Endocrine Abstracts

Objective: Dysarthria is a motor speech disorder resulting from impairment in strength, speed and coordination of neural and/or muscular structures that are related to respiration, voice and speech. They may be classified as motor neuron dysarthria, cerebellar dysarthria and extrapyramidal dysarthria (subdivided as hypokinetic and hyperkinetic). Patients with dysarthria are evaluated primarily by neurology specialists. Though, we present our case to emphasize that dysarthria may not only result from neurological disorders but also metabolical disorders.

Case report: A 51-year-old male patient was brought to emergency clinic with complaint of sudden onset speech disorder. With prediagnosis of cerebrovascular disorder, cerebral magnetic resonance imaging (MRI) and computed tomography (CT) scan were performed. For presence hyperdense lesions in CT scan, he was consulted to a neurosurgery specialist with prediagnosis of intracerebral hemorrhage. Lesions were not considered as hemorrhage by the neurosurgeon did not consider the lesions as intracerebral hemorrhage or subarachnoidal hemorrhage and referred the patient to neurology department for basal ganglia pathology. Patient’s clinical and radiological findings was not considered as cerebrovascular disease by neurology. There was no low ADC values to suggest acute stroke in diffusion weighted MRI. Cerebral MRI revealed T2A hyperintensity in supratentorial periventricular regions suggesting leukoaraiosis. Cranial CT scan revealed calcifications in deep gray matter, thalamus, supra- and infratentorial regions and was reported as Fahr’s diseased. Total serum calcium level was low (4.5 mg/dl). Ionized calcium study was not available. From his background evaluation, he complaint of tingling in his hands and muscle cramps for a few years. He had a history of pathological fracture in his leg 20 years before and there was gait disturbance.

His physical and neurological examinations were performed. He was awake but dysoriented. Dysarthria was present. Chvostek and Trousseau signs were positive. Respiratory system, cardiovascular system and abdominal examinations were normal. There was genu varum deformity in lower extremities. He had candida onychomycosis in his hands and feet and hyperpigmented regions on the anterior part of tibia secondary to convlescent exematous lesions. Bone mineral density T scores in the distal radius, lumbar spine and femur neck were −5.7, −0.1 and +1.5 respectively. Total serum calcium, parathyroid hormone (PTH) and magnesium levels were low, and phosphorus and alkaline phosphatase (ALP) levels were high. Urea, creatinine, alanine aminotransferase (ALT), aspartate aminotransferase (AST), sodium, potassium, chlorine and thyroid hormone levels were normal. The patient who had primary hypoparathyroidism and mucocutaneous candidiasis is diagnosed with autoimmune polyendocrinopathy type 1. The patient was given peroral calcitriol, peroral and intravenous calcium and peroral magnesium daily. He was in need of high dose calcium. For candida onychomycosis, terbinafine was given.

During follow-up, dysarthia was improved and cramps did nor reccur. Celiac disease was ruled out. He was discharged with peroral calcium carbonate 3000 mg/day and peroral calcitriol 3 μg/day.

Result: Though dysarthria originates mostly from neurological disorders, metabolic disorders should also be looked for.