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A 60-year-old woman presented with a clinical picture consistent with multiple system atrophy of cerebellar type (MSA-C) and a 4-year history of involuntary movement. These movements consisted of painless semirhythmic, semicontinuous flexion and extension of the toes (Video). Nerve conduction studies and MRI scans of lumbosacral spine showed no abnormalities. Because the patient also had slight rigidity in her right arm, we obtained a DaTscan, which showed uptake reduction bilaterally with more reduction on the left side (Figure). We diagnosed her with painless legs and moving toes1,2 associated with MSA-C. The involuntary movements resolved with levodopa treatment.
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