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Older-onset levodopa-responsive parkinsonism with normal DAT-SPECT and pterin hypometabolism
  1. Kazuyuki Togo1,2,
  2. Toshiya Ishihara1,
  3. Kenji Yamamoto1 and
  4. Hideyuki Sawada1
  1. 1Department of Neurology, National Hospital Organization Utano National Hospital, Kyoto, Japan
  2. 2Neurology, Osaka University Graduate School of Medicine, Suita, Japan
  1. Correspondence to Dr Kenji Yamamoto;{at}


Pterin species participate in dopamine biosynthesis, and abnormal pteridine metabolism contributes to reduced dopamine. GTP cyclohydrolase 1 (GCH-1) deficiency, which triggers pteridine hypometabolism and normally develops in childhood, can mediate an adult-onset decrease in levodopa production and dopa-responsive dystonia (DRD), with normal dopamine transporter single-photon emission computed tomography (DAT-SPECT). A recent study described normal DAT-SPECT in adult-onset cases with GCH-1 mutations, clinically diagnosed with Parkinson’s disease, which raises the possibility that the abnormal metabolism of pteridine may be a differential diagnosis for adult-onset parkinsonism. We report an older patient with levodopa-responsive parkinsonism with normal DAT-SPECT, or scans without evidence of dopamine deficit (SWEDD), whose biochemical analysis showed pterin hypometabolism, which occurs in GCH-1-deficient DRD. Surprisingly, this patient presented no dystonia or GCH-1 gene mutation or deletion. This case suggests that low pterin metabolism should be considered in older-onset levodopa-responsive parkinsonism with normal DAT-SPECT, even without GCH-1 mutations or deletions.

  • movement disorders (other than Parkinsons)
  • drugs: CNS (not psychiatric)
  • neuroimaging

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  • Contributors KT, TI and KY were equally involved in the medical management of the patient. KT evaluated the patient, analysed and interpreted the data, reviewed the literature, and drafted the initial and revised article. KY contacted the patient for consent and contributed to project conception and writing/manuscript preparation. TI and HS contributed to critical review, commentary and revisions. HS was involved in the planning and guidance of the written manuscript. All authors approved the final version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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