A 4-year-old boy presented with insidious psychomotor regression at the age of 12 months. Brain MRI revealed symmetric lesions in the bilateral basal ganglia (Fig. 1a), whereas brain magnetic resonance spectroscopy (MRS) revealed no abnormalities (Fig. 1b). Muscle biopsy revealed ragged red fibers, megaconia, and mitochondrial respiratory chain complex I defect. Genetic investigation confirmed the ND3 mitochondrial mutation 10191T>C. He was diagnosed with Leigh syndrome. Two years later, he experienced seizures. MRI revealed new focal diffusion-restricted lesions in multiple cortices (Fig. 2a), and MRS revealed an inverted doublet lactate peak (Fig. 2b). He was finally diagnosed with Leigh-MELAS overlap syndrome.
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