PMC7196137_01
Axial T1-weighted MRI brain performed serially over three months, showing the progression of the T1 hyperintensities in the globus pallidi from June 2018 to July 2018, followed by the improvement of the T1 hyperintensities in August 2018, one month after discontinuation of TPN. (a) Evidence of developing T1 hyperintensities in the bilateral globus pallidi on a previous hospital admission in June 2018. (b) Further increase in signal in the bilateral globus pallidi on T1-weighted images in July 2018, corresponding to her pronounced Parkinsonian features on clinical presentation. (c) Improvement in the T1 hyperintensities in the globus pallidi, collected one month after cessation of TPN use and corresponding to near-resolution of her Parkinsonism.
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Figures 1(a) and 1(b), which were thought to be secondary to manganese toxicity from chronic TPN use. Furthermore, a repeat MRI brain was performed in August 2018, one month after discontinuation of TPN, which showed improvement of the T1 hyperintensities in the bilateral globus pallidi, as evidenced by the white arrows in Figure 1(c), approaching the intensity level noted in June 2018. Her MRI brain, shown in Figure 1, showed symmetric T1 hyperintensities in the bilateral globus pallidi, a finding compatible with manganese toxicity.
Axial T1-weighted MRI brain from July 2018 showing hyperintensities in the substantia nigra, as evidenced by the two white arrows.
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Other supporting findings included T1 hyperintensities in the substantia nigra, as evidenced by the arrows in Figure 2, and decreased signal in the bilateral globus pallidi on T2-weighted images, as evidenced by the arrows in Figure 3.
Supporting evidence for manganese neurotoxicity includes decreased signal intensity in the bilateral globus pallidi on axial T2-weighted images of the MRI brain from July 2018.
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Other supporting findings included T1 hyperintensities in the substantia nigra, as evidenced by the arrows in Figure 2, and decreased signal in the bilateral globus pallidi on T2-weighted images, as evidenced by the arrows in Figure 3.