Lentiform fork sign in a uremic patient after inadvertent exposure to metformin

Abstract

This case report describes a 56-year-old woman receiving regular hemodialysis for three years who presented with an unsteady gait for one month, dysarthria, and frequent choking on liquids for two weeks. Brain MRI revealed a characteristic “lentiform fork sign” with hyperintense T2W/FLAIR signal in the bilateral lentiform nuclei and restricted diffusion in bilateral globus pallidus. She was inadvertently prescribed metformin 1,000 mg per day one month ago by a physician who was unaware of her end-stage kidney disease. After intensive hemodialysis therapy with eight hemodialysis sessions within 12 days, her neurological deficits fully resolved. Clinicians should be aware of metformin-induced encephalopathy, presenting with relevant medication history, neurological symptoms, and the lentiform fork sign.

Keywords:

• End-stage kidney disease
• metformin
• metabolic acidosis
• encephalopathy
• lentiform nucleus

Disclosure statement

None declared.

Additional information

Funding

The authors acknowledge the financial support for research purpose by the “Yin Yen-Liang Foundation Development and Construction Plan” of the School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan [107F-M01-0504], the Ministry of Science and Technology, Taipei, Taiwan [MOST 109-2314-B-010-053-MY3, MOST 109-2321-B-009-007, MOST 109-2811-B-010-532, and MOST 110-2811-B-010-510], Taipei Veterans General Hospital, Taipei, Taiwan [VGHUST109-V5-1-2 and V110C-194], and the “Center for Intelligent Drug Systems and Smart Bio-devices (IDS²B)” from The Featured Areas Research Center Program, MOE in Taiwan.