviewed the Medline literature up to January of 2020 using key words movement disorders and chronic kidney disease. The reviewed articles were studied for mechanisms of subcortical damage in CKD as well as type of the reported movements, their frequency and updated treatment. RESULTS The search revealed 183 articles most of them dealing with restless legs syndrome. The damage to basal ganglia in CKD resulted from several mechanisms including accumulation of nitro tyrosine caused by reactive oxygen species and action of uremic toxins leading to endothelial damage and dysfunction of blood-brain barrier. Involuntary movements in CKD include restless legs syndrome (RLS), myoclonus, asterixis, dystonia, chorea, tremor, and Parkinsonism. CONCLUSIONS Chronic kidney disease can cause several abnormal involuntary movements via damaging basal ganglia and subcortical structures. The most common movement disorders in CKD are RLS, myoclonus and asterixis. Restless legs syndrome and myoclonus when severe, need and respond to treatment. Movement disorders in CKD improve with improvement of kidney function.
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Affiliation(s)
- Yasaman Safarpour
- Department of Medicine. University of California Riverside, School of Medicine, United States.
| | - Nosratola D Vaziri
- Division of Nephrology, Department of Medicine, University of California Irvine, United States.
| | - Bahman Jabbari
- Division of Movement Disorders, Department of Neurology, Yale University School of Medicine, United States.
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Bhowmick SS, Lang AE. Movement Disorders and Renal Diseases. Mov Disord Clin Pract 2020; 7:763-779. [PMID: 33043074 DOI: 10.1002/mdc3.13005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 02/06/2023] Open
Abstract
Movement disorders often emerge from the interplay of complex pathophysiological processes involving the kidneys and the nervous system. Tremor, myoclonus, ataxia, chorea, and parkinsonism can occur in the context of renal dysfunction (azotemia and electrolyte abnormalities) or they can be part of complications of its management (dialysis and renal transplantation). On the other hand, myoglobinuria from rhabdomyolysis in status dystonicus and certain drugs used in the management of movement disorders can cause nephrotoxicity. Distinct from these well-recognized associations, it is important to appreciate that there are several inherited and acquired disorders in which movement abnormalities do not occur as a consequence of renal dysfunction or vice versa but are manifestations of common pathophysiological processes affecting the nervous system and the kidneys. These disorders are the emphasis of this review. Increasing awareness of these conditions among neurologists may help them to identify renal involvement earlier, take timely intervention by anticipating complications and focus on therapies targeting common mechanisms in addition to symptomatic management of movement disorders. Recognition of renal impairment in a patient with complex neurological presentation may narrow down the differentials and aid in reaching a definite diagnosis.
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Affiliation(s)
- Suvorit S Bhowmick
- Division of Neurology, Department of Medicine, Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital University Health Network Toronto Ontario Canada
| | - Anthony E Lang
- Division of Neurology, Department of Medicine, Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital University Health Network Toronto Ontario Canada
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