Sydenham's chorea—clinical characteristics of nine patients

Sydenham's chorea is still the most frequently seen form of acquired chorea in childhood in developing countries. Nine patients presented with Sydenham's chorea as one of the major criteria (one or more attacks) were evaluated their clinical characteristics and treatment. All patient were given sodium valproate. Clinical improvement began 11+/-4.0 days in sodium valproate treatment, and no adverse effect was seen due to the drugs. Echocardiography revealed rheumatic carditis sequela in all patient. The nine Sydenham's chorea patients presented 13 attacks of chorea in follow-up. We observed isolated chorea in 44% of patients, and 22% presented one or more recurrences. The interval between the attacks ranged from months to 2 years. The 90% of the patients were not on prophylaxis with benzathine penicillin. One patient had diagnosis of obsessive-compulsive disorder, and one had diagnosis of attention deficit hyperactivity disorder in the follow-up period. This report emphasizes the significance of Sydenham's chorea and sequela of rheumatic carditis association and a high risk of developing neuropsychiatric disorders in the follow-up period. Valproic acid is an effective and safe drug in the treatment of Sydenham's chorea.

Choreic syndrome and coeliac disease: a hitherto unrecognised association

Coeliac disease has been associated with a variety of neurological conditions, most frequently cerebellar ataxia and peripheral neuropathy. To date, chorea has not been associated with coeliac disease. We present the case histories of 4 individuals with coeliac disease and chorea (4 women, average age of onset of chorea 61 years). Unexpectedly, most of these patients showed a notable improvement in their motor symptoms after the introduction of a gluten-free diet.

Bilateral chorea-ballism associated with hyperthyroidism

We describe a 50-year-old patient with four episodes of recurrent bilateral chorea-ballism (BCB) and associated hyperthyroidism. Reappearance of BCB, associated with increased serum levels of thyroid hormones and lack of relevant changes on brain computed tomography/magnetic resonance imaging scans, suggested that the involuntary movements were likely due to thyrotoxicosis-induced biochemical changes.

Are sensory phenomena present in Sydenham's Chorea? Evaluation of 13 cases

Sydenham's Chorea (SC) is an early complication of rheumatic fever caused by group A beta-hemolytic streptococcal infection that manifests itself with adventitious choreatic movements and behavioral problems. Sensory phenomena are the premonitory sensory experiences that are described prior to tics. Tic disorders and SC share common underlying neurobiological substrates, yet sensory phenomena have not previously been examined in SC. We aimed to explore the presence of sensory phenomena associated with choreatic movements in children with SC. Thirteen SC patients are examined on measures of sensory phenomena using a semi-structured instrument. 10 out of 13 patients described sensory phenomena. Five of the SC patients described sensory phenomena as "between physical and mental". The patients described physical feelings of tension in joints, tingling and trembling sensations on skin. 69 % of them described movements as "completely involuntary". Sites of choreatic movements that were consistently preceded by sensory phenomena were upper and lower extremities, and trunk. Children may have difficulty in articulating sensory phenomena due to the subjective nature of premonitory feelings in SC. We recommend exploring the sensory experiences that might accompany the choreatic movements in children with SC.

Chorea as manifestation of epilepsia partialis continua in a child

The authors present a case of a child with epilepsy who developed choreoathetotic movements coinciding with the development of epilepsia partialis continua. His abnormal movements and seizures resolved after successful management of his epilepsia partialis continua with intravenous immunoglobulin and steroid therapy. The authors propose that the chorea was an unusual manifestation of epilepsia partialis continua.

On-line anosognosia: Unawareness for chorea in real time but not on videotape delay

In hemiplegics, anosognosia (unawareness of deficit) rests on a mismatch between expected and actual movement: a feedback hypothesis emphasizes sensory deficits or neglect, a feedforward hypothesis postulates impaired intention to move. Anosognosia for other problems is less studied. The authors report a man without sensory deficits who was unaware of choreiform movements, except on videotape delay. The authors believe that a feed-forward mechanism underlies his "on-line" unawareness.

Carotid transient ischemic attacks presenting as limb-shaking syndrome: report of two cases

Limb shaking syndrome (LSS) is a rare presentation of transient ischemic attacks (TIAs), usually secondary to a critical carotid stenosis compromising intracranial circulation, first described 40 years ago. Two additional cases are described herein, aiming to add on to previous descriptions, and to warn physicians about this potentially harming and rather uncommon condition.

Effective treatment with oxcarbazepine in paroxysmal kinesigenic choreoathetosis

Paroxysmal kinesigenic choreoathetosis is often responsive to anticonvulsants such as carbamazepine and phenytoin. We report a boy with paroxysmal kinesigenic choreoathetosis, which is dramatically relieved by oxcarbazepine even after unsatisfactory treatment with carbamazepine and other medications.

Distressing belching and neuroacanthocytosis

We report on an uncommon manifestation of molecularly proven neuroacanthocytosis in a 32-year-old man in whom dyspnea with desaturation while awake accompanied by continuous involuntary belching were the major consequences of the disease.

Chorea-acanthocytosis associated with tourettism

We report on a case of Chorea-acanthocytosis (ChAc) in association with Tourettism that consisted of motor and vocal tics, attention deficit-hyperactivity disorder, and obsessive-compulsive disorder in addition to the typical symptoms of ChAc. The subject was compared with his elder sister who had the same disease but milder clinical profile and neuroradiological findings. The [(18)F]-2-fluoro-2-deoxyglucose positron emission tomography (FDG-PET) findings did not explain the differences in symptomatology between the patient and his sister, although they may have correlated with severity.

Pure cerebello-olivary degeneration of Marie, Foix, and Alajouanine presenting with progressive cerebellar ataxia, cognitive decline, and chorea

Parenchymatous cerebellar cortical atrophy (CCA) usually presents with a "pure" cerebellar ataxia. We describe a patient with a sporadic, late-onset progressive cerebellar ataxia plus cognitive decline and chorea who had CCA at post mortem. We discuss this unique case in the current context of classification of idiopathic cerebellar ataxia.

Benign familial and non-familial infantile seizures: a study of 64 patients

INTRODUCTION

The recently proposed diagnostic scheme for people with epileptic seizures and with epilepsy (Epilepsia 2001) includes two idiopathic focal epileptic syndromes with onset during the first year of life, the benign familial and non-familial infantile seizures.

OBJECTIVES

To analyze the electroclinical features and evolution in patients with benign familial and non-familial infantile seizures.

PATIENTS AND METHODS

Sixty-four patients (36 males and 28 females) were evaluated at the Neurology Department of the J. P. Garrahan Children's Hospital between February 1990 and December 2001. We analyzed gender, age at onset, duration, manifestations, circadian distribution and frequency of seizures, family history of epilepsy and paroxysmal dyskinesias. EEG and neuroradiological studies were performed. The semeiology of the seizures was analyzed only according to the description in the clinical history. Ictal EEGs could not be recorded.

RESULTS

Twenty-five patients, 14 girls and 11 boys, had a family history of similar seizures with an age at seizure onset of 3 to 22 months (median of 5.5 months). Nine patients (36%) had apparently generalized convulsions only; five patients (20%) partial seizures only and ten patients (50%) had both partial and generalized seizures. Convulsions were brief, during wakefulness in all, and occurred in clusters in 12 patients (48%). Interictal EEG was normal in 24 patients (96%). Similar seizures and age at onset were found in 14 fathers, ten mothers and one uncle of these patients. Twenty-two patients (88%) had their last seizure before the age of 30 months. Two siblings of the same family later had brief episodes of paroxysmal kinesigenic dyskinesia, which in one of them were associated with infantile seizures. Later, two fathers developed paroxysmal kinesigenic dystonia. One of them also had had infantile seizures. A second group of 39 patients (25 boys and 14 girls) showed similar electroclinical features and evolution but there was no history of infantile seizures in first-degree relatives family history of epilepsy was found in 12.8% of second-degree relatives, but the type of epilepsy could not be defined.

CONCLUSION

This study confirms the existence of a familial benign epileptic syndrome in infancy, of probable dominant autosomical transmission. A large group also had similar electroclinical features but without a family history. We discuss the possible relationships between the two groups and suggest that further genetic studies may solve the problem.

Phenotypical variability of expanded alleles in the TATA-binding protein gene. Reduced penetrance in SCA17?

Trinucleotide expansions in the gene for the TATA-binding protein (TBP) have recently been described in cerebellar ataxia associated with dementia, pyramidal tract and basal ganglia symptoms. Expansions above 45 repeat units are commonly considered pathological, causing SCA17. Here, we present a German kindred with four siblings affected by cerebellar ataxia, chorea and dementia. Molecular genetic analysis yielded an expanded SCA17 allele coding for 48 glutamine residues that was transmitted from the mother to all of her six children. Apparently, the expanded allele does not cosegregate with the disease phenotype since the mother and two of the siblings do not show any clinical abnormality. This appears to be the first description of non-penetrance in SCA17.

Minimal tissue damage after stimulation of the motor thalamus in a case of chorea-acanthocytosis

Autopsy findings are reported from a patient with chorea-acanthocytosis treated for 2 years by deep brain stimulation (DBS) of the motor thalamus. Postoperative testing showed a progressive improvement in axial truncal spasms. Although relatively high currents were used for 2 years in this patient, postmortem analysis showed minimal tissue damage in the vicinity of the electrode tip. It is concluded that DBS has little impact on the surrounding tissues.

Tetrabenazine treatment for Huntington's disease-associated chorea

Tetrabenazine (TBZ), a monoamine depleter and dopamine receptor blocker, is used to treat a variety of hyperkinetic movement disorders. The objective was to study the efficacy and tolerability of TBZ for chorea associated with Huntington's disease (HD). Nineteen patients (12 female), mean age 56.3 +/- 12.4 years (range 37-76 years) diagnosed with HD were prospectively evaluated at initial and follow-up visits using a modified Abnormal Involuntary Movement Scale (AIMS). Patients were videotaped, and the randomized videotapes were rated with the motor subset of the AIMS by two investigators who were blinded to treatment assignment. Eighteen patients completed and were rated after 5.9 +/- 3.3 months (range 2-11) at a final mean TBZ dose of 62.5 +/- 37.4 mg/day (range 25-150). The blinded videotaped motor scores showed that 15 were better on TBZ, 2 were better before TBZ, and 1 was unchanged (p < 0.001, Wilcoxon signed rank test). The mean score improved from 16.2 +/- 4.8 to 12.8 +/- 4.4. Adverse events included akathisia, insomnia, constipation, depression, drooling, and subjective weakness. All 18 of these patients have continued to take TBZ since completion of the study. TBZ was well tolerated and resulted in a significant improvement in modified AIMS scores in HD patients. These results support the use of TBZ for chorea in patients with HD.

A case of paroxysmal kinesigenic dyskinesia with spastic paraparesis

We report the first case of paroxysmal kinesigenic dyskinesia (PKD) with spastic paraparesis. A 17-year-old male began to show a dystonic posture in both his upper limbs when walking at age 12 years. Neurological examination revealed bilateral talipes cavus, spasticity in all extremities with general hyperreflexia and pathological reflexes. On starting to walk, he showed a dystonic posture in bilateral maniphalanx, wrists, elbows, and toes. Magnetic resonance imaging (MRI) revealed high T2-weighted signal intensity in bilateral pyramidal tract. Although the combination of pyramidal and the basal ganglia disorders is very rare, the present case suggests an inter-relation of the pyramidal and the basal ganglia systems.

Chorea associated with non-ketotic hyperglycemia and hyperintensity basal ganglia lesion on T1-weighted brain MRI study: a meta-analysis of 53 cases including four present cases

BACKGROUND

Chorea associated with non-ketotic hyperglycemia and high signal intensity lesions on T1-weighted brain magnetic resonance images (C-H-BG) is recognized as a unique syndrome that affects elderly women exclusively. However, its overall clinical features are unclear.

MATERIAL AND METHODS

The literature describing patients with C-H-BG from 1985 to 2001 was reviewed using MEDLINE. Their clinical features and those of four patients with C-H-BG at this hospital were analyzed.

RESULTS

This study included 49 patients from the literature and four patients at this hospital. Their mean age at the onset was 71.1 years (range=22-92 years). Women were affected more frequently than men (men/women=17:30). The mean serum glucose level measured after the onset of chorea was 481.5 mg/dl (ranging from 169 to 1264), HbA1c level was 14.4% (ranging from 9.9 to 19.2), and the serum osmolarity was 305.9 mmol/kg (ranging from 291 to 335). Forty-seven patients developed hemichorea. Six patients developed bilateral chorea, and magnetic resonance imaging (MRI) showed bilateral basal ganglia lesions. MRI showed that putamen was involved in all cases (isolated putamen=31 patients, additional basal ganglia lesions=22 patients). None had lesions confined to the caudate nucleus or the globus pallidus. In all, except one, the anterior limb of the internal capsule was spared. Follow-up MRI studies were performed in 22 patients. In most, hemichorea improved along with the disappearance of the lesions. In 39 patients, chorea had ameliorated completely. The remaining 14 cases showed some improvement during the follow-up period. The chorea recurred in seven patients.

CONCLUSION

C-H-BG is a benign disorder affecting the elderly. It affects men much more frequently than has been reported. The high signal intensity basal ganglia lesion on the T1-weighted brain MRI study was reversible, and correlated with the clinical improvement in chorea.