[A case of facioscapulohumeral muscular dystrophy complicated with complete A-V block]

Myocardial involvement and serious electrocardiographic abnormalities are rare in patients with facioscapulohumeral (FSH) muscular dystrophy. We reported a case of FSH muscular dystrophy complicated with complete A-V block. The case was that of a 48 year-old male with the complaints of exertional dyspnea. His chest X-ray showed cardiomegaly, and the electrocardiogram recorded on admission showed complete A-V block. On the His bundle electrogram, complete A-H block and prolongation of H-V intervals were noted. Therefore, a permanent pacemaker was implanted, and he has been doing well for over 10 years after implantation. Although it is well known that serious electrocardiographic abnormalities are not infrequently associated with Duchenne's progressive muscular dystrophy (DMD), there are few reports about pacing therapy for patients with muscular dystrophy. Because the daily activity of patients with rapidly progressive type of muscular dystrophy such as DMD is at a very low level, they do not require pacing therapy. Whereas in patients with the FSH type of muscular dystrophy, which is a slowly progressive type, their daily activity is maintained at a high level. Therefore, pacing therapy should be recommended if the FSH type of muscular dystrophy is accompanied with serious bradyarrhythmias.

Domiciliary investigation of sleep-related hypoxaemia in Duchenne muscular dystrophy

In Duchenne muscular dystrophy (DMD) nocturnal oxygen desaturation occurs during rapid eye movement (REM) sleep. Polysomnography, which requires hospital admission, will detect sleep-related breathing abnormalities. In order to avoid the inconvenience of hospital admission for the disabled patient, we investigated overnight oxygenation in ten boys with DMD by domiciliary oximetry. In four boys the results of oximetry were compared with those of a polysomnographic recording. The "repeatability" of domiciliary oximetry was assessed in six boys by performing oximetry on two non-consecutive nights. Older boys with DMD may develop a cardiomyopathy. In order to assess cardiac rhythm and ST segment changes we performed simultaneous Holter monitoring and oximetry in seven boys with overnight hypoxaemia. Six of the initial ten boys studied demonstrated episodic nocturnal hypoxaemia and there was a strong correlation between minimum oxygen saturation overnight and daytime arterial oxygen and carbon dioxide tensions (PaO2 r = 0.89; PaCO2 r = -0.87). Despite adequate REM time during polysomnography, greater oxygen desaturation was found during domiciliary oximetry. No difference was found in the severity of desaturation recorded in the boys who were studied on two separate occasions. Five boys demonstrated marked heart rate variation during hypoxaemic episodes and more serious arrhythmias occurred overnight in the three most hypoxaemic boys. Domiciliary oximetry is a simple, repeatable method of assessing overnight oxygenation and compares well with polysomnography. In boys with advanced DMD and severe nocturnal hypoxaemia, 24 h electrocardiographic monitoring may detect potentially life-threatening arrhythmias.

Lethal congenital muscular dystrophy with cataracts and a minor brain anomaly: new entity or variant of Walker-Warburg syndrome?

A term newborn male with severe hypotonia and contractures was found to have dense bilateral cataracts. He died at age 3 days of respiratory failure. Amino acidopathies and disorders of peroxisome function were excluded, and results of serologic studies and placental histopathology, specifically seeking evidence of intrauterine infection, were normal. Autopsy showed changes in the skeletal muscles consistent with congenital muscular dystrophy and a small focal anomaly of the cerebral cortex. These findings either represent a new syndrome or raise further questions about broadening the spectrum of known congenital muscular dystrophy syndromes with associated eye and brain anomalies.

The effect of neuromuscular diseases on the development of dental and occlusal characteristics

Fourteen patients suffering from primary muscular disease (myopathies), including seven with Duchenne's muscular dystrophy, were compared to 11 patients whose neuromuscular disorders were of neuropathic origin. Mesioclusion was observed only in the group with Duchenne's muscular dystrophy. Posterior crossbite, anterior open bite, mouth breathing, and large tongue were also more prevalent in the group with myopathies, especially the Duchenne's patients, than they were in the group with neurogenic disorders. The Duchenne's patients exhibited a statistically significant delay in dental emergence, unlike the patients with other myopathies and those with neurogenic disorders. Dentition and occlusion may be more affected in patients with myopathies, especially Duchenne's muscular dystrophy, than they are in patients with neurogenic disorders.

DMD carrier detection in a female with mosaic Turner's syndrome

Images

[Myocardial involvement in 2 women, carriers of Duchenne de Boulogne muscular dystrophy]

Duchenne muscular dystrophy is the commonest genetic muscular disease. The prognosis, which depends on cardiac involvement, is poor. In boys, this takes the form of a hypokinetic cardiomyopathy particularly affecting the postero-lateral wall of the left ventricle which then dilates. The recent identification of the gene which transmits the disease on the X chromosome and of the coded protein, dystrophin, has improved our understanding of the disease. We report two cases of isolated cardiac involvement in two female carriers of the disease, classically thought to be unaffected. They presented with apparently idiopathic dilated cardiomyopathies. These cases show that Duchenne muscular dystrophy is an original example of a genetically determined diffuse muscular disease with cardiac involvement.

[Respiratory failure and its care in Duchenne muscular dystrophy]

Respiratory failure is the major cause of death in patients with Duchenne muscular dystrophy (DMD). In this report we retrospectively examined the clinical courses, pulmonary function, progression of scoliosis and the time of assisted ventilation. Forty nine patients, aged 2 to 27 years were studied and thirty eight patients of them were examined twice in some intervals. The subjects of examinations included pulmonary function studies consisting of spirometry, measurement of the thoracic scoliosis measured according to the method of Cobb and room air arterial blood gas values. The results were the following; 1) The decline in percentage values of vital capacity (%VC) began at age 8 or 9 and decreased consistently with age. Finally %VC reached under 10 percent at mean age of 21.53 with respiratory failure. 2) Thoracic scoliosis measured according to the method of Cobb increased further with advancing age. The greater the angle of curvature, the more likely the development of respiratory failure. 3) Sixteen patients received negative pressure ventilator (chest respirator: CR) between 16.5 and 25.1 years of age. Twelve patients used part-time (mainly night-time) ventilator and four patients used it in full-time. The average PaCO2 and PaO2 before administration of ventilator were 67.49 mmHg and 71.46 mmHg, respectively. The levels after ventilation were 58.01 mmHg (PaCO2) and 82.09 mmHg (PaO2).

Benign muscular dystrophy with autosomal dominant inheritance

A slowly progressive myopathy was discovered in a family in four successive generations. Eight patients (four female, four male) from three generations were examined and they showed muscle weakness affecting predominantly proximal, but also distal, muscles. Two patients had unequivocal findings in childhood, the others showed myopathy in their twenties or thirties. Working ability was lost in physically demanding jobs in the thirties, but activities of daily living were still preserved. Elbow contractures, tight heel cords and contractures of the interphalangeal joints were frequent. Serum CK activity was usually mildly elevated and electromyographic examinations revealed myopathic changes. Histopathological changes were compatible with moderately advanced muscular dystrophy in two patients, the six others had mild myopathic changes.

Evidence supporting tight linkage of X-linked Emery-Dreifuss muscular dystrophy to the factor VIII:C gene

In a large German family with Emery-Dreifuss muscular dystrophy (EDMD) linkage analysis was performed using the factor IX gene (F9), the factor VIII:C gene (F8), the anonymous DNA probe DXS52, and DXS15 as markers. Tight linkage was found between the EDMD locus and the F8 probe (Zmax = 1.19; theta max = 0.00), DXS15 (Zmax = 1.75; theta max = 0.00) and DXS52 (Zmax = 2.26; theta max = 0.00). Weak linkage was found to F9 (Zmax = 0.02; theta max = 0.43). The data from the literature and our results suggest that the gene locus of EDMD is close to F8 (confidence interval theta = 0-0.07). The new linkage data are useful for carrier detection and diagnosis of EDMD patients before onset of major clinical signs.

Correlation between clinical features and deletions of the gene for dystrophin in Duchenne muscular dystrophy

The clinical course and prognosis of Duchenne muscular dystrophy (DMD) was compared in patients with deletions of the gene for dystrophin (cDMD) and those without such deletions. A total of 24 patients was followed for at least 2 yrs. At age 12 the rating of the activities of daily life (ADL) and disease stage were less favorable in those patients with deletions of the gene for cDMD. At age 14, no difference in ADL and disease stage was observed between the two groups. The percent vital capacity was lower in those patients with the cDMD deficit. When the prognosis was evaluated by multivariate analysis of the data obtained at age 12, the percent of patients predicted as dying before the age of 20 was 40% for those without the cDMD deficit but 76% for those who were cDMD defective. None of the cDMD defective patients lived longer than 20 yrs, whereas 5 of 14 patients without the cDND deficit survived longer than 20 yrs. Disorders such as cardiac and respiratory failure were also seen more frequently in the cDND defective patients. These results suggest that patients with Duchenne muscular dystrophy with defective cDMD have more severe disease than those without cDMD deficit.

Fatal rhabdomyolysis complicating general anaesthesia in a child with Becker muscular dystrophy

A 6-yr-old boy who presented with brown urine due to myoglobinuria and who was otherwise virtually asymptomatic was diagnosed as having Becker muscular dystrophy on the basis of a greatly elevated creatine kinase, muscle biopsy, dystrophin analysis, and a deletion of exons 3-7 in the dystrophin gene. Fifteen months later, during a general anaesthetic for dental treatment, he had a cardiac arrest associated with acute rhabdomyolysis, hyperkalaemia and hypocalcaemia. He died 4 days later. This case is reported to highlight this rare but potentially fatal complication of anaesthesia in muscular dystrophy, and to discuss possible ways of preventing such a catastrophe.

Fractures in myopathies

The paper reports the results obtained in a study on the frequency of fractures in patients affected with Duchenne Muscular Dystrophy and Spinal Muscular Atrophy, types II and type III; the patients were observed between 1974 and 1988 at the muscle clinic of the Rizzoli Orthopaedic Institute. Out of a total of 238 cases, 36 (15.1%) reported one or more fractures during the follow-up period. For each fracture, age, functional capacity, the particular circumstances in which fractures occurred, site and type of fracture, medical treatment and consequences were all considered. A protocol for fracture prevention in neuromuscular patients is proposed, and suitable methods of treatment suggested.

[A case report of monitoring neuromuscular blockade during anesthesia in a patient with facioscapulohumeral muscle dystrophy]

Facioscapulohumeral muscle dystrophy (FSHMD) is characterized by slowly progressive wasting of facial, pectoral and shoulder-girdle muscles that begins in adolescence. A 31 year-old man with FSHMD had dystrophic changes in the deltoid, anterior serratus and pectoralis major muscles but not in the distal muscle of his arms and legs. He underwent an operation for thoraco-scapula fixation under enflurane-nitrous oxide anesthesia with vecuronium 6 mg. At the end of the surgical procedure, the train-of-four (TOF) responses of a thumb and a toe, as measured by using an acceleration transducer, were recorded simultaneously. TOF stimulation in an arm demonstrated an apparent fade phenomenon (TOF; 0.54), while a TOF test in the leg showed complete recovery of the TOF ratio (TOF; 1.0). The patient revealed no clinical signs of residual neuromuscular blockade. It was clear that there was a difference in the degree of neuromuscular block between the arm and the leg in a FSHMD patient. Use of the peripheral nerve stimulator only in the arm may be an unreliable guide to assess neuromuscular block in FSHMD patients. Therefore, two sites should be chosen for monitoring neuromuscular blockade in a FSHMD patient.

A manifesting carrier of Duchenne muscular dystrophy with severe myocardial symptoms

A 42-year-old so-called manifesting carrier of Duchenne muscular dystrophy (DMD), whose first complaints were severe myocardial symptoms, is described. Immunohistochemical study using anti-dystrophin anti-serum and analysis of cloned segments of X chromosome DNA were performed. Her two sons and one of her brothers appear to have had the same disease. She was admitted to the hospital complaining of dyspnoea, back pain and palpitations and was first diagnosed as having myocardial infarction. However, this diagnosis was excluded. The echocardiogram showed diffuse abnormalities of myocardial function. Serum enzymes were increased. Minimal weakness and decreased deep tendon reflexes were detected in her left lower extremity. Muscle biopsy revealed a small number of necrotic fibres. Immunohistochemical study using anti-dystrophin antiserum showed a mosaic pattern of the surface membrane. Analysis of cloned segments of X chromosome DNA from the patient and her son showed the XmnI(Asp) alleles of pERT 87-15 and the TaqI alleles of pERT 87-8 in both patients.

Equilibrium radionuclide ventriculography in Duchenne's cardiomyopathy

Myocardial dysfunction in 14 patients with Duchenne's muscular dystrophy (DMD) was evaluated by Tc-99m HSA multigated radionuclide ventriculography (MGRV). Follow-up studies were performed on eight patients for 5 years. Left ventricular ejection fraction and standard deviation of the phase angle were abnormal in all patients older than 15 years. Hypokinetic changes and phase delay were recognizable in most patients older than 17 years. Peak filling rate decreased in patients older than 17 years. MGRV was considered an effective method for evaluating serial changes in cardiomyopathy of patients with DMD.

[Electrocardiographic evaluation of myocardial co-involvement in Duchenne muscular dystrophy: prognostic implications in a case with multiple localizations]

After a review of the literature on myocardial involvement (MI) in Duchenne's progressive muscular dystrophy (DMD), the authors report a case with an extensive MI. This severe myocardial functional impairment is a poor index in the prognosis of DMD. The authors emphasize the use of echocardiography in the screening of MI in DMD.

[Severe tooth agenesis. Presentation of a case]

In the present work the Authors describe a case of a patient affected by Duchenne disease as well as by dental multiple agenesis. It is a particular case of such rare syndromes in the same subject.

Deletion mapping of Aland Island eye disease to Xp21 between DXS67 (B24) and Duchenne muscular dystrophy

Aland Island Eye Disease (AIED) is an X-linked form of ocular hypopigmentation--also known as Forsius-Eriksson, or type 2, ocular albinism--in which affected males demonstrate subnormal visual acuity, protanomalous red-green colorblindness, axial myopia, astigmatism, hypoplasia of the fovea, and hypopigmentation of the fundus. A patient has previously been described who, in addition to AIED, manifested a contiguous gene syndrome which included congenital adrenal hypoplasia (AHC), glycerol kinase deficiency (GKD), and Duchenne muscular dystrophy (DMD). In the present paper report we report the molecular genetic analysis of his deletion. Initially, multiplex polymerase-chain-reaction amplification was used to screen for a DMD-locus deletion which was then further characterized, using DMD cDNA and genomic probes, via Southern blot analysis. The deletion includes the region encompassed by probes C7 (DXS28) and DMD cDNA 8. Probes B24 (DXS67) and DMD cDNA 5b-7 show normal hybridization patterns and appear to flank the deletion, while the DMD cDNA 8 detects a junction fragment. Molecular genetic techniques have mapped the deletion in this patient to the subbands Xp21.3-21.2, between DXS67 and DMD.

[A case of Becker muscular dystrophy with schizophrenic symptoms]

A 23-year-old male patient with Becker muscular dystrophy (BMD) who showed schizophrenic symptoms was reported. He tumbled easily and was poor at running since age at 8 years. He had difficulty in climbing stairs and was idle away all day long since age at 21 years. Although his premorbid personality was not schizoid, he showed auditory hallucinations and delusions without any psychogenetic moment at the age of 23. At first, he seemed to be schizophrenic, but after the treatment with antipsychotics, he always had an insight into his disease and exhibited natural emotional communication. He showed no autism and character changes. According to the Wechsler Adult Intelligence Scale (WAIS), intellectual impairment was notified (total IQ58). Neurological examinations revealed weakness and atrophy of muscles in the proximal part of his lower extremities, and pseudohypertrophy of calves. In the serum enzyme, serum creatine kinase (CK) level was elevated (700 U/L). Abnormal Q waves appeared in the leads, II, III, aVF, V5, V6 on the electrocardiogram (ECG), and the finding of the echocardiography suggested dilated cardiomyopathy. The electroencephalogram (EEG) revealed the basic rhythm of 9-10 Hz with 0 activities of 6-7 Hz which were predominant in frontparietal and central leads. The electromyogram (EMG) revealed a myopathic pattern with low voltage and short duration. A muscle biopsy from right biceps brachii disclosed the abnormal immunofluorescent staining pattern of dystrophin which is consistent with BMD patient, i.e., "patchy," discontinuous and faint immunoreaction at surface membrane of the fiber. Both molecular weight (380 kd: n = 400) and amount (30%; n = 100) of dystrophin were reduced.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardiomyopathy in progressive muscular dystrophy]

A dilated cardiomyopathy with clear signs of left-ventricular functional abnormalities occurred in a 21-year-old man with known Duchenne's progressive muscular dystrophy. Echocardiography and magnetic resonance imaging delineated the regional disorder of ventricular wall motion and defined its segmental extent. With neither method was it possible to analyse texture with demonstration of differential regional involvement. As a noninvasive method echocardiography is suitable for diagnosing Duchenne's cardiomyopathy and monitoring its progression.

[Cardiac disorders in Steinert's disease. Indication of pacemaker in two patients of the same family]

From the study of two cases of Steinert's disease in the same family, who have benefited by the implantation of pacemaker for troubles of conduction, we propose to make a review of the present knowledge related to this pathology with a particular emphasis on the cardiac symptomatology.

The relationship between 24 hour total heart beats or ventricular arrhythmias and cardiopulmonary function in patients with Duchenne's muscular dystrophy

To evaluate the relationship of 24 hour total heart beats (THB) or ventricular arrhythmias and cardiopulmonary function, 29 patients with Duchenne's muscular dystrophy (DMD) were studied using Holter electrocardiographic and echocardiographic recordings. The THB were 144,428 +/- 12,237 beats per 24 hours in the child group (8 to 15 years, n = 12) and 136,355 +/- 19,991 beats per 24 hours in the adult group (16 to 25 years, n = 17). The THB in the adult group significantly correlated well with % VC (r = -0.74), PaCO2 (r = 0.67), PaO2 (r = -0.59) and the respiration rate (r = 0.71), but not in the child group. In both groups, the echocardiographic parameters of the left ventricular size and function (left ventricular dimension, ejection fraction and D/S ratio) did not significantly correlate with the THB. Premature ventricular contractions (PVCs) were observed in 14 of the 29 patients (48.3%), and high risk PVCs (Lown's grade 3-4b) were observed in 11 of these 14 patients (78.6%). Echocardiographic parameters of the left ventricular function in the high risk PVC group were significantly deteriorated as compared with the low risk PVC group (Lown's grade 0-2) (p less than 0.02-p less than 0.001). We conclude that the THB in the adult group was mainly related to depressed pulmonary function, and the severity of the PVCs in both the adult and child groups was mainly related to the degree of left ventricular dysfunction.