Reversible parkinsonism with lentiform fork sign as an initial and dominant manifestation of uremic encephalopathy

Abstract

Since its first description, clinicians have paid close attention to a syndrome associated with bilateral basal ganglia lesions in uremic patients, whose magnetic resonance imaging (MRI) findings prompted the description as “lentiform fork sign” [ 1 Fabiani G. Teive H.A. Munhoz R.P. Lentiform fork sign and fluctuating, reversible parkinsonism in a patient with uremic encephalopathy. Mov. Disord. 2013; 28: 1053 Crossref PubMed Scopus (9) Google Scholar , 2 Wang H.C. Brown P. Lees A.J. Acute movement disorders with bilateral basal ganglia lesions in uremia. Mov. Disord. 1998; 13: 952-957 Crossref PubMed Scopus (56) Google Scholar ]. The pathogenesis of lentiform fork sign is still unknown. Possible hypotheses include metabolic causes, such as uremic toxins, metabolic acidosis, diabetes, and hypoglycemia [ [3] Lee P.H. Shin D.H. Kim J.W. Song Y.S. Kim H.S. Parkinsonism with basal ganglia lesions in a patient with uremia: evidence of vasogenic edema. Parkinsonism Relat. Disord. 2006; 12: 93-96 Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar ]. Various movement disorders, including chorea and parkinsonism, have been reported to accompany the presentation [ 1 Fabiani G. Teive H.A. Munhoz R.P. Lentiform fork sign and fluctuating, reversible parkinsonism in a patient with uremic encephalopathy. Mov. Disord. 2013; 28: 1053 Crossref PubMed Scopus (9) Google Scholar , 2 Wang H.C. Brown P. Lees A.J. Acute movement disorders with bilateral basal ganglia lesions in uremia. Mov. Disord. 1998; 13: 952-957 Crossref PubMed Scopus (56) Google Scholar , 3 Lee P.H. Shin D.H. Kim J.W. Song Y.S. Kim H.S. Parkinsonism with basal ganglia lesions in a patient with uremia: evidence of vasogenic edema. Parkinsonism Relat. Disord. 2006; 12: 93-96 Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar , 4 Nzwalo H. Sa F. Capela C. Ferreira F. Basilio C. Reversible acute parkinsonism and bilateral basal ganglia lesions in a diabetic uremic patient. Case Rep. Neurol. 2012; 4: 156-158 Crossref PubMed Scopus (8) Google Scholar , 5 Lin H.L. Lin H.C. Chen Y.H. Increased risks of parkinsonism in the 3 years after chronic renal failure. Int. J. Clin. Pract. 2012; 66: 499-503 Crossref PubMed Scopus (19) Google Scholar ]. Of greatest interest is the reversible nature of the symptoms and MRI findings. We herein report the lentiform fork sign in a uremic patient who presented with an initial clinical manifestation of tremulous parkinsonism.