Video 1
Movement disorders phenomenology: In sequence, Video 1 segment 1 pre-treatment condition recorded in 2014 shows polyminimyoclonus with dystonic posturing of the left hand, tremor of the right hand, tremor of the head and bilateral blepharospasm, dysdiadochokinesia and impaired finger tapping bilaterally. The tremor usually commences in the first hour of the wake and remains unchanged throughout wakefulness. This involuntary motor activity consisted of abnormal, slow, segmental, continuous, multifocal and predominantly involving the distal muscles. There is an observable pattern of 1 to 2 sequences of muscle contractions every 2 to 3 seconds continuously during day or night. The tremor stops when patient grasps an object or a body part or when she places the hands firmly on a surface. Video 1 segment 2 pre-treatment condition recorded in 2014 exhibits dysmetria and ataxic gait (Ambulation assisted using a cane). Video 1 segment 3 post-treatment condition recorded from 2015 to 2020 demonstrates movements of the upper limbs and hands markedly diminished in amplitude and intensity bilaterally, no detectable head tremor or blepharospasm, marked improvement in dysdiadochokinesia, finger tapping bilaterally and dysmetria, and ambulation without assistance.
Figure 1
Brain MRI shows non-enhancing bilateral increased signal intensity on axial T1-weighted (A), axial T2-weighted (B) and axial T2-Fluid-attenuated inversion recovery (FLAIR)-weighted (C) images in periventricular regions, basal ganglia and internal/external capsules. Mild cerebral and cerebellar atrophy is exhibited in (A), (C), and (D). Sagittal T2-weighted image (D) shows normal corpus callosum, brainstem, and cervical-medullary junction. Axial diffusion-weighted image demonstrates no areas of restricted diffusion to suggest ischemia/infarction (E).
Figure 2
Schematic diagram of the timeline of events in relation to serum aluminium level and Mini Mental Status Examination (MMSE).
Table 3
Summary of the Literature on Aluminum-Related Encephalopathy.
| CASE | AGE (YEARS) | GENDER | PROBABLE CAUSE | CLINICAL MANIFESTATIONS | AL CONCENTRATION | PATHOLOGY OR MRI FINDINGS | REFERENCE |
|---|---|---|---|---|---|---|---|
| 1 | n.d. | n.d. | Al-containing vaccine | Motor symptoms, cerebellar signs, visual loss, sensory disturbances, cognitive and behavioral problems. | n.d. | MS-like features by MRI | 1 |
| 2 | 58 | female | Al-containing water | Mental deterioration, visual hallucinations 15 years later. | 23.3 µg/g (Reference value <2) in cortex | Congophilic angiopathy | 2 |
| 3 | 37 | male | Unknown | Mental deterioration for 10 years. | n.d. | Patchy demyelination, calcifications with Al deposits | 3 |
| 4 | 52 | female | Al-containing cement bone when reconstruction | Loss of consciousness, myoclonic jerks, seizures for 6 months. | 9.3 µg/g (Reference value <2) in cortex | Al-containing argyrophilic inclusions in neurons, glia and choroid plexus | 4 |
| 5 | 59 | female | 3.0 g hydroxyl-Al gel for 15 years | Tremor, delirium for 9 months. | 195 µg/L (Reference value <10) in serum, 12 µg/L (Reference value <5) in CSF | Nonspecific mild atrophy, calcification | 5 |
| 6 | 20 | female | Unknown | Mental deterioration, epilepsy. | n.m. | Cystic and spongy white matter, Al deposits in the myelin sheath | 6 |
| Our patient | 55 | female | 30% Al-containing marine grade paints for 12 years | Intention tremor of the hands and jerks of the upper limbs, polyminimyoclonus and slight dystonic posturing of the left hand, tremor of the head, bilateral blepharospasm and impaired finger tapping, dysdiadochokinesia and dysmetria with spastic ataxic gait and ample sustentation base. Romberg sign positive, dementia, and microcytic anemia. Movement disorders markedly improved or resolved after chelation therapy (Video 1). | Pretherapy: 1,391 µg/L (Reference value 0-9) in serum. Posttherapy: 879 µg/L in serum. Follow up 5 years: 212 in serum. | Brain MRI showed mild cerebral and cerebellar atrophy, with sparing of the corpus callosum, brainstem and cervical-medullary junction. |
[i] Abbreviations: n.d., not described; Al, aluminium; MS, multiple sclerosis; CSF, cerebrospinal fluid; n.m., not measured.