We describe a 56-year-old man with relapsing sarcoidosis who presented with persistent hiccup responsive to steroid and clonazepam treatments. The patient also showed parkinsonism. The interval between the initial presentation and current symptoms was about 30 years. Brain MRI demonstrated foci of abnormal signal intensity in the cerebral white matter bilaterally, with decreased signal intensity on T1-weighted imaging and increased signal intensity on T2-weighted, diffusion-weighted, and FLAIR images. Gadolinium-enhanced MRI of the brain showed diffuse linear enhancement throughout the cerebral white matter with a confi guration suggesting perivascular infi ltration. Spinal MRI revealed spotty gadolinium-enhancing lesions from C2 to T3 segments. This case suggests that in some sarcoidosis patients intractable hiccup may be associated with high spinal cord lesions and parkinsonism with frontal white matter lesions.

We describe the first case of a patient with Japanese encephalitis suffering from central sleep apnea. The patient was a 58-year-old man who presented with high fever, semicomatose state, nuchal stiffness, and incontinence of feces. The patient had complication of severe pneumonia, and was ventilated with a respirator. After weaning from the respirator, desaturation of oxygen was observed during the night. Simplified polysomnography revealed a pure central apnea pattern. This case illustrates that Japanese encephalitis can result in central sleep apnea.

We report a case of unilateral tonic pupil in spinocerebellar ataxia without brainstem atrophy in a 42- year-old man. On neurological examination, he showed cerebellar symptoms and unilateral tonic pupil. Deep tendon reflexes were normal except for brisk patellar tendon reflexes. Brain MRI demonstrated cerebellar atrophy only. There was neither orthostatic hypotension nor bowel and bladder failure. The right pupil constricted from 5.0 mm to 1.7 mm 60 minutes after 0.125% pilocarpine administration, whereas the left pupil did not change, remaining at 3.7 mm. Although it is not proven that tonic pupil is causally related to spinocerebellar ataxia, physicians must remain aware of spinocerebellar ataxia as a disease that can demonstrate tonic pupil.

Objective: Cervical dystonia (CD) is a clinically under-recognized symptom occurring at the later- to end-stages of Parkinson’s disease (PD). The frequency of CD and its influence on prognosis have not been well studied. Here, we conducted an in-depth examination of CD incidence and impact on disease progression in later-stage PD. Methods: We retrospectively reviewed the clinical features of 22 deceased patients with sporadic PD treated at a hospital in Japan from 1983 to 2008. Results: The most common cause of death in PD was pneumonia. CD, in particular retrocollis, was frequent in the later stages of the disease in elderly patients (9/22, 40.9%). Pneumonia incidence increased sharply in the later period with CD. There was a positive trend between CD duration and duration of pergolide use. Conclusion: Analysis revealed that CD increases markedly in late- to end-stage PD, which may be associated with aspiration pneumonia due to dysphagia. Pathological mechanisms underlying CD might be influenced by treatments including dopamine agonists. Prevention of CD may increase quality of life and prolong survival of PD patients.