Magnetic resonance images of the brain showed striking symmetric increased signal in the globus pallidus, substantia nigra, dentate nucleus, and pontine tegmentum on T1-weighted images (Figure) with little correlation on T2-weighted images (not shown), which demonstrated only modest hyperintensity in the region of the posterior limb of the internal capsule. There was no evidence of edema. Laboratory tests showed normal concentrations of blood albumin, alkaline phosphatase, γ-glutamyl transferase, total bilirubin, ceruloplasmin, serum copper, and 24-hour urine copper. Prothrombin time was 51.8 seconds (reference range, 33-43 seconds); aspartate aminotransferase level, 67 U/L (reference range, 10-40 U/L); and alanine aminotransferase level, 114 U/L (reference range, 2-60 U/L). Blood manganese concentration was 49 μg/L (897 nmol/L) (reference range, 4-16 μg/L [78-289 nmol/L]), and urine manganese concentration, 2804.3 nmol/24 h. A second blood manganese concentration 5 months after the first determination was 102 μg/L (1860 nmol/L) while the patient was still self-injecting methcathinone but before he admitted this to us. Tests for hepatitis A and B yielded negative results. Hepatitis C RNA was 405 000 IU/L, and a percutaneous liver biopsy specimen showed chronic active hepatitis with fibrosis. 6-[18F]-Fluorodopa positron emission tomography performed as previously described8 showed a mild reduction in fluorodopa uptake (Ki) limited to the posterior putamen (Table).