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Dunkerton S, Clarke AJ, Thompson EO, Xie P, Tisch S, Worthington JM, Azadi A, Halmagyi GM. Wilson Disease: A Case Report of Psychosis Preceding Parkinsonism. Am J Case Rep 2023; 24:e940561. [PMID: 37583127 PMCID: PMC10441581 DOI: 10.12659/ajcr.940561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/11/2023] [Accepted: 06/28/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND A first psychotic episode requires the exclusion of toxic-metabolic, inflammatory, infective, and neoplastic causes. Wilson disease is a rare, autosomal recessive disorder of copper metabolism and can present with neuropsychiatric symptoms secondary to copper accumulation in the brain. CASE REPORT We describe the case of a 48-year-old man with parkinsonism on a background of longstanding schizophrenia and psychotic depression in the setting of previously undiagnosed Wilson disease. The common history of neuropsychiatric disturbance and neuroleptic use complicated the assessment of parkinsonism. However, close attention to the temporal appearance of symptoms and signs differentiated his case from drug-induced parkinsonism, which commonly develops hours to weeks after commencement or uptitration of antipsychotic medication. The early features of sialorrhea and dysarthria were also atypical for idiopathic Parkinson disease. The diagnosis was confirmed by serum copper testing and supported by Kayser-Fleischer rings on bedside ophthalmological examination. Magnetic resonance imaging (MRI) of the brain demonstrated copper accumulation in the basal ganglia and pons, contributing to the characteristic neurological manifestations of an akinetic-rigid syndrome with dysarthria. CONCLUSIONS Serum copper testing is easily obtained and should be considered as part of the first-line investigations for new neuropsychiatric disturbances. Although rare, Wilson disease, if diagnosed early, is a potentially treatable and reversible cause of psychosis. With advanced disease, extrapyramidal findings on examination correlate with MRI brain changes, aiding the clinical assessment in differentiating the disease from drug-induced parkinsonism.
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Affiliation(s)
- Sophie Dunkerton
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Antonia J. Clarke
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | | | - Peter Xie
- Department of Psychiatry, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Stephen Tisch
- Department of Neurology, St Vincent’s Hospital, Sydney, NSW, Australia
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - John M. Worthington
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Azadeh Azadi
- Department of Psychiatry, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Gabor M. Halmagyi
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Dunkerton S, Penninkilampi R, Beadnall H, Fulham M, Colebatch A, Jankelowitz S, Ahmed R, Thayer Z, Halmagyi M, Abadir E. Erdheim-Chester disease presenting as precipitous cognitive decline. Pract Neurol 2023; 23:91-92. [PMID: 36283804 DOI: 10.1136/pn-2022-003504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2022] [Indexed: 02/01/2023]
Affiliation(s)
- Sophie Dunkerton
- Neurology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Ross Penninkilampi
- Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Heidi Beadnall
- Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,The University of Sydney, Sydney, New South Wales, Australia
| | - Michael Fulham
- Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,The University of Sydney, Sydney, New South Wales, Australia
| | - Andrew Colebatch
- Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Stacey Jankelowitz
- Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,The University of Sydney, Sydney, New South Wales, Australia
| | - Rebekah Ahmed
- Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,The University of Sydney, Sydney, New South Wales, Australia
| | - Zoe Thayer
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Macquarie University, Sydney, New South Wales, Australia
| | - Michael Halmagyi
- Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,The University of Sydney, Sydney, New South Wales, Australia
| | - Edward Abadir
- The University of Sydney, Sydney, New South Wales, Australia.,Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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Chew BLA, Garcia‐Esperon C, Dunkerton S, Spratt NJ. Pilot experience using a portable electrocardiography device for atrial fibrillation detection in an outpatient stroke clinic. Aust J Rural Health 2022. [DOI: 10.1111/ajr.12957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Beng Lim Alvin Chew
- Department of Neurology John Hunter Hospital Newcastle New South Wales Australia
| | - Carlos Garcia‐Esperon
- Department of Neurology John Hunter Hospital Newcastle New South Wales Australia
- College of Health, Medicine, and Wellbeing University of Newcastle New Lambton Heights New South Wales Australia
- Hunter Medical Research Institute Newcastle New South Wales Australia
| | - Sophie Dunkerton
- Department of Neurology John Hunter Hospital Newcastle New South Wales Australia
| | - Neil J. Spratt
- Department of Neurology John Hunter Hospital Newcastle New South Wales Australia
- College of Health, Medicine, and Wellbeing University of Newcastle New Lambton Heights New South Wales Australia
- Hunter Medical Research Institute Newcastle New South Wales Australia
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Garcia-Esperon C, Ostman C, Walker FR, Chew B, Edwards S, Emery J, Bendall J, Alanati K, Dunkerton S, Starling de Barros R, Amin M, Gangadharan S, Lillicrap T, Parsons M, Levi CR, Spratt NJ. The Hunter-8 scale prehospital triage workflow for identification of large vessel occlusion and brain haemorrhage. PREHOSP EMERG CARE 2022:1-7. [PMID: 36053543 DOI: 10.1080/10903127.2022.2120134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
ObjectiveThe Hunter-8 prehospital stroke scale predicts large vessel occlusion in hyperacute ischemic stroke patients (LVO) at hospital admission. We wished to test its performance in the hands of paramedics as part of a prehospital triage algorithm. We aimed to determine a) the proportion of patients identified by the Hunter-8 algorithm, receiving reperfusion therapies, b) whether a call to stroke team improved this, and c) performance for LVO detection using an expanded LVO definition.MethodsA prehospital workflow combining pre-morbid functional status, time from symptom onset, and the Hunter-8 scale was implemented from July 2019. A telephone call to the stroke team was prompted for potential treatment candidates. Classic LVO was defined as a proximal middle cerebral artery (MCA-M1), terminal internal carotid artery, or tandem occlusion. Extended LVO added proximal MCA-M2 and basilar occlusions.ResultsFrom July 2019 to April 2021, there were 363 Hunter-8 activations, 320 analysed: 181 (56.6%) had confirmed ischemic strokes, 13 (4.1%) transient ischemic attack, 91 (28.5%) stroke mimics, and 35 (10.9%) intracranial haemorrhage. Fifty-two patients (16.3%) received reperfusion therapies, 35 with Hunter-8 ≥ 8. The stroke doctor changed the final destination for 76 patients (23.7%), and five received reperfusion therapies. The AUCs for classic and extended LVO were 0.73 (95% CI 0.66-0.79) and 0.72 (95% CI 0.65-0.77), respectively.ConclusionThe Hunter-8 workflow resulted in 28.7% of confirmed ischemic stroke patients receiving reperfusion therapies, with no secondary transfers to the comprehensive stroke centre. The role of communication with stroke team needs to be further explored.
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Affiliation(s)
- C Garcia-Esperon
- Department of Neurology, John Hunter Hospital, Australia.,College of Health, Medicine, and Wellbeing, University of Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia
| | - C Ostman
- Department of Neurology, John Hunter Hospital, Australia.,College of Health, Medicine, and Wellbeing, University of Newcastle, Australia
| | - F R Walker
- College of Health, Medicine, and Wellbeing, University of Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia
| | - Bla Chew
- Department of Neurology, John Hunter Hospital, Australia
| | - S Edwards
- New South Wales Ambulance, Rozelle, Australia
| | - J Emery
- New South Wales Ambulance, Rozelle, Australia
| | - J Bendall
- Department of Neurology, John Hunter Hospital, Australia.,New South Wales Ambulance, Rozelle, Australia
| | - K Alanati
- Department of Neurology, John Hunter Hospital, Australia
| | - S Dunkerton
- Department of Neurology, John Hunter Hospital, Australia
| | | | - M Amin
- Department of Neurology, John Hunter Hospital, Australia
| | - S Gangadharan
- Department of Neurology, John Hunter Hospital, Australia
| | - T Lillicrap
- Hunter Medical Research Institute, Newcastle, Australia
| | - M Parsons
- College of Health, Medicine, and Wellbeing, University of Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia.,University of New South Wales South Western Sydney Clinical School, Ingham Institute for Applied Medical Research, Department of Neurology, Liverpool Hospital, Sydney, Australia
| | - C R Levi
- Department of Neurology, John Hunter Hospital, Australia.,College of Health, Medicine, and Wellbeing, University of Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia
| | - N J Spratt
- Department of Neurology, John Hunter Hospital, Australia.,College of Health, Medicine, and Wellbeing, University of Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia
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Lycett MJ, Dunkerton S, Miteff F. Internal carotid artery blister aneurysm rupture: a unifying diagnosis for massive epistaxis and unilateral embolic strokes. BMJ Case Rep 2022; 15:e246866. [PMID: 35058286 PMCID: PMC8783830 DOI: 10.1136/bcr-2021-246866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2021] [Indexed: 11/04/2022] Open
Abstract
Concurrent epistaxis, embolic stroke and a ruptured internal carotid artery are rare but life-threatening delayed complications of cured nasopharyngeal squamous cell carcinoma. A timely diagnosis and effective management can be problematic. We report a case that highlights the unique diagnostic features of this presentation and contemporary endovascular treatment options available.
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Affiliation(s)
- Mitchell Joseph Lycett
- John Hunter Hospital Department of Neurology, New Lambton Heights, New South Wales, Australia
| | - Sophie Dunkerton
- John Hunter Hospital Department of Neurology, New Lambton Heights, New South Wales, Australia
| | - Ferdinand Miteff
- John Hunter Hospital Department of Neurology, New Lambton Heights, New South Wales, Australia
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El-Wahsh S, Dunkerton S, Ang T, Winters HS, Delcourt C. Current perspectives on neuroimaging techniques used to identify stroke mimics in clinical practice. Expert Rev Neurother 2021; 21:517-531. [PMID: 33787426 DOI: 10.1080/14737175.2021.1911650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Urgent clinical assessment and brain imaging are essential for differentiating stroke mimics from stroke and to avoid unnecessary initiation of reperfusion and other therapies in stroke mimic patients. AREAS COVERED In this article, the authors will review acute stroke imaging and then the imaging patterns of the most common stroke mimics. The authors have focused our review on brain CT scan, and more specifically CT perfusion, as this is the most commonly available and emerging tool in emergency settings. The authors also provide information on acute brain MRI and MR perfusion. EXPERT OPINION Imaging can contribute to the detection and diagnosis of acute stroke mimics. Knowledge of imaging findings in different stroke mimics can help distinguish these from patients with stroke who require timely reperfusion therapy. CT and MRI perfusion and diffusion-weighted imaging (DWI) MRI are useful imaging modalities for the assessment of acute stroke patients as they provide more accurate information than plain CT scan. Some of these modalities should be available in the emergency setting. The authors recommended CT perfusion as a useful tool for stroke management and differentiation with stroke mimics.
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Affiliation(s)
- Shadi El-Wahsh
- Neurology Department, Royal Prince Alfred Hospital, the University of Sydney, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Sophie Dunkerton
- Neurology Department, Royal Prince Alfred Hospital, the University of Sydney, Sydney, New South Wales, Australia
| | - Timothy Ang
- Neurology Department, Royal Prince Alfred Hospital, the University of Sydney, Sydney, New South Wales, Australia
| | - Hugh Stephen Winters
- Neurology Department, Royal Prince Alfred Hospital, the University of Sydney, Sydney, New South Wales, Australia
| | - Candice Delcourt
- The George Institute for Global Health, The University of New South Wales, Sydney, Australia.,Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park, New South Wales, Australia
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Abstract
Traditional vascular imaging focuses on non-invasive cross-sectional imaging to assess luminal morphology; however, the vessel wall itself may be specifically involved in many diseases. Newer pulse sequences, and particularly black blood MRI of intracranial vessels, have brought a paradigm shift in understanding the pathophysiology of many vasculopathies. Black blood MRI of intracranial vessel walls can help in a range of pathologies with differing pathophysiology, including intracranial atherosclerosis, aneurysms, vasculitis and vasculopathy, moyamoya disease, dissection and vertebrobasilar hypoplasia. This review highlights how vessel wall imaging can contribute to the clinical diagnosis and management of patients with intracranial vascular pathology.
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Affiliation(s)
- Joga Chaganti
- Department of Radiology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Department of Radiology, Nepean Hospital, Penrith, New South Wales, Australia
| | - Hannah Woodford
- Department of Radiology, Nepean Hospital, Penrith, New South Wales, Australia
| | - Susan Tomlinson
- Department of Neurology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - Sophie Dunkerton
- Department of Neurology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - Bruce Brew
- Department of Neurology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
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Elder A, Dunkerton S, Arnold R, Amos D, French A, Ryan E, Faddy S, McMullen M. Delays in Treatment of Rural STEMI: Stoic Patients or System Delays? Heart Lung Circ 2016. [DOI: 10.1016/j.hlc.2016.06.753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Elder A, Dunkerton S, Arnold R, French A, Amos D, Ryan E, Faddy S, McMullen M. Early Cardiologist Input via LIFENET ECG Transmission and Pre-Hospital Thrombolysis Achieves Improved Lysis Times for STEMI in a Rural Setting. Heart Lung Circ 2016. [DOI: 10.1016/j.hlc.2016.06.627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Dunkerton S, Field M, Cho V, Bertram E, Whittle B, Groves A, Goel H. A de novo Mutation in KMT2A (MLL) in monozygotic twins with Wiedemann-Steiner syndrome. Am J Med Genet A 2015; 167A:2182-7. [PMID: 25929198 DOI: 10.1002/ajmg.a.37130] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 04/09/2015] [Indexed: 01/28/2023]
Abstract
Growth deficiency, psychomotor delay, and facial dysmorphism was originally described in a male patient in 1989 by Wiedemann et al. and later in 2000 by Steiner et al. Wiedemann-Steiner syndrome (WSS) has since been described only a few times in the literature, with the phenotypic spectrum both expanding and becoming more delineated with each patient reported. We report on the clinical and molecular features of monozygotic twins with a de novo mutation in KMT2A. Single nucleotide polymorphism (SNP) microarray was done on both twins and whole-exome sequencing was done using both parents and one of the affected twins. SNP microarray confirmed that they were monozygotic twins. A de novo heterozygous variant (p. Arg1083*) in the KMT2A gene was identified through whole-exome sequencing, confirming the diagnosis of WSS. In this study, we have identified a de novo mutation in KMT2A associated with psychomotor developmental delay, facial dysmorphism, short stature, hypertrichosis cubiti, and small kidneys. This finding in monozygotic twins gives specificity to the WSS. The description of more cases of WSS is needed for further delineation of this condition. Small kidneys with normal function have not been described in this condition in the medical literature before.
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Affiliation(s)
| | - Matthew Field
- Department of Immunology, John Curtin School of Medical Research, Australian National University, Canberra City, Australian Capital Territory, Australia
| | - Vicki Cho
- Department of Immunology, John Curtin School of Medical Research, Australian National University, Canberra City, Australian Capital Territory, Australia
| | - Edward Bertram
- Australian Phenomics Facility, The Australian National University, Canberra City, Australian Capital Territory, Australia
| | - Belinda Whittle
- Australian Phenomics Facility, The Australian National University, Canberra City, Australian Capital Territory, Australia
| | | | - Himanshu Goel
- University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Genetics, Waratah, New South Wales, Australia
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