The Wilson Films — Sydenham Chorea Francisco Cardoso, MD, PhD* Neurology Service, Internal Medicine Department, The Federal University of Minas Gerais, Belo Horizonte, MG, Brazil Patient number 10 on the film by Samuel Alexander Kin- nier Wilson is a girl with generalized chorea, which is, however, asymmetric with greater involvement of the left side. Unlike some of the other cases recorded on the video, the authors of the paper were not able to locate the file of this patient in the archives of the National Hospital of Neurology, Queen Square, London. 1 The patient was filmed in at least 2 different settings: in a ground area, where she is sitting, and, rather surprisingly, at a narrow fire escape where her gait is recorded. The captions inform that Wilson diagnosed the girl with Sydenham’s chorea (SC). I will discuss the demographics, investigation, differ- ential diagnosis, and management of this case. Demographics In the absence of the file of the patient, one limits himself to speculate about her demographics. She seems to be entering puberty, with a possible age of 12 or 13 years. Her modest outfit, in contrast to some of the other patients shown on the video (eg, the patient with possible Huntington’s disease [HD]) leads one to suggest that she came from a poor family. Although London is not particu- larly renowned for its sunshine, the cloudy sky in the back- ground of the clip showing the gait of the girl as well as her overcoat suggest that the temperatures were low, although certainly not too low since the film was shot out- doors. It is well known that the incidence of SC increases after cold weather when Streptococcus infection is ramp- ant. All these demographic features are in keeping with what had been firmly established by the observation of numerous cases of SC a few decades earlier at the same National Hospital. Indeed, in his textbook, based on the observation of a large number of patients, Gowers demon- strates that SC was overrepresented among the poor, being more frequent in girls and with the onset usually at late childhood. 2 Contemporary studies confirm these notions. 3,4 Despite the fact that SC is more commonly seen in underdeveloped areas of the world, it must be emphasized that it remains the most common cause of acute chorea in children worldwide. 5,6 Phenomenology As stated in the caption, the film shows a continuous flow of unpredictable movements, which are generalized and asymmetric (left greater than right). These movements meet current criteria of chorea. 4 Among all causes of cho- rea, it is SC whose phenomenology mostly evokes the impression of dance, which justifies the choice of the Greek word to designate this movement disorder. I add that the movements of the girl have a pure nature that conforms to this notion. This contrasts with, for instance, HD, in which chorea is blended with dystonia, rigidity, and other movement disorders. 4 In at least 20% of patients with SC, there is only hemichorea. In many other subjects, the movement disorder is asymmetric. The chorea of the girl being more severe on her left side is thus in line with contemporary knowledge of SC. 7 Another interesting fea- ture well-recorded by Wilson is the lack or persistence of the tongue protrusion in consequence of the choreic movements, which often lead to its retraction. The author draws the attention of the viewers to the abnormal swing- ing of the arms during the gait. These are the so-called pseudointentional movements, whose underlying mecha- nism is the disinhibited ventrolateral thalamus sending fragments of motor program to the cortex. 4 Considering that he uses 1 of the segments of the film to demonstrate the difficulty in eliciting knee jerks of the patients, Wilson seems to give great importance to this clinical feature in SC. More recently, the decreased tendon reflexes in SC also struck us. In 1 study, we failed to identify evidence of peripheral nerve involvement in SC, suggesting that the reflex abnormality is secondary to CNS dysfunction. 8 Investigation In the early 20th century, there was already a realization of the link between SC and ‘‘cardiac rheumatism.’’ 9 Indeed, up to 80% of patients with SC have coexistent cardiac lesion, particularly mitral stenosis. 4,7 If we had access to the file of the patient, it would not surprise us to find men- tion to physical examination showing a cardiac murmur ------------------------------------------------------------ *Correspondence to: Dr. Francisco Cardoso, Dr. Francisco Cardoso, Av Pasteur 89/1107, 30150-290 Belo Horizonte, MG, Brazil; cardosofe@ terra.com.br Relevant conflicts of interest/financial disclosures: Dr Cardoso has received a research grant from FAPEMIG and honoraria from Novartis and Roche. Full financial disclosures and author roles may be found in the online version of this article. Received: 3 October 2011; Revised: 10 October 2011; Accepted: 23 October 2011 Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/mds.24032 REVIEW Movement Disorders, Vol. 26, No. 14, 2011 2477