Restless legs syndrome in Wilson's disease: frequency, characteristics, and mimics.

OBJECTIVE: To determine characteristics, clinical significance, frequency, and mimics of restless legs syndrome (RLS) in a cohort of Wilson's disease (WD, n = 42/f = 18), compared to healthy, matched controls. MATERIALS AND METHODS: Structured clinical interviews (patients and caregiving family members), repeated neurological examinations (afternoon and presleep), comprehensive laboratory tests, WD-, RLS-, and sleep-specific rating scales, and video-polysomnography. RESULTS: Thirteen patients with WD (13/42 = 31.0%) clearly fulfilled the five diagnostic criteria of RLS; in eight patients (19.1%), the burden of RLS was clinically significant. The RLS was of moderate severity, equally distributed among sexes, manifested mainly in the evening and before falling asleep, and had developed mostly after clinical manifestation of WD (time elapsed 10.2 ± 14.5 years), still at a young mean age (27.5 ± 11.5 years). The known RLS-associated features were absent (normal iron and kidney parameters) or rare (positive family history, polyneuropathy). Compared to WD patients without RLS, patients with RLS were significantly elder and had suffered longer from WD. WD-specific RLS mimics as well as RLS confounding motor comorbidities (dystonia, tremor, chorea) were frequent and a diagnostic challenge; in difficult cases, the differentiation was reached by clinical observation of the motor behavior in the evening or at nighttime. CONCLUSION: RLS was frequent in this cohort of WD and might be causally related to WD. RLS should be included in the diagnostic work-up of WD. In complex motor disorders, differential diagnosis of RLS might require evening/nighttime examination and video-polysomnography. In WD patients with a clinically significant RLS, treatment with dopaminergic substances may be considered.

Cognitive impairment and magnetic resonance imaging correlations in Wilson's disease.

OBJECTIVES: To evaluate the cognitive performance of a group of patients with Wilson's disease (WD) and to correlate the cognitive findings with changes in magnetic resonance imaging (MRI). METHODS: All patients with WD consecutively attended in a Movement Disorders Clinic between September 2006 and October 2007 were invited to participate in the study, together with a group of matched healthy controls. Patients and controls were submitted to comprehensive neuropsychological assessment. MRI was performed in all patients, and abnormalities (high-intensity signal, low-intensity signal and atrophy) were semi-quantitatively rated. Performance of patients and controls in each cognitive test was compared, and correlations between cognitive scores and MRI changes were investigated within the patients' group. RESULTS: Twenty patients with WD (11 men) and 20 controls (nine men) were evaluated. Mean age in the WD and control groups was 30.05 ± 7.25 and 32.15 ± 5.37 years, respectively. Mean schooling years were 11.15 ± 3.73 among WD cases and 10.08 ± 2.62 among controls. Patients with WD performed significantly worse than controls in the Mini-Mental State Examination, Dementia Rating Scale, phonemic verbal fluency (FAS), verb generation, digit span forward, Stroop test, Frontal Assessment Battery and in the Brief Cognitive Screening Battery. A significant correlation emerged between global cognitive impairment and MRI scale (r = 0.535), being higher for high-intensity signal plus atrophy (r = 0.718). CONCLUSION: Patients with WD presented cognitive impairment, especially in executive functions, with good correlation between cognitive abnormalities and MRI changes.

Multicenter analysis of glucocerebrosidase mutations in Parkinson's disease.

BACKGROUND: Recent studies indicate an increased frequency of mutations in the gene encoding glucocerebrosidase (GBA), a deficiency of which causes Gaucher's disease, among patients with Parkinson's disease. We aimed to ascertain the frequency of GBA mutations in an ethnically diverse group of patients with Parkinson's disease. METHODS: Sixteen centers participated in our international, collaborative study: five from the Americas, six from Europe, two from Israel, and three from Asia. Each center genotyped a standard DNA panel to permit comparison of the genotyping results across centers. Genotypes and phenotypic data from a total of 5691 patients with Parkinson's disease (780 Ashkenazi Jews) and 4898 controls (387 Ashkenazi Jews) were analyzed, with multivariate logistic-regression models and the Mantel-Haenszel procedure used to estimate odds ratios across centers. RESULTS: All 16 centers could detect two GBA mutations, L444P and N370S. Among Ashkenazi Jewish subjects, either mutation was found in 15% of patients and 3% of controls, and among non-Ashkenazi Jewish subjects, either mutation was found in 3% of patients and less than 1% of controls. GBA was fully sequenced for 1883 non-Ashkenazi Jewish patients, and mutations were identified in 7%, showing that limited mutation screening can miss half the mutant alleles. The odds ratio for any GBA mutation in patients versus controls was 5.43 across centers. As compared with patients who did not carry a GBA mutation, those with a GBA mutation presented earlier with the disease, were more likely to have affected relatives, and were more likely to have atypical clinical manifestations. CONCLUSIONS: Data collected from 16 centers demonstrate that there is a strong association between GBA mutations and Parkinson's disease.

Effects of exercise training on autonomic modulation and mood symptoms in patients with obstructive sleep apnea.

We evaluated the effects of exercise training (ET) on the profile of mood states (POMS), heart rate variability, spontaneous baroreflex sensitivity (BRS), and sleep disturbance severity in patients with obstructive sleep apnea (OSA). Forty-four patients were randomized into 2 groups, 18 patients completed the untrained period and 16 patients completed the exercise training (ET). Beat-to-beat heart rate and blood pressure were simultaneously collected for 5 min at rest. Heart rate variability (RR interval) was assessed in time domain and frequency domain (FFT spectral analysis). BRS was analyzed with the sequence method, and POMS was analyzed across the 6 categories (tension, depression, hostility, vigor, fatigue, and confusion). ET consisted of 3 weekly sessions of aerobic exercise, local strengthening, and stretching exercises (72 sessions, achieved in 40±3.9 weeks). Baseline parameters were similar between groups. The comparisons between groups showed that the changes in apnea-hypopnea index, arousal index, and O2 desaturation in the exercise group were significantly greater than in the untrained group (P<0.05). The heart rate variability and BRS were significantly higher in the exercise group compared with the untrained group (P<0.05). ET increased peak oxygen uptake (P<0.05) and reduced POMS fatigue (P<0.05). A positive correlation (r=0.60, P<0.02) occurred between changes in the fatigue item and OSA severity. ET improved heart rate variability, BRS, fatigue, and sleep parameters in patients with OSA. These effects were associated with improved sleep parameters, fatigue, and cardiac autonomic modulation, with ET being a possible protective factor against the deleterious effects of hypoxia on these components in patients with OSA.

Hypothalamic sites responding to predator threats--the role of the dorsal premammillary nucleus in unconditioned and conditioned antipredatory defensive behavior.

In this study we provide a comprehensive analysis of the hypothalamic activation pattern during exposure to a live predator or an environment previously associated with a predator. Our results support the view that hypothalamic processing of the actual and the contextual predatory threats share the same circuit, in which the dorsal premammillary nucleus (PMd) plays a pivotal role in amplifying this processing. To further understand the role of the PMd in the circuit organizing antipredatory defensive behaviors, we studied rats with cytotoxic PMd lesions during cat exposure and examined the pattern of behavioral responses as well as how PMd lesions affect the neuronal activation of the systems engaged in predator detection, in contextual memory formation and in defensive behavioral responses. Next, we investigated how pharmacological blockade of the PMd interferes with the conditioned behavioral responses to a context previously associated with a predator, and how this blockade affects the activation pattern of periaqueductal gray (PAG) sites likely to organize the conditioned behavioral responses to the predatory context. Behavioral observations indicate that the PMd interferes with both unconditioned and conditioned antipredatory defensive behavior. Moreover, we have shown that the PMd influences the activation of its major projecting targets, i.e. the ventral part of the anteromedial thalamic nucleus which is likely to influence mnemonic processing, and PAG sites involved in the expression of antipredatory unconditioned and conditioned behavioral responses. Of particular relevance, this work provides evidence to elucidate the basic organization of the neural circuits integrating unconditioned and contextual conditioned responses to predatory threats.

Sensory abnormalities and pain in Parkinson disease and its modulation by treatment of motor symptoms.

Pain and sensory abnormalities are present in a large proportion of Parkinson disease (PD) patients and have a significant negative impact in quality of life. It remains undetermined whether pain occurs secondary to motor impairment and to which extent it can be relieved by improvement of motor symptoms. The aim of this review was to examine the current knowledge on the mechanisms behind sensory changes and pain in PD and to assess the modulatory effects of motor treatment on these sensory abnormalities. A comprehensive literature search was performed. We selected studies investigating sensory changes and pain in PD and the effects of levodopa administration and deep brain stimulation (DBS) on these symptoms. PD patients have altered sensory and pain thresholds in the off-medication state. Both levodopa and DBS improve motor symptoms (i.e.: bradykinesia, tremor) and change sensory abnormalities towards normal levels. However, there is no direct correlation between sensory/pain changes and motor improvement, suggesting that motor and non-motor symptoms do not necessarily share the same mechanisms. Whether dopamine and DBS have a real antinociceptive effect or simply a modulatory effect in pain perception remain uncertain. These data may provide useful insights into a mechanism-based approach to pain in PD, pointing out the role of the dopaminergic system in pain perception and the importance of the characterization of different pain syndromes related to PD before specific treatment can be instituted.

Effects of exercise training on autonomic modulation and mood symptoms in patients with obstructive sleep apnea

We evaluated the effects of exercise training (ET) on the profile of mood states (POMS), heart rate variability, spontaneous baroreflex sensitivity (BRS), and sleep disturbance severity in patients with obstructive sleep apnea (OSA). Forty-four patients were randomized into 2 groups, 18 patients completed the untrained period and 16 patients completed the exercise training (ET). Beat-to-beat heart rate and blood pressure were simultaneously collected for 5 min at rest. Heart rate variability (RR interval) was assessed in time domain and frequency domain (FFT spectral analysis). BRS was analyzed with the sequence method, and POMS was analyzed across the 6 categories (tension, depression, hostility, vigor, fatigue, and confusion). ET consisted of 3 weekly sessions of aerobic exercise, local strengthening, and stretching exercises (72 sessions, achieved in 40±3.9 weeks). Baseline parameters were similar between groups. The comparisons between groups showed that the changes in apnea-hypopnea index, arousal index, and O2 desaturation in the exercise group were significantly greater than in the untrained group (P<0.05). The heart rate variability and BRS were significantly higher in the exercise group compared with the untrained group (P<0.05). ET increased peak oxygen uptake (P<0.05) and reduced POMS fatigue (P<0.05). A positive correlation (r=0.60, P<0.02) occurred between changes in the fatigue item and OSA severity. ET improved heart rate variability, BRS, fatigue, and sleep parameters in patients with OSA. These effects were associated with improved sleep parameters, fatigue, and cardiac autonomic modulation, with ET being a possible protective factor against the deleterious effects of hypoxia on these components in patients with OSA.

An alternative experimental procedure for studying predator-related defensive responses.

In the present study, we introduce an experimental procedure to study, in rats, a wide range of natural defensive reactions. Animals were tested in an experimental apparatus that consisted of a home cage (25 x 25 x 25 cm) connected to another chamber (25 x 25 x 25 cm-the food compartment) by a hallway (12.5 cm wide and 100 cm long, with 25-cm high walls). During 10 days before the testing procedures, each animal was isolated in the home cage, and, at the beginning of the dark phase, allowed to explore the rest of the apparatus and obtain food pellets stored in the food compartment. The testing consisted of three phases: exploring a familiar and safe environment (phase 1, on the 10th day), cat exposure (phase 2, on the 11th day), and, on the following day, exposure to the environment where the predator had been previously encountered (phase 3). These three conditions thus provided a low-defense baseline; a high level of freezing during cat exposure; and a high level of risk assessment to the hostile environment condition. An important feature of the present experimental procedure was that the behavioral responses were very stable among the animals tested within each individual phase of the testing schedule. In each phase of the testing schedule, we have also examined the Fos immunoreactivity in pontine periventricular sites related to controlling behavioral activation (i.e. the nucleus incertus) or attentional status (i.e. the locus coeruleus). Animals actively exploring a safe and familiar environment presented an increased activation of the nucleus incertus; the locus coeruleus, in turn, was particularly activated during cat exposure, and also, to lesser degree, during exposure to the hostile environment. These results give further support to the view that the animals present quite distinct behavioral states during each one of the testing situations. Taken together, the evidence suggests the present experimental procedure as particularly suitable for analyzing the neural basis of a number of specific defensive responses.

Functional mapping of the prosencephalic systems involved in organizing predatory behavior in rats.

The study of the neural basis of predatory behavior has been largely neglected over the recent years. Using an ethologically based approach, we presently delineate the prosencephalic systems mobilized during predation by examining Fos immunoreactivity in rats performing insect hunting. These results were further compared with those obtained from animals killed after the early nocturnal surge of food ingestion. First, predatory behavior was associated with a distinct Fos up-regulation in the ventrolateral caudoputamen at intermediate rostro-caudal levels, suggesting a possible candidate to organize the stereotyped sequence of actions seen during insect hunting. Insect predation also presented conspicuous mobilization of a neural network formed by a distinct amygdalar circuit (i.e. the postpiriform-transition area, the anterior part of cortical nucleus, anterior part of basomedial nucleus, posterior part of basolateral nucleus, and medial part of central nucleus) and affiliated sites in the bed nuclei of the stria terminalis (i.e. the rhomboid nucleus) and in the hypothalamus (i.e. the parasubthalamic nucleus). Accordingly, this network is likely to encode prey-related motivational values, such as prey's odor and taste, and to influence autonomic and motor control accompanying predatory eating. Notably, regular food intake was also associated with a relatively weak Fos up-regulation in this network. However, during regular surge of food intake, we observed a much larger mobilization in hypothalamic sites related to the homeostatic control of eating, namely, the arcuate nucleus and autonomic parts of the paraventricular nucleus. Overall, the present findings suggest potential neural systems involved in integrating prey-related motivational values and in organizing the stereotyped sequences of action seen during predation. Moreover, the comparison with regular food intake contrasts putative neural mechanisms controlling predatory related eating vs. regular food intake.

Tracing from the dorsal premammillary nucleus prosencephalic systems involved in the organization of innate fear responses.

The dorsal premammillary nucleus (PMd) is thought to play a critical role in the expression of fear responses to environmental threats. We have previously reported that, during an encounter with a predator, the PMd presents an impressive increase in Fos levels and cell body-specific chemical lesions therein virtually eliminated the expression of escape and freezing responses. Therefore, the PMd may be viewed as a strategic starting point to delineate prosencephalic circuits seemingly critical for the organization of innate fear responses. In the present review, we provide a comprehensive examination of the neural circuits putatively involved in influencing this hypothalamic site, and supplement this analysis with recent observations from our laboratory on the expression of Fos protein in the central nervous system of rats exposed to a live predator.

Afferent connections of the dorsal premammillary nucleus.

The dorsal premammillary nucleus (PMd) is thought to play a critical role for the expression of fear responses to environmental threats. We have reported previously that during an encounter with a predator the PMd presents an impressive increase in Fos levels and cell body-specific chemical lesions therein virtually eliminate the expression of escape and freezing responses. In the present study, we carried out a systematic analysis of PMd afferent connections combining anterograde and retrograde tracing methods in the rat. We show that the nucleus receives inputs from several widely distributed areas in the forebrain and, to a much lesser extent, from the brainstem as well. From this information, it seems that the major telencephalic source of input to the PMd is the interfascicular nucleus of the bed nuclei of the stria terminalis. In addition, substantial telencephalic inputs to the nucleus seem to arise from the infralimbic and prelimbic areas, and the lateral septal nucleus. In the diencephalon, massive inputs to the PMd arise from the anterior hypothalamic nucleus, specific parts of the perifornical region, the retinoceptive region of the lateral hypothalamic area, and the anterior and dorsomedial parts of the ventromedial hypothalamic nucleus. In contrast, the ventral tegmental nucleus seems to be the only brainstem site that provides substantial inputs to the PMd. Overall, the present analysis helps to delineate prosencephalic circuits seemingly critical for the organization of innate fear responses to environmental threats, where the PMd presents a major associative role. Furthermore, by means of massive inputs from the ventral tegmental nucleus, the PMd is in a position to integrate information from a neural system involved in spatial working memory, which may be of particular relevance for an effect of attentional mechanisms on the selection of appropriate escape strategies.

Predatory hunting and exposure to a live predator induce opposite patterns of Fos immunoreactivity in the PAG.

Considering the periaqueductal gray's (PAG) general roles in mediating motivational responses, in the present study, we compared the Fos expression pattern in the PAG induced by innate behaviors underlain by opposite motivational drivers, in rats, namely, insect predation and defensive behavior evoked by the confrontation with a live predator (a cat). Exposure to the predator was associated with a striking Fos expression in the PAG, where, at rostral levels, an intense Fos expression was found largely distributed in the dorsomedial and dorsolateral regions, whereas, at caudal levels, Fos-labeled cells tended to be mostly found in the lateral and ventrolateral columns, as well as in the dorsal raphe nucleus. Quite the opposite, insect predation was associated with increased Fos expression predominantly in the rostral two thirds of the lateral PAG, where the majority of the Fos-immunoreactive cells were found at the oculomotor nucleus levels. Remarkably, both exposure to the cat and insect predation upregulated Fos expression in the supraoculomotor region and the laterodorsal tegmental nucleus. Overall, the present results clearly suggest that the PAG activation pattern appears to reflect, at least partly, the animal's motivational status. It is well established that the PAG is critical for the expression of defensive responses, and, considering the present findings, it will be important to investigate how the PAG contributes to the expression of the predatory behavior, as well.

Projections of the basal retrochiasmatic area: a neural site involved in the photic control of pineal metabolism.

It has been shown that the basal retrochiasmatic area (RCHb), situated immediately ventral to the third ventricle behind the suprachiasmatic nucleus and in front of the arcuate nucleus, is implicated in the nocturnal inhibitory process of melatonin production induced by short-term retinal photo-stimulation. In the present study, the projections of the RCHb have been examined using the Phaseolus vulgaris leucoagglutinin (PHA-L) method in the rat. Considering the putative role of the RCHb in contributing to the short-term photo-inhibition of the pineal gland during the night, it is reasonable to suppose that the RCHb may ultimately inhibit the sympathetic outflow of the upper thoracic segments, known to be critically involved in the control of melatonin secretion. Of particular interest, the present anterograde tract-tracing study indicates all possible paths from the RCHb which may conceivably be involved in influencing the sympathetic outflow and, therefore, melatonin production. Thus, apart from a direct projection to the intermediolateral column at thoracic levels of the spinal cord, the RCHb is in a position to control the sympathetic outflow through other potential routes, such as the dorsal parvicellular part of the paraventricular nucleus of the hypothalamus, lateral hypothalamic area, ventromedial nucleus of the hypothalamus, lateral part of the periaqueductal gray and Barrington's nucleus.

Parkinson's disease.

Parkinson's disease (PD) is one of the most common neurodegenerative diseases and affects 150 to 200 people per 100,000 population. Rapid advances have been made in the neurobiology of PD; this disorder is now recognized as a model of dysfunction in fronto-striatal circuits expressed by motor and behavioral symptoms. Several clinical and surgical strategies for the management of PD are discussed.

[Hepatolenticular degeneration: evaluation of neurological course in 76 treated cases]. / Degeneração hepatolenticular. Avaliação da evolução neurológica em 76 casos tratados.

A series of 76 patients with hepatolenticular degeneration (HLD) followed up at the Hospital of the University of São Paulo Medical School between 1963 and 1988 have been studied focusing the evolution under treatment of neurological features. The assessment of neurological symptoms included 12 specific items, and it was made by a scoring system ranging from 0 to 3 (absent, mild, moderate and severe). Global score varied between 0 to 36. A functional disability scale (0, normal; 1, mild; 2, moderate; 3, severe) was also adopted. All patients received D-penicillamine but three of them developed serious renal toxic side-effects, and this drug was replaced by zinc (sulphate or acetate). Fifty-nine patients (77.6%) improved, 8 (10.6%) remained unchanged, and 9 (11.8%) got worse. The main features related to bad results were poor compliance, predominance of dystonic symptoms, and short time treatment (death due hepatic complications). Eight patients (10.5%) developed transient worsening of neurological symptoms during the first weeks of treatment. Three patients who have D-penicillamine replaced by zinc salts presented satisfactory evolution. From them, only one had neurological symptoms. Death due to infectious complications related to severe motor disability occurred in three patients, representing only 10.7% of fatal evolution.

[Parkinson disease associated to a brain tumor: a case report]. / Parkinsonismo associado a tumor cerebral. Relato de caso.

We are presenting an uncommon case of cerebral tumor whose major manifestation was parkinsonism. The patient was a 50-year-old woman presented with a 5-month history of tremor of the right hand, particularly at rest, and headache. On neurological examination of March, 1987 there were: slight right-sided hemiparesis with symmetrical hyperreflexia; discrete bradykinesia in combination with cogwheel rigidity also on the right-side; resting tremor of the right hand; and bilateral papilledema. The neuropsychological examination disclosed: nominative aphasia, impaired recent memory and right-left disorientation. The computed tomography showed a large, left frontotemporal tumor. Angiograms of the left internal and external carotid arteries revealed a tumor blush in the left frontotemporal region supplied by a enlarged middle meningeal artery. An electromyogram revealed a 4-6 HZ tremor on right hand. A course of treatment with dexamethasone 16 mg/day and levodopa plus benzerazine (500 mg/day) was unsuccessful. A left fronto-temporo-parietal craniotomy was performed and an attached sphenoid wing tumor was macroscopically completely removed. Microscopy indicated that the tumor was a meningioma. Postoperatively, the patient made an uneventful recovery. After two weeks, her right-sided palsy and parkinsonism had disappeared, and neuropsychological deficits improved. Two months later there was no abnormalities on neurological and neuropsychological examination. It was concluded that the parkinsonism was caused by mechanical pressure on the basal ganglia.

[Benign familial chorea: report of 2 cases]. / Coréia familiar benigna: relato de dois casos.

Two cases (siblings) of benign familial chorea are reported. The family's pedigree shows an autosomic dominant form of inheritance with incomplete penetrance. The differential diagnosis is discussed as well a brief literature revision is made.

[Hepatolenticular degeneration: critical evaluation of the diagnostic criteria in 95 cases]. / Degeneração hepatolenticular: avaliação crítica dos critérios diagnósticos em 95 casos.

Ninety-five cases of hepatolenticular degeneration have been studied, focusing particularly the clinical and laboratory characterization of the disease. On the clinical viewpoint the variability of the starting symptoms and the frequency of the Kayser-Fleischer rings were analyzed. As regards the laboratory findings the ceruloplasmin, blood and urinary copper, and aminoaciduria levels have been evaluated, as well as the radiological and scintillographic study of joints and bones, cranial computerized tomography and liver biopsy. In 54.4% of the cases the opening clinical picture was neurological, in 31.1% hepatic, in 14.4% psychiatric, in 7.8% osteoarticular, in 2.2% ophtalmologic (Kayser-Fleischer rings), in 1.1% hematologic (hemolytic anemia), and in 1.1% cardiac. Kayser-Fleischer rings were present in 84 of the 92 cases in which they have been searched for (91.3%). Concerning the laboratory findings, hypoceruloplasminemia was found in 98.8% of the cases in which it was investigated, hyperaminoaciduria in 94.7%, hypocupremia in 87.0%, increased cupruresis in 78.2%, osteoporosis in 79.4%, scintillographic changes of the joints in 67.6%; the CT-scan, performed in 11 cases, showed low attenuation areas in the basal ganglia of 2 patients. The significance of the mentioned laboratory findings and the presence of the Kayser-Fleischer rings for the diagnosis of Wilson's disease is discussed.

[Gilles de la Tourette syndrome: a clinical study on 58 cases]. / Síndrome de Gilles de la Tourette: estudo clínico de 58 casos.

Gilles de la Tourette's syndrome (GTS) is a neuropsychiatric disorder with a childhood onset and is characterized by motor and vocal tics. Fifty-eight patients with GTS were evaluated during a period of three years. Thirty-six patients were male and twenty two female, with an age range of 7 to 51 years (mean 20.33 years). The male to female ratio was 1.6:1. The age of onset ranged from 3 to 15 years (mean 7.81 years). Seventy nine percent of the patients presented motor tics as the initial symptom of the disease. In terms of complex tics, coprolalia was present in 27.6% of the patients; copropraxia in 20.1%; palilalia in 20.1%; ecolalia in 27.6%; and ecopraxia in 27,6%. Associated manifestations, such as attention deficit, hyperactivity disorder and obsessive-compulsive disorder were present in 25.8% and 39.6%, respectively. Sensory phenomena were present in 54.8% of the patients.

[Parkinsonism secondary to ethylene oxide exposure: case report]. / Parkinsonismo secundário a exposição a óxido de etileno. Registro de caso.

Ethylene oxide is a gas widely used in the production of industrial chemicals. It is also used to sterilize heat-sensitive medical supplies. Previous reports of acute and chronic exposure have described neurotoxic effects like peripheral neuropathy and cognitive impairment. We describe a pure parkinsonian syndrome following acute ethylene oxide intoxication. A 39-years-old male was referred to our Movement Disorders Clinic for evaluation of a parkinsonian syndrome. He was acutely exposed to ethylene oxide four years before and remained comatose for three days, and gradually regained consciousness. At that time he showed a global parkinsonian syndrome including bradykinesia, rigidity and rest tremor, with a severe motor disability; no other neurological disorders were found. The symptomatology was partially controlled with biperidene and levodopa plus carbidopa. Two years later he developed L-dopa induced dyskinesias. Four years after the intoxication he was evaluated at our clinic. General examination showed no abnormalities. Neurologic examination revealed a normal mental status. Motor evaluation disclosed moderate bradykinesia, rigidity and rest tremor, shuffling gait, poor facial mimic, stooped posture, and his speech was low and monotonous; deep tendon reflexes were brisk. The Hoehn-Yahr disability score was degree IV. Routine laboratory and radiological exams showed results within normal limits. The CSF examination was normal. Brain computed tomography and magnetic ressonance were normal. A trial with bromocriptine and levodopa plus carbidopa did not improve dyskinesia, and he was put on a schedule including amantadine and biperidene with improvement to grade III in Hoehn-Yahr scale. In the present case there was a clear relation between the acute exogenous intoxication and irreversible parkinsonism.(ABSTRACT TRUNCATED AT 250 WORDS)