Although a mild stooped posture is a hallmark of
parkinsonism, extreme trunk forward flexion is not common. This phenomenon was described in different etiological entities and called
camptocormia. Other similar presentations called Pisa syndrome and antecollis were described mainly in
extrapyramidal disorders. Authors present two cases of probable
multiple system atrophy (MSA) with predominant
parkinsonism and Pisa syndrome (or
camptocormia). Both of them were previously misdiagnosed as
idiopathic Parkinson's disease (PD) and one was reported 1 year earlier. The typical clinical presentation fulfilling the diagnostic criteria for
multiple system atrophy, rapid progression with lack of responsiveness to
L-DOPA and
apomorphine and typical MRI putaminal pathology observed in both cases allowed us to make a diagnosis. Accuracy of clinical diagnosis in
multiple system atrophy is still very poor. Therefore, unusual or rare clinical presentations may support the final diagnosis. The
camptocormia, Pisa syndrome and antecollis may represent the continuum of the same motor phenomenon and most of the authors refer them to unusual form of axial
dystonia. According to many clinical presentations on different forms of
camptocormia/Pisa syndrome authors conclude that not etiology, but the localization of specific lesion, probably within putamen is responsible for that form of
dystonia. In cases of
parkinsonism and severe forward flexion of trunk
multiple system atrophy, diagnosis should be considered.