A case of gait spasticity.

We have been saying it for a long time now. Gait is a huge window into the function of the human brain and nervous system. It is often the first presenting sign that something is wrong. In the case below, a 48 year old woman presented because of a gradually developing spastic gait. 
Lab testing showed mild increases of transaminase and total bilirubin. Blood manganese level was markedly elevated. 
MRI showed high signal intensities at the globus pallidus and cerebral peducles, and bilateral deep white matter, posterior limbs of the internal capsule and right upper cervical spinal cord. 
A diagnosis of Idiopathic portal hypertension was made. 
According to this article:

“Hepatic diseases often show high signal intensities at the basal ganglia on T1-weighted images, and this seemed to be due to accumulation of manganese in our case. Because demyelination or axonal injury of the spinal cord are found in hepatic disease, we speculate that the high signal intensities at the spinal cord on T2-weighted images of our case reflect hepatic myelopathy, which may also be caused by high blood levels of manganese.”

The Gait Guys say once again, “gait changes in a client may be the first clinical presentation of other pathology, not all the time, but enough that you should be looking for anomalies.

Rinsho Shinkeigaku. 2002 Sep;42(9):885-8.
[A case of idiopathic portal hypertension (IPH) with hypermanganemia presenting as spastic gait].
Obama R1, Tachikawa H, Yoshii F, Takeoka T, Shinohara Y.