Chronic proximal spinal muscular atrophy

Spinal muscular atrophy type III complicated by spinal superficial siderosis: a case report with molecular and neuropathological findings

Spinal muscular atrophy (SMA) is largely linked to deletion or mutation of the Survival motor neuron 1 (SMN1) gene located on chromosome 5q13. Type III (Kugelberg–Welander disease) is the mildest childhood form and patients may become ambulatory and have a normal life expectancy. We report the clinical history and morphological findings of a 55-year-old woman who began to experience motor problems at the age of two. She was never fully ambulatory, and her severe scoliosis required the insertion of surgical rod at age 19. Unexpectedly, around 35 years of age, she began to experience sensory symptoms best characterized as a myelo-radiculo-neuropathy with pain as the dominant symptom. Investigations never clarified the etiology of these symptoms. Molecular confirmation of SMA type III was done post-mortem. Neuropathological examination showed classic changes of lower motor neuron neurodegeneration, in line with those reported in the single molecularly confirmed case published so far, and with findings in rare cases reported prior to the discovery of the gene defect. A key autopsy finding was the presence of a severe superficial siderosis of the lower half of the spinal cord. In recent years, the concept of duropathy was put forward, associating superficial siderosis of the spinal cord with various spinal abnormalities, some of which were present in our patient. The presence of significant hemosiderin deposits in the spinal cord and sensory nerve roots with associated tissue and axonal damage provide a plausible explanation for the unexpected sensory symptomatology in this mild lower motor neurodegeneration.

Isolated spinal accessory mononeuropathy associated with neurogenic muscle hypertrophy: restricted neuralgic amyotrophy or stretch-palsy? A case report

A 55-year-old man developed transient bi-brachial paresthesias followed by severe pain over his left shoulder ridge and periscapular region within 8 hours of rigorous hand-over-hand hoisting of a 33.8-kg (75-lb) object. He experienced weakness in shoulder abduction followed several weeks later by focal hypertrophy of the left trapezius. Electrophysiologic studies showed significant spontaneous motor activity in the form of denervation potentials, fasciculations, and complex repetitive discharges. The 2 major diagnostic considerations were restricted neuralgic amyotrophy versus stretch palsy of the spinal accessory nerve. The clinical similarities and differences between restricted forms of neuralgic amyotrophy and stretch palsies are discussed.

Deletion of murine SMN exon 7 directed to skeletal muscle leads to severe muscular dystrophy

Spinal muscular atrophy (SMA) is characterized by degeneration of motor neurons of the spinal cord associated with muscle paralysis and caused by mutations of the survival motor neuron gene (SMN). To determine whether SMN gene defect in skeletal muscle might have a role in SMA pathogenesis, deletion of murine SMN exon 7, the most frequent mutation found in SMA, has been restricted to skeletal muscle by using the Cre-loxP system. Mutant mice display ongoing muscle necrosis with a dystrophic phenotype leading to muscle paralysis and death. The dystrophic phenotype is associated with elevated levels of creatine kinase activity, Evans blue dye uptake into muscle fibers, reduced amount of dystrophin and upregulation of utrophin expression suggesting a destabilization of the sarcolemma components. The mutant mice will be a valuable model for elucidating the underlying mechanism. Moreover, our results suggest a primary involvement of skeletal muscle in human SMA, which may contribute to motor defect in addition to muscle denervation caused by the motor neuron degeneration. These data may have important implications for the development of therapeutic strategies in SMA.

Electrodiagnostic studies in amyotrophic lateral sclerosis and other motor neuron disorders

The clinical electrodiagnostic medicine (EDX) consultant asked to assess patients with suspected amyotrophic lateral sclerosis (ALS) has a number of responsibilities. Among the most important is to provide a clinical assessment in conjunction with the EDX study. The seriousness of the diagnoses and their enormous personal and economic impact require a high-quality EDX study based on a thorough knowledge of and experience with motor neuron diseases (MNDs) and related disorders. Clinical evaluation will help determine which of the EDX tools available to the EDX consultant should be applied in individual patients. Although electromyography (EMG) and nerve conduction study are the most valuable, each of the following may be helpful in the assessment of selected patients based on their clinical findings: repetitive nerve stimulation, motor unit number estimate, single-fiber EMG, somatosensory evoked potential, autonomic function test, and polysomnography. The pertinent literature on these is reviewed in this monograph. The selection and application of these EDX tools depend on a thorough knowledge of the MNDs and related disorders.

Segmental distribution of muscle weakness in SMA III: implications for deterioration in muscle strength with time

We examined 26 spinal muscular atrophy type III (SMA III) patients with SMNt deletions, searching for possible segmental distribution of muscle weakness. In those with disease duration of < or = 11 years, the weakest muscles were upper lumbar innervated ones in the lower extremities. In the upper extremities, early involvement of triceps muscle suggested the possibility of lower cervical (C7) onset. Electrophysiologically, weaker muscles had a more severe reduction in the recruitment pattern, particularly in the lower extremities. However, severe reduction in recruitment was sometimes also observed in clinically strong muscles. In patients with disease duration of > or = 16 years and regardless of disease duration, in those with disease onset at < or = 3 years of age, weakness and severe electrophysiological changes were more widespread. These findings may suggest a progression in muscle weakness with time. When compared to 12 patients with Becker muscular dystrophy (BMD), early stage SMA III with weak iliopsoas-strong gluteus maximus stood in contrast to BMD with weak gluteus maximus-strong iliopsoas.

Calf enlargement in neuromuscular diseases: a quantitative ultrasound study in 350 patients and review of the literature

Calf hypertrophy is a typical clinical feature in neuromuscular diseases such as X-linked muscular dystrophies of Duchenne and Becker type and can be seen as an atypical feature in numerous other diseases. The diagnosis of calf hypertrophy usually is based on subjective visual assessment. The aim of this prospective study was to examine the prevalence of calf hypertrophy in a large number of patients with various neuromuscular diseases based on quantitative ultrasound measurement of calf muscle thickness. Additionally, true and pseudohypertrophy should be distinguished according to the absence or presence of abnormal muscle echointensities caused by infiltration of fat tissue. Fifty adult normal controls and 350 patients with various neuromuscular diseases were investigated. Absolute calf hypertrophy was diagnosed if the combined thickness of the gastrocnemius and soleus muscles exceeded the mean value of the control persons by at least 3.0 standard deviations (SD). Relative calf hypertrophy was diagnosed when the ratio of the combined thicknesses of the gastrocnemius and soleus muscles divided by the combined thicknesses of the rectus femoris and vastus intermedius muscles lay at least 3.0 SD below the mean value of the controls. Pseudohypertrophy was present if the echointensities of the gastrocnemius and soleus muscles reached or exceeded 3.0 SD above the mean value of the controls. An absolute hypertrophy of the calves was detected in 80 patients (= 22,9%; 64 true and 16 pseudohypertrophies), 16 patients exhibited a relative hypertrophy of the calves (= 4.6%; 12 true and 4 pseudohypertrophies). A significantly increased portion of both absolute calf hypertrophies and pseudohypertrophies as compared to the control group were found in juvenile proximal spinal muscular atrophy type 3, central core disease, centronuclear myopathy, benign X-linked muscular dystrophy of Becker type, autosomal recessive limb girdle muscular dystrophy, acid maltase deficiency, polymyositis, and granulomatous myositis. A significantly increased number of relative calf hypertrophies was present in juvenile proximal spinal muscular atrophy type 3, facioscapulohumeral muscular dystrophy, and inclusion body myositis. In the majority of the diseases included in the study, calf hypertrophy occurred in at least some patients. In conclusion, calf hypertrophy is a frequent and unspecific clinical feature in many neuromuscular diseases. Ultrasound is a convenient method for the exact definition of calf hypertrophy.

Familial bulbospinal neuronopathy with optic atrophy: a distinct entity

A 61 year old woman and her 58 year old brother presented with the clinical picture of late onset progressive bulbar and spinal muscular atrophy with family history of involvement in successive generations. The sister also had optic neuropathy and the brother developed diabetes mellitus and sex hormone abnormalities. Neurophysiological and histopathological studies showed a pattern of motor and sensory neuronopathy. There was no abnormal expansion of CAG repeats in the androgen receptor gene. This family seems to have a previously unrecognised entity with the bulbospinal neuronopathy phenotype.

AAEM minimonograph #46: neurogenic muscle hypertrophy

Muscle hypertrophy occurs uncommonly in several neurogenic disorders including neuropathies, radiculopathies, spinal muscular atrophy, and post-polio syndrome. Its pathogenesis varies in different circumstances. In the presence of generalized myokymia and neuromyotonia (Isaacs' syndrome), symmetrical hypertrophy appears to be the result of continuous spontaneous electrical stimulation of myofibers and, in some cases, results in type 1 myofiber preponderance. Focal hypertrophy occurring with radiculopathies and mononeuropathies was associated with complex repetitive discharges (CRDs) in approximately half the cases. CRDs may play a role in the pathogenesis of myofiber hypertrophy by continuous myofiber stimulation, but in some cases, with and without CRDs, myofiber hypertrophy may be related to mechanical events. Muscle enlargement seen in old polio appears to involve a significant degree of pseudohypertrophy, although some myofiber hypertrophy occurs. The symmetrical occurrence of hypertrophy in genetically determined disorders, such as spinal muscular atrophy, and hereditary motor and sensory neuropathy types 1 and 2 may have both a genetic and a mechanical basis in addition to pseudohypertrophy in some cases.

Scoliosis and lung function in spinal muscular atrophy

The notes and radiographs of 43 patients with a confirmed diagnosis of spinal muscular atrophy were reviewed. A significant inverse linear relationship between the severity of scoliosis and the percentage of predicted vital capacity and peak flow was found. The patients who stood had a significantly better lung function than patients who were confined to a wheelchair, and their scoliosis deteriorated significantly more slowly. Sixteen patients underwent surgical spinal stabilisation, 4 with Harrington instrumentation and 12 with segmental spinal instrumentation, at an average age of 12 years and 11 months. The average curve correction achieved was 40%. The decline in lung function seen pre-operatively was not only reversed, but a significant improvement was found at final follow-up.

Limb girdle muscular dystrophy: description of a phenotype

The phenotype is reported of 20 patients with autosomal recessive or sporadic, pelvifemoral limb girdle muscular dystrophy (LGMD). Selective wasting of muscles was observed at the moderately advanced stage of illness. The pattern of weakness was uniform. Attention to clinical detail allowed the identification of a phenotype different from a hypothetical scheme of LGMD based on previous literature, and other causes of limb girdle weakness. These patients may represent yet another nosologic entity within the autosomal recessive dystrophies; molecular genetic studies are awaited. A limited magnetic resonance imaging (MRI) study of muscle was of little consequence. Although additional detail was obtained, no pathognomonic distribution of the dystrophic process was observed; interindividual variation existed even among closely matched siblings. The severity of MRI signal change did not consistently correlate with the degree of weakness in an individual. When a diagnosis is uncertain, however, the added detail may be useful.

Possible influences on the expression of X chromosome-linked dystrophin abnormalities by heterozygosity for autosomal recessive Fukuyama congenital muscular dystrophy

Abnormalities of dystrophin, a cytoskeletal protein of muscle and nerve, are generally considered specific for Duchenne and Becker muscular dystrophy. However, several patients have recently been identified with dystrophin deficiency who, before dystrophin testing, were considered to have Fukuyama congenital muscular dystrophy (FCMD) on the basis of clinical findings. Epidemiologic data suggest that only 1/3500 males with autosomal recessive FCMD should have abnormal dystrophin. To explain the observation of 3/23 FCMD males with abnormal dystrophin, we propose that dystrophin and the FCMD gene product interact and that the earlier onset and greater severity of these patients' phenotype (relative to Duchenne muscular dystrophy) are due to their being heterozygous for the FCMD mutation in addition to being hemizygous for Duchenne muscular dystrophy, a genotype that is predicted to occur in 1/175,000 Japanese males. This model may help explain the genetic basis for some of the clinical and pathological variability seen among patients with FCMD, and it has potential implications for understanding the inheritance of other autosomal recessive disorders in general. For example, sex ratios for rare autosomal recessive disorders caused by mutations in proteins that interact with X chromosome-linked gene products may display predictable deviation from 1:1.

Werdnig Hoffman's disease (spinal muscular atrophy type I): A clinical study of 25 Saudi nationals in Al-Khobar

We describe the clinical features of 25 cases of Werdnig Hoffman's disease (spinal muscular atrophy (SMA) type I) seen propectively over a two-year period at the King Fahd Hospital of the University (KFHU), Al-Khobar. The hospital incidence rate was 1.93 per 1,000 live births (95% confidence limits, 0.80-3.06/1,000). The estimated prevalence rate for the community was 0.92/10,000 with 0.59-1.25 per 10,000 children as its 95% confidence limits. The male to female ratio was 2:3. Reduced fetal movements were reported by six mothers; 8 children (32%) had symptoms at birth, and 24 (96%) had symptoms by the time they were six months old. Other features apart from hypotonia, muscle weakness, and absent deep tendon reflexes included head lag with inability to achive head control at six months (88%), respiratory problems consisting of difficulty with breathing or frequent chest infections (44%), and difficulty with feeding (40%). Wasting with fisciculations of the tongue was seen in 64%. Death occurred within six months of presentation in 75% of the cases. The parents were consanguineous in 64% of the cases. This high consanguinity rate was probably the major cause for the high population prevalence rate.

Sensory axonopathy in hereditary distal spinal muscular atrophy

A girl of 14 year is presented with a distal spinal muscular atrophy (SMA) with autosomal recessive inheritance. The technical findings are in agreement with the diagnosis. Light microscopical examination of sural nerve biopsy, including teased fiber studies and morphometry, showed no abnormalities. Electron microscopical investigation however demonstrated axonal pathology. The question arises if distal SMA is a distal axonopathy mainly of motor nerves, but to some extent also of sensory nerves.

Multifocal acquired demyelinating neuropathy masquerading as motor neuron disease

We report five patients with pure motor neuropathy characterized by multifocal weakness, muscle atrophy that was sometimes profound, cramps, and fasciculations with relatively preserved reflexes. The clinical picture led to an initial diagnosis of motor neuron disease in all cases, but nerve conduction studies revealed multifocal conduction block confined to motor axons and predominantly involving proximal nerve segments. Routine sensory nerve conduction studies, ascending compound nerve action potentials, and somatosensory evoked potentials were all normal even through nerve segments in which motor conduction was severely blocked. Onset of symptoms was insidious, and progression was indolent. In two cases, after many years of neuropathy, sensory abnormalities developed but remained clinically trivial. These unusual cases probably have the same pathogenesis as previously described patients with persistent multifocal conduction block. Distinction from motor neuron disease is critical, since chronic demyelinating neuropathy may respond to treatment.

A follow-up study of 60 cases of chronic spinal muscular atrophy

60 cases of chronic spinal muscular atrophy (CSMA) were followed-up for a period varying from 5 to 40 years. The neuromuscular impairment was evaluated by Norris' ALS score, both at the time of last examination and retrospectively at the time of diagnosis. Age at onset of symptoms was the most important factor in the progression of the neuromuscular damage. Monomelic or asymmetric location of symptoms at the time of diagnosis and duration of the disease were not significantly correlated to the worsening of ALS score.

Static spinal muscular atrophy causing temporomandibular joint dysfunction

A case of static spinal muscular atrophy is described. The patient presented with temporomandibular joint dysfunction. This case is unusual, not only from the perspective of clinical disease progression, but also that markedly elevated creatine kinase levels were demonstrated. Despite an obvious association of neuromuscular disorders and TMJ disease, reports of primary disorders of muscle and nerve which may predispose to this condition are rare. This case emphasizes the need for careful neuromuscular evaluation in all patients with TMJ dysfunction of nonarticular origin.

Clinical-anatomic study of a family with bulbo-spinal muscular atrophy in adults

Four cases are presented, with bulbo-spinal muscular atrophy characterised by adult onset and rapid evolution. They belong to a family in which the type of inheritance is probably dominant. Two cases were studied histologically. The most striking feature was the disappearance of neurons in the lower motor nuclei of medulla and of the spinal anterior horns. An electron microscopic study was carried out in one case. Accumulation of neurofilaments was a general characteristic, in addition to the picture of different sized spheroids. The clinical-pathological relationship is discussed.

Muscle diseases in Singapore

This study aims to establish the pattern of muscle diseases in Singapore. Two hundred consecutive muscle biopsies collected prospectively over a period of 7 yr (1978-1984) were studied using light microscopy, histochemistry and electron microscopy. Muscle diseases were not uncommon. There was no racial predilection. The common muscle diseases were polymyositis, spinal muscular atrophies and muscular dystrophies. Less common ones included congenital myopathies and storage diseases due to disorders of glycogen and lipid metabolism. Other muscle diseases were uncommon. Polymyositis was the commonest muscular disorder in adults and spinal muscular atrophy in childhood. This finding is encouraging as polymyositis is a treatable condition. The common occurrence of spinal muscular atrophies in this country was not fully appreciated. They were often misdiagnosed clinically as muscular dystrophies. It is hoped that this finding will result in greater awareness of this condition which is necessary for proper genetic counselling and management.

Chronic proximal spinal muscular atrophy of childhood and adolescence: sex influence

Segregation analysis was performed on 354 cases of chronic proximal spinal muscular atrophy of childhood and adolescence (CPSMA) in the total series and in a number of subgroups formed according to the age at onset and sex. The analysis provided evidence of sex influence in the series studied, particularly in a subgroup of the milder form of the disease with onset between the 37th month and 18th year of life. In the latter subgroup, females were affected much less frequently. This was particularly striking after age at onset of 8 years, and only exceptionally were females affected after the age of 13 years. These facts point to incomplete penetrance of the gene.

Clinical study of proximal spinal muscular atrophy. Report on 89 cases

A report on 89 cases of proximal Spinal Muscular Atrophy with observations on the clinical features, criteria of classification and modes of inheritance. The various forms into which SMA is divided probably represent a single disease that may begin at any age and may vary in severity, due, as a rule, to an autosomal recessive gene.

Single fiber electromyography in the differential diagnosis of myopathic limb girdle syndromes and chronic spinal muscular atrophy

Single fiber electromyography ( SFEMG ) of the extensor digitorum communis muscle was performed on 20 patients with either myopathic limb girdle syndromes ( LGS ) or chronic spinal muscular atrophy ( CSMA ) to assess its value in the differential diagnosis of these disorders. Neurologic examinations (muscle biopsies, standard electromyography, or both) were reviewed in 16 patients and resulted in diagnosing LGS in 11 patients and CSMA in 5 patients. In four patients, discordance between EMG and biopsy, or mixed features of myopathy and neuropathy in either test, resulted in an indeterminate diagnosis. Two groups were discerned from SFEMG , one with higher fiber density, jitter, and percentage of abnormal pairs consistent with neuropathy and another with lower values consistent with myopathy. In all 16 patients, SFEMG confirmed the initial diagnosis, and in the four patients with indeterminate diagnoses, SFEMG suggested diagnoses of LGS in two patients and CSMA in two patients. Single fiber electromyography may be a useful diagnostic aid in the differential diagnosis of myopathic LGS and CSMA .

Adult spinal muscular atrophy. A report of four cases

Four cases of spinal muscular atrophy (SMA) are reported, 3 with detailed autopsy findings. These are compared with 2 cases of typical amyotrophic lateral sclerosis (ALS) with neuropathological data. The 3 autopsy cases of SMA only showed decreased numbers of anterior horn cells in the spinal cord, with no change in the cortical pyramidal cells, including the Betz cells, and no degeneration of the pyramidal tracts, while the ALS cases showed loss both of lower and upper motor neurons and degeneration of the pyramidal tracts. In our opinion, the infantile, juvenile, adult, and late-life forms of SMA are really a single disease entity that occurs at varying ages and is separate from ALS. The term lower motor neuron disease would be preferable because the lesions are not limited to the spinal cord, but also occur in the brain stem.

A family with adult spinal and bulbar muscular atrophy, X-linked inheritance and associated testicular failure

A family with adult spinal and bulbar muscular atrophy with X-linked recessive inheritance (Kennedy's disease) is described. Affected members presented at age 20 with muscle cramps followed insidiously by gynaecomastia, partial loss of secondary sexual traits, loss of libido and inability to maintain an erection. Three had also testicular atrophy and severe oligospermia was found in two patients. Testicular biopsy in one case showed germinal failure with almost normal Leydig cells. Hormonal tests were suggestive of a primary testicular failure. Etiologic possibilities are considered.

Juvenile proximal spinal muscular atrophy with early hypertrophy of calves

The clinical, electrophysiological, histological and ultrastructural features of a patient with chronic spinal muscular atrophy of adolescent onset associated with hypertrophied calf-muscle are described. This recently recognised entity must be distinguished from other types of spinal muscular atrophy.

Progressive bulbar paralysis in childhood: a case report

The case of a progressive bulbar paresis in a nine and a half year old child is reported. The first symptoms were present at birth; however, the subsequent evolution was very low. Lesion of the motor nuclei of the V, VII, IX, XII, cranial nerves was evident on electromyographic investigation. Damage to the acoustic brain stem pathway was documented by the brain stem evoked potentials although audiometry was normal. No other neuronal systems or districts appeared to be damaged. The case suggests Fazio-Londe disease, although the involvement (albeit partial) of the auditory pathways recalls Van Laere syndrome. This supports the view that motor neuron disease in infancy is not an autonomous entity but a variant in a wide spectrum of progressive neuronal diseases.

A clinico-pathological study of chronic hereditary motor neuropathy

Forty cases of chronic hereditary motor neuropathy (CHMN) were divided into five categories according to the distribution of muscle atrophy; they were proximal, facioscapulohumeral, bulbospinal, distal and scapuloperoneal forms. Their clinical features and laboratory data were analysed, and muscle biopsies from 32 of them were studied by histological, histochemical and electron microscopical methods. An attempt at quantitative assessment of the histological changes was also made. All muscle biopsies showed a mixture of neurogenic and 'myopathic' changes in varying proportions. They showed more 'myopathic' changes than Werdnig-Hoffmann's disease, amyotrophic lateral sclerosis and other neurogenic atrophies except Charcot-Marie-Tooth disease. There was marked variation in the average number of atrophied muscle fibers contained in grouped atrophy. Frequently, deranged internal structure of the muscle fibres was revealed both by histochemical and electron microscopical methods. Based on the evidence of heterogeneity of CHMN in respect of genetics, clinical features and histological changes, it was speculated that CHMN represents a group of diseases which involves primarily different parts of the motor units.

X-linked adult form of spinal muscular atrophy

Neurological and endocrinological studies were carried out in 8 of 12 male patients with X-linked spinal muscular atrophy. In six investigated cases, gynaecomastia was discovered. First muscle symptoms started between 21 and 44 years of age, at which time the patients observed disturbances in their sexual life. In three cases decreased fertility and in two cases sterility was reported. Diagnostic testicular biopsy showed pronounced involutional changes of the Leydig cells. The plasma testosterone level was decreased, while the levels of luteinizing hormone and prolactine were normal, and the follicle stimulating hormone was at a high normal level. The dexamethasone/human chorionic gonadotrophin test revealed a pronounced decrease in the functional reserve of the Leydig cells. It is suggested that all these anomalies are connected with an increased ratio of oestrogen to androgen level.

Wasted leg syndrome: a clinical, electrophysiological and histopathological study

Forty cases of 'wasted leg syndrome' were studied clinically and electrophysiologically. Muscle biopsy was examined in nine cases, majority of patients were adults engaged in heavy manual work. The illness was noticed incidently with a strictly unilateral wasting of the whole lower limb (in 65% of cases), of all muscles below the knee (in 22.5% of cases) or of quadriceps muscles only (in 12.5% of cases). The nerve conduction studies and the electromyographic pattern suggested anterior horn cell disorder. Neurogenic atrophy was seen in 7 out of 9 muscle biopsies. A follow up in 12 patients (2-6 years) revealed no progression of the disease. It is suggested that possibly these cases represent an entity, clinically different from other anterior horn cell disorders.

Hereditary distal spinal muscular atrophy. A report on 34 cases and a review of the literature

A description is given of 34 patients with the distal form of hereditary spinal muscular atrophy. This disorder constitutes one form of "peroneal muscular atrophy". It resembles types I and II hereditary motor and sensory neuropathy but differs from them in displaying less upper limb weakness, relative preservation of the tendon reflexes and an entirely normal clinical sensory examination. Motor nerve conduction velocity and sensory nerve action potentials are normal. Previous reports of this disorder are reviewed and compared with the present series.

Spinal muscular atrophy and hypertrophy of the calves

In 100 patients (59 males and 41 females) suffering from proximal spinal muscular atrophy, 23 presented with hypertrophy of the calves. These were all males. They all showed an elevation of serum CK-activity. The combination of spinal muscular atrophy, hypertrophy of the calves and elevated serum CK activity was not found in females.

Late onset spinal muscle atrophy--a sex linked variant of Kugelberg-Welander

A syndrome of progressive muscular atrophy in reported in male members of a Caucasian family. Two affected members were examined in detail, one with post mortem. Fasciculations and atrophy of tongue as well as of the proximal limb muscles were observed, and there was profound weakness of the proximal muscles. The EMG and muscle biopsy were consistent with a neurogenic disease. The most pronounced lesion was in the lateral part of the anterior horn, with minimal involvement of the ventral portion of the anterior horns and sparing of the neurons of Clarke's column. Two earlier families with possible Kugelberg-Welander syndrome have been reported in which a sex-linked form also seems probable, and the varied inheritance pattern and uncertain pathological correlations suggest that the Kugelberg-Welander and familial amyotrophic lateral sclerosis both represent heterogenous neurological disorders.

Spinal muscular atrophy in childhood: review of 50 cases

The clinical findings in 50 children with intermediate or mild spinal muscular atrophy are reviewed. An early age of onset and the presence of tongue fasciculation carry a poor prognosis for disability. Scoliosis appears early in nearly all children with the more severe forms of spinal muscular atrophy and early energetic treatment is indicated. Contractures are also found in both the more severe and the milder forms and are the main cause of progressive disability, since continuous deterioration of muscle power was not evident in the present series. Respiratory failure is rare but potentially fatal, and may occur even in mild forms of the disease. Clinically evident weakness of the axial musculature may give warning of this complication.

A genetic study of subacute and chronic spinal muscular atrophy in childhood. A nosological analysis of 124 index patients

A genetic study of the subacute spinal muscular atrophies (SMA) of late infancy and early childhood has been undertaken. All such patients with chronic disease (with ages at onset up to 14 years, and excluding SMA Type I) known to 2 large Neurological Centres were reassessed clinically and genetically. There were 124 index patients (67 females and 57 males) and 17 secondary cases, which formed two consecutive unselected series. To investigate the genetic composition of this group, 4 nosological approaches were used; cluster analysis of clinical features of the disease, Haldane's sib-sib analysis on familial cases, interpretation of frequency distribution histograms, and a segregation analysis. A single autosomal recessive gene accounts for over 90% of cases, causes a clinical syndrome which manifests its first clinical signs before 5 years of age and in almost all cases before two years of age, but which is compatible with life into the third decade. Moderate intrafamilial discordance for some clinical features may be observed, but no genetic heterogeneity within this group was demonstrated. A small group of cases is caused by (a) new dominant mutation(s), or (b) is composed of phenocopies, or both. This relatively uncommon form may comprise the majority of late-presenting cases, and may account for all cases which manifest the first signs after 5 years of age. The spectrum of age-at-onset of this group cannot be determined at present, but the disease may be manifest before the age of two years; it is clinically indistinguishable from SMA caused by an autosomal recessive gene. The literature has been reviewed in the light of these findings. Empirical risks for use in genetic counselling are presented.

Late-onset X-linked recessive spinal and bulbar muscular atrophy

A family is described in which five males have late-onset facial weakness, dysarthria, dysphagia, and slowly progressive proximal weakness. Electrodiagnostic studies and muscle biopsy were compatible with spinal muscular atrophy. This family appears quite similar to several previously reported families with late-onset X-linked recessive spinal and bulbar muscular atrophy. Because of the relative homogeneity of this particular phenotype of spinal muscular atrophy, a single metabolic derangement was sought. Three obligate carriers were studied, and no abnormality was detected. A further family with this condition is briefly discussed.

Ocular findings in a patient with Kugelberg-Welander syndrome: a case report

A four-year-old female child with Kugelberg-Welander syndrome has been presented. She demonstrated ptosis, exotropia, and decreased vision with unilateral high myopia. Unlike the Werdnig-Hoffman type of spinal muscular dystrophy Kugelberg-Welander disease has a protracted, somewhat benign course, necessitating proper evaluation and care of the ocular problems of these patients. The most common among these problems are the presence of severe to moderate ptosis and strabismus which appears usually to be an exotropia.

Sensory nerve conduction in the spinal muscular atrophies

Sensory conduction velocities were determined in the sural or median nerve in 16 patients with spinal muscular atrophy of the severe (Werdnig-Hoffmann), intermediate, or mild (Kugelberg-Welander) forms. In all cases there were normal sensory conduction velocities in one of the nerves tested, although sural nerve responses were not obtained in the four youngest patients.

Genetic investigations on chronic forms of infantile and juvenile spinal muscular atrophy

A material of 247 cases selected from 260 cases of spinal muscular atrophy in the Warsaw Department of Neurology in 1960-1974 was analyzed. The size of sibships was established and calculations were made of the mean distribution of the age at onset, also according to sex, for the different clinical forms, genetical proportions by the method of siblings and of probands, and coefficient of sib-sib correlation for the material as a whole and separately for males, females and male-female pairs. The analysis shows the course of the disease to differ between the sexes and to be mild in males more often than in females, as is particularly noticeable in the higher age groups. Cases of Kugelberg-Welander's disease are predominantly male. The hypothesis is advanced that a proportion of male patients have a sex-linked modifying gene of a fairly high frequency (possibly of the range of 1 in 5 males, and 1 in 25, in the homozygous state, in females). Although it would not disprove conclusively the nosological distinctness of different forms of infantile and juvenile spinal muscular atrophy, the existence of the modifying gene, if proved, would tend rather to add to the likelihood of their constituting a single recessive autosomal disease.

A family of juvenile proximal spinal muscular atrophy with dominant inheritance

A family with juvenile proximal spinal muscular atrophy with dominant inheritance and complete penetrance is reported. The disease occurred in three generations and showed high variations in the age of onset and progression among the affected members. A characteristic feature was the constant involvement of facial nuclei.

Anterior horn cell disease seen in South India

Thirty-two patients with clinical evidence of anterior horn cell dysfunction are descirbed. This group of patients could be divided into those with bulbar dysfunction, and those without. Eighth cranial nerve involvement was seen in 10%. The commonest perpheral distribution seen was symmetrical involvement of all four extremities. During the period of follow-up (1 to 5 years) none of the patients without bulbar dysfunction initially developed such symptoms. In all these patients electromyographic evidence of anterior horn cell disease was confirmed. The motor nerve conduction velocities in all of these patients were normal. None of them showed signs of pyramidal tract involvement. Muscle biopsy showed evidence of group fibre atrophy in 10 cases, was normal in 3, and showed a myopathic pattern in 1. Sural nerve biopsy obtained in a single patient was considered histologically normal. Plasma citrate and plasma pyruvate levels obtained in 5 patients of this group, showed elevated values for plasma citrate with normal plasma pyruvate levels. Conspicuous absence of pyramidal signs, elevated plasma citrate, normal plasma pyruvate values and the extremely slow progression suggest that this group of patients are different from other varieties of anterior horn cell dysfunction previously described.

Appearance of acetylcholinesterase and creatine kinase in plasma of normal chickens after denervation

Evidence that acetylcholinesterase (AChE) activity is released from normal chick embryonic muscle fibers and from muscles of chickens with inherited muscular dystrophy suggested that denervated chick muscles, which have AChE properties similar to dystrophic muscles, would also release AChE. Bilateral denervation of the breast and wing muscles of normal chickens was followed by the appearance of AChE activity, distinguished from plasma cholinesterase by differential substrate hydrolysis, inhibitor sensitivity, and electrophoretic migration. Plasma creatine kinase (CK) activity was also elevated after denervation.

The nosology of the spinal muscular atrophies

Images