Parkinsonism in patient with hepatitis C

Abstract

T1-weighted MRI of the brain revealed hyperintensity in the basal ganglia, a finding characteristic of hepatic encephalopathy. Therapy with L-ornithine-L-aspartate (5 g, three times daily) was initiated along with antibiotic treatment, which resulted in resolution of the parkinsonian symptoms and improvement in cognition. On review visit at one month, MMSE was 29/30, clock drawing was unchanged, and there was a significant reduction in parkinsonism symptoms (Fig. 3). Hyperintensities in the basal ganglia on T1-weighted brain MRI sequences have been reported in the majority of cirrhosis patients. Elevated serum manganese concentrations are considered responsible for these hyperintensities of the globus pallidus, with manganese interfering with dopamine metabolism, thus causing parkinsonian features in up to 89% of patients with cirrhosis. Although the exact mechanism of the disorder is unknown, ammonia plays a crucial role, supported by the finding that the administration of L-ornithine-L-aspartate significantly reduced serum ammonia and neurological symptomatology. Although parkinsonism is an idiopathic disorder in most cases, secondary forms of the disease should be sought, particularly if the patient’s history points to some of the known causes. The case presented also illustrates the importance of brain MRI in selected patients with newonset parkinsonism.