BMJ Case Reports 2012; doi:10.1136/bcr-2012-006263
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The Hummingbird sign: a diagnostic clue for Steele-Richardson-Olszweski syndrome

  1. Sayantan Ray
  1. Department of General Medicine, Medical College and Hospital, Kolkata, West Bengal, India
  1. Correpondence to Dr Nikhil Sonthalia, nikhil_zenith{at}


Progressive supranuclear palsy (PSP), previously known as Steele-Richardson-Olszweski syndrome, is an atypical parkinsonian syndrome with a prevalence of ∼5/100 000. It is an important differential diagnosis of more common idiopathic Parkinson's disease (iPD), where clinical differentiation is not straightforward and characteristic neuroimaging often yields a diagnostic clue. We describe a case of 75-year-old man with a history of slowness of activities and recurrent fall while walking, which was insidious in onset and gradually progressive for last 2 years. There was no history of tremor, stooping postures, urinary incontinence or hallucination. On examination supranuclear vertical gaze palsy with slow horizontal saccades, axial rigidity and bradykinesia were present. He had a slow gait with lack of associated movements and tendency to fall backwards. He had positive ‘dirty tie sign’ while eating. The patient was diagnosed as a probable case of PSP and MRI of the brain was done. Mid-sagittal T2-weighted MRI of the brain revealed characteristic selective atrophy of midbrain tegmentum (mesencephalon), with relatively preserved …

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