Pisa syndrome in an elderly elite mountain walker: an exceptional mode of presentation of extrapyramidal disease.

A 68-year-old fell walker, at the end of a 20 miles walk taking 12 h, noticed the progressive onset over several minutes of an irresistible lean to the left forcing him to rest before carrying on to his destination (Figure 1). The symptoms worsened and were provoked by shorter distances over the next 6 months. He had no other serious illnesses other than wellcontrolled hypertension. He displayed bilateral cogwheel hypertonia, reduced arm swing and impaired balance on the left. A CT head scan showed evidence of the widespread small vessel disease. A Dat-SPECT scan was normal.