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Abstract
A rapidly progressive, generally symmetric, ascending flaccid paraparesis or quadriparesis that develops in an infant or child constitutes an uncommon but important pediatric neurologic emergency that requires immediate evaluation and treatment. The differential diagnosis primarily includes acute neuropathies, most commonly the childhood Guillain-Barré syndrome and, rarely, acute transverse myelitis or infantile poliomyelitis. A clinical distinction may be difficult in the younger child in whom detailed sensory examination is not possible. Although most children with Guillain-Barré syndrome usually have a benign and relatively limited clinical illness, some become severely ill, requiring intubation and careful intensive monitoring. To date, no well-controlled multi-institutional studies of treatment with either plasmapheresis or intravenously administered immunoglobulin have been developed in children despite the success of these modalities in adults. A review of the data available using these therapies is included in this study.
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Jones HR, Herbison GJ, Jacobs SR, Kollros PR, Macones GA. Intrauterine onset of a mononeuropathy: peroneal neuropathy in a newborn with electromyographic findings at age one day compatible with prenatal onset. Muscle Nerve 1996; 19:88-91. [PMID: 8538675 DOI: 10.1002/(sici)1097-4598(199601)19:1<88::aid-mus12>3.0.co;2-#] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Mononeuropathies are unusual at birth, and electromyographic (EMG) definition the first day of life has not been reported previously. Although neonatal mononeuropathies may be related to obstetric complications, prenatal mechanisms also merit consideration. We report an infant, born with a peroneal neuropathy, whose EMG was performed 18 h after birth. An isolated peroneal nerve lesion with lack of compound muscle action potential and the presence of fibrillation potentials, confined to the tibialis anterior muscle, suggested a primary intrauterine mechanism for this mononeuropathy. Because of an infant's small size, the temporal profile used in adults for appearance of EMG signs of wallerian degeneration may not apply. Inaccurate conclusions may result if the EMG standards for timing adult nerve injury are applied to newborns. To our knowledge, previous published cases of neonatal mononeuropathies have not included babies whose first EMG was performed before age 4 days. Therefore, an EMG study shortly after birth needed to be accomplished if strong support for the hypothesis of a prenatal onset were to be generated. Our findings are compatible with an intrauterine onset of this baby's peroneal neuropathy.
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Jones HR. Guillain-Barré syndrome in children. Curr Opin Pediatr 1995; 7:663-8. [PMID: 8776016 DOI: 10.1097/00008480-199512000-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The Guillain-Barré syndrome is a pediatric neurologic emergency and the most common cause in children of rapidly evolving, usually flaccid, weakness with associated areflexia. Two treatable illnesses, namely tick paralysis and acute cord compression, demand immediate differential diagnosis. Rarely, poliomyelitis still mimics infantile Guillain-Barré syndrome. Specific precursor infections, such as Campylobacter jejuni, are now recognized to affect the clinical presentation of Guillain-Barré syndrome. Cerebrospinal fluid evaluation and electromyography are usually diagnostic; new modalities, such as anti-GM1 antibodies, magnetic resonance imaging, and magnetic stimulation, are being evaluated in childhood Guillain-Barré syndrome. Although most cases of Guillain-Barré syndrome have benign courses, all require initial respiratory and autonomic monitoring to prevent fatal outcomes. No well-controlled pediatric studies comparing plasmapheresis with intravenous immunoglobulin have occurred. Results of treatment with either modality are encouraging. A synopsis of these reports is included in this review.
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Deymeer F, Jones HR. Pediatric median mononeuropathies: a clinical and electromyographic study. Muscle Nerve 1994; 17:755-62. [PMID: 8008002 DOI: 10.1002/mus.880170709] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Seventeen children, 6 girls and 11 boys, aged 5-17 years with pediatric median mononeuropathies (PMM) were identified among 1809 who had EMGs primarily in the electromyographic laboratory at The Children's Hospital, Boston, between 1979 and 1993. Electromyography documented the PMM to be at the wrist in 7 children, including 3 children with idiopathic carpal tunnel syndrome (CTS)--1 whose symptoms were accentuated by skiing--2 with a systemic illness (mucolipidosis III and scleroderma), and in 1 child each the distal PMM was secondary to a cast or laceration. A proximal PMM was identified in 10 children, including 8 with trauma, 1 with an osteoid osteoma, and 1 with juvenile cutaneous mucinosis. Five children (3 with CTS and 1 each with mucolipidosis III and juvenile cutaneous mucinosis) had bilateral disease. The localization (59% proximal) and cause of these PMMs differed greatly from our experience with adult median neuropathies.
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Olafsson E, Jones HR, Guay AT, Thomas CB. Myopathy of endogenous Cushing's syndrome: a review of the clinical and electromyographic features in 8 patients. Muscle Nerve 1994; 17:692-3. [PMID: 8196719 DOI: 10.1002/mus.880170625] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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32
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David WS, Jones HR. Electromyography and biopsy correlation with suggested protocol for evaluation of the floppy infant. Muscle Nerve 1994; 17:424-30. [PMID: 8170489 DOI: 10.1002/mus.880170410] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Eighty infants with nonarthrogrypotic floppy infant syndrome (FIS) were evaluated between 1979 and 1990. Electromyographic data were correlated with results of muscle and nerve biopsies in 41 of 80 who had concomitant biopsies (38) or other diagnostic analyses (3). A diagnosis was made of Werdnig-Hoffmann disease (WHD) in 15, a congenital infantile polyneuropathy (IPN) in 3, neuromuscular transmission defect (NMTD) in 2, myopathy in 12, and presumed "central" hypotonia in 9. A very positive correlation rate between nerve conduction studies with electromyography and biopsy results was found in 93% (14 of 15) with WHD and 100% in IPN (3 of 3). However, only 4 of 10 infants (40%) with biopsy-proven myopathy had an abnormal EMG. Only once did the results of electromyography and biopsy conflict.
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Jones HR, Felice KJ, Gross PT. Pediatric peroneal mononeuropathy: a clinical and electromyographic study. Muscle Nerve 1993; 16:1167-73. [PMID: 8413369 DOI: 10.1002/mus.880161105] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Seventeen children with pediatric peroneal mononeuropathies evaluated between 1979 and 1991 are reported. Twelve boys and 5 girls, ranging in age from 1.5 months to 17 years, were referred for footdrop in 16 children (94%) or for lower extremity pain in 1 child (6%). Causes included compression in 10 children (59%), trauma in 3 children (18%), entrapment in 3 children (18%), and indeterminate in 1 child (5%). Based on nerve conduction studies and electromyography, the level of the pediatric peroneal mononeuropathic lesion was the common peroneal nerve in 10 children (59%), the deep peroneal nerve in 2 children (12%), and the superficial peroneal nerve in 1 child (5%). In 4 other children (24%), pediatric peroneal mononeuropathy at the knee was not more precisely identified. Surgical exploration in 3 children with progressive pediatric peroneal mononeuropathy was valuable. Improvement occurred in 13 of 17 children (76%).
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Felice KJ, Schneebaum AB, Jones HR. McArdle's disease with late-onset symptoms: case report and review of the literature. J Neurol Neurosurg Psychiatry 1992; 55:407-8. [PMID: 1602316 PMCID: PMC489087 DOI: 10.1136/jnnp.55.5.407] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
McArdle's disease with late-onset symptoms is an unusual cause for muscle disease in older patients. The case of a patient with McArdle's disease whose symptoms began at 60 years of age is presented, and seven previous cases of late-onset McArdle's disease reported since 1963 are discussed. In five of the eight patients, the clinical presentation was similar to the early onset disorder with exercise intolerance, cramps, and myoglobinuria. In contrast, the remaining three patients presented with fixed proximal limb and bulbar weakness. Electromyography confirmed a myopathic process in four of four patients. Results of the forearm ischaemic exercise test were positive in seven of seven patients with complete myophosphorylase deficiency; results of muscle biopsies were diagnostic in all patients. McArdle's disease with late-onset symptoms is rare and clinically more variable than the early onset disorder.
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Bradshaw DY, Jones HR. Guillain-Barré syndrome in children: clinical course, electrodiagnosis, and prognosis. Muscle Nerve 1992; 15:500-6. [PMID: 1565119 DOI: 10.1002/mus.880150415] [Citation(s) in RCA: 115] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The electrodiagnostic features of acute childhood Guillain-Barré syndrome (GBS) have not been distinguished from those in the adult. We report nerve conduction and electromyographic data from 23 children. Sixty-one percent (14 of 23) fulfilled strict electrodiagnostic criteria for a demyelinating neuropathy, and the remainder demonstrated demyelination in at least one nerve. Reduced compound muscle action potential (CMAP) amplitude was the most common finding overall. Children less than 10 years old demonstrated significantly greater slowing of motor CV than children greater than 10 years old. Electrodiagnostic criteria associated with poor outcome (low mean CMAP and fibrillation potentials) in previous studies, primarily of adult patients, occurred in 39% (9 of 23 children). All patients on whom follow-up data were obtained recovered without residual disability. We conclude that electrodiagnostic prognostic indicators identified in general series of GBS may not apply to children.
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Abstract
Results of electrophysiologic and clinical findings in 17 patients with proximal median neuropathy were reviewed. The cause of neuropathy was trauma in 5 patients, overuse of the pronator teres in 3 patients, postinfectious in 2 patients, secondary to a congenital lesion in 1 patient, and undetermined in 6 patients. The neuropathy involved the main branch of the median nerve at or proximal to the pronator teres muscle (high median neuropathy) in 14 patients, and the anterior interosseous portion of the nerve in 3 patients. Electrophysiologic findings, especially needle electromyography (EMG), were more definitive than findings expected from clinical examinations. EMG and operative findings demonstrated that median nerve compression by the pronator teres produces denervation of this muscle as well as distal muscles. EMG cannot differentiate a median nerve lesion at the pronator teres from a more proximal lesion. Follow-up data were available in 7 of 10 nonsurgically managed patients, and in 6 of 7 patients with surgical decompression. Six patients in each group were either improved or normal.
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37
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Lee NS, Jones HR. Extracranial cerebrovascular disease. Cardiol Clin 1991; 9:523-34. [PMID: 1913731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The prevention, management, and prognosis of patients with transient ischemic attack or stroke caused by extracranial cerebrovascular disease depend on the underlying pathophysiologic mechanisms involved. Atherosclerotic vascular disease is the predominant pathophysiologic mechanism. Management of this entity remains controversial and should be individualized. Recent data have clearly confirmed that carotid endarterectomy is better than medical therapy. Patients with a critically tight carotid stenosis appropriate in location to their symptoms are considered for carotid endarterectomy. This procedure should be performed only in the setting of excellent neuroradiologic support and surgical expertise, however, with a cumulative complication risk of less than 3%. Intimal dissection appears to be associated with a good prognosis with or without treatment. However, patients with symptoms should receive short-term therapy with antiplatelet or anticoagulant agents to prevent distal embolization. Corticosteroids are the drugs of choice for treatment of patients with extracranial arteritis. The presence of fibromuscular dysplasia in the cerebrovascular system has not proved to be a definitive risk for stroke or transient ischemic attack.
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38
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Abstract
Nontraumatic childhood peroneal mononeuropathy is uncommon and should initiate a search for surgically correctable causes. In 3 children, 2 age 12 years and 1 age 13 years, unilateral footdrop developed over a few days to a month. Electrodiagnostic findings demonstrated lesions with maximal or exclusive involvement of the deep peroneal nerve. Radiologically, bony exostoses were identified at or near the fibular head in each patient. In 2 patients, the lesions were clinically occult. An osteochondroma was removed from each patient and 2 patients had excellent clinical recoveries.
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39
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Newmark J, Jones HR, Thomas CB, Aretz HT, Freiberg SR, Baker RA. Vertebral haemangioma causing acute recurrent spinal cord compression. J Neurol Neurosurg Psychiatry 1991; 54:471. [PMID: 1865219 PMCID: PMC488559 DOI: 10.1136/jnnp.54.5.471] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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40
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Salgado ED, Jones HR. Indications for carotid endarterectomy: when to operate and when not to operate. J Neurosurg Anesthesiol 1990; 2:201-2. [PMID: 15815343 DOI: 10.1097/00008506-199009000-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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41
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Abstract
Electromyographic examination of the newborn and young infant provides a relatively uncommon challenge to most electromyographers. The usual reason for referral for electromyographic studies in the newborn and young infant is to evaluate a floppy baby. The electromyographer must not only be aware of important differences in normal physiologic parameters but must also be familiar with a spectrum of diseases that are not typically encountered in the adult. The results of electromyography must also be correlated with the normal maturation of neuromuscular function. Although the most common pathophysiologic mechanisms affecting the peripheral motor unit are infantile motor neuron disease and the congenital myopathies, a large number of other disease entities warrant careful consideration.
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42
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Jones HR, Siekert RG. Neurological manifestations of infective endocarditis. Review of clinical and therapeutic challenges. Brain 1989; 112 ( Pt 5):1295-315. [PMID: 2679968 DOI: 10.1093/brain/112.5.1295] [Citation(s) in RCA: 79] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The nervous system is frequently involved in patients with infective endocarditis. When a careful review of presenting complaints is undertaken, neurological symptoms have been found in as high as 29% of patients. Because these manifestations may be so protean in nature, for example, stroke or transient ischaemic attack (the most common), toxic encephalopathy, meningitis, brain abscess, visual loss, seizures, headache, backache, or acute mononeuropathy, the neurologist needs to consider infective endocarditis as a possible diagnosis in many patients. During the past two decades, infective endocarditis has occurred in an ever widening clinical setting. It may often be found in persons unknown to have predisposing cardiac disease. This is particularly true in certain subsets of the population, including the elderly, patients subjected to various invasive procedures leading to nosocomial infection, and drug abusers. New diagnostic studies, including refined bacteriological culture techniques, echocardiography, computed tomography, magnetic resonance imaging, and greater availability of skillful cerebral angiography, make earlier diagnosis of infective endocarditis possible. Despite this, patients with neurological complications continue to have an uncertain prognosis.
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43
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Ridout PS, Jones HR, Williams JG. Determination of trace elements in a marine reference material of lobster hepatopancreas (TORT-1) using inductively coupled plasma mass spectrometry. Analyst 1988; 113:1383-6. [PMID: 3239819 DOI: 10.1039/an9881301383] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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44
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Abstract
A latissimus dorsi muscle flap was used to repair a severe traumatic avulsion defect of the dorsum of the foot in a 3-year-old girl. The severed peroneal nerve apparently regenerated across a large gap and spontaneously reinnervated the denervated muscle flap. This resulted in a functional flap as demonstrated clinically and electromyographically. Surgical methods of muscle reinnervation and the influence of neurotrophic factors are discussed.
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45
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Jones HR. Pizza cutter's palsy. N Engl J Med 1988; 319:450. [PMID: 3398902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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46
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Jones HR, Gianturco LE, Gross PT, Buchhalter J. Sciatic neuropathies in childhood: a report of ten cases and review of the literature. J Child Neurol 1988; 3:193-9. [PMID: 2850315 DOI: 10.1177/088307388800300309] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Primary lesions affecting the sciatic nerve are uncommon, especially in children. Isolated sciatic nerve involvement was found in ten patients during an 8 1/2-year period at a metropolitan children's hospital. Etiologic mechanisms included three with compression and one each with stretch injury after operation using the lithotomy position, stretch injury after closed reduction of hip dislocation, puncture wound, lymphoma, hypersensitivity vasculitis associated with hypereosinophilia, indeterminate lesion associated with transverse myelitis, and idiopathic progressive lesion with negative findings on exploration. Neonatal injuries associated with breech delivery or intragluteal injections were not causative factors in this series. Children with sciatic neuropathies have a variable prognosis depending on the etiology. Compression was the only potentially preventable pathophysiologic mechanism.
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47
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Jones HR, Ho DD, Forgacs P, Adelman LS, Silverman ML, Baker RA, Locuratolo P. Acute fulminating fatal leukoencephalopathy as the only manifestation of human immunodeficiency virus infection. Ann Neurol 1988; 23:519-22. [PMID: 3389758 DOI: 10.1002/ana.410230515] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A case of acute human immunodeficiency virus (HIV) infection manifested by a rapidly fulminating, necrotizing, demyelinating encephalopathy that led to brain death in 5 days is reported. Autopsy demonstrated predominant white matter lesions, acute neuronal damage, and scanty cellular response. Cultures of cerebrospinal fluid were positive for HIV, suggesting an acute infection.
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48
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Abstract
A case of severe bilateral injury to the hypoglossal nerves after two-stage carotid endarterectomy is described. Injury to the hypoglossal nerve occurs in up to 20% of patients undergoing carotid endarterectomy and may result in mild or unnoticed deficits. These injuries must be carefully searched for in patients who will undergo a similar procedure on the opposite side since a bilateral deficit of the hypoglossal nerve is poorly tolerated, causing potentially serious impairment of speech and risk of aspiration.
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Perlmutter DH, Gross P, Jones HR, Fulton A, Grand RJ. Intramuscular vitamin E repletion in children with chronic cholestasis. AMERICAN JOURNAL OF DISEASES OF CHILDREN (1960) 1987; 141:170-4. [PMID: 3468801 DOI: 10.1001/archpedi.1987.04460020060027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Progressive spinocerebellar degeneration was identified in six children with chronic cholestatic liver disease and attributed to severe vitamin E deficiency. In addition to areflexia, ataxia, dysmetria, and diminished vibratory and position sense, three patients had pigmentary retinopathy. Abnormalities were present on electromyography, nerve conduction studies, and electroretinography. Because the vitamin E deficiency was not corrected by oral administration of massive doses of vitamin E, vitamin E was administered by the intramuscular route. With doses of 50 to 100 mg of vitamin E every three to seven days, over a 32-month interval (range, 15 to 44 months), vitamin E deficiency and abnormal red blood cell peroxide hemolysis were corrected. Other than discomfort and occasional edema at the site of injection, there were no side effects of parenteral vitamin E therapy. In several other studies intramuscular vitamin E therapy has produced significant neurologic improvement in patients with similar characteristics. In this study clinical progression of spinocerebellar degeneration was arrested but improvement could not be demonstrated despite adequate vitamin E replacement.
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50
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Russell JA, Jones HR. Clinical value of electrodiagnostic studies in neuromuscular disorders. Med Clin North Am 1986; 70:1333-47. [PMID: 3784694 DOI: 10.1016/s0025-7125(16)30902-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
EMG and conduction studies provide the physician with a precise means of defining the multiple diseases affecting the peripheral motor-sensory unit. These studies frequently provide clues that may be useful in arriving at the appropriate therapeutic decisions and in determining prognosis. Normal results may also support a suspected clinical diagnosis of inorganic illness, providing no evidence of central nervous system disease can be defined. Like any other test, however, results of EMG may be false-negative in bona fide neuromuscular disorders. This is particularly true early in a disease process; in neuropathies restricted primarily to small, unmyelinated nerve fibers; and in certain of the less virulent diseases of muscle and muscle energy metabolism.
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