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Braun AA, Atiya M, Göhner K, Hortobagyi T, Burkhardt T, Schreiner B. Anti-HMGCR myopathy mimicking facioscapulohumeral muscular dystrophy. Open Med (Wars) 2024; 19:20241033. [PMID: 39247442 PMCID: PMC11377977 DOI: 10.1515/med-2024-1033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Revised: 08/06/2024] [Accepted: 08/15/2024] [Indexed: 09/10/2024] Open
Abstract
Introduction Statin use can lead to various muscle-related issues, including benign creatine kinase (CK) elevations, myalgias, toxic myopathies, rhabdomyolysis, and immune-mediated necrotizing myositis (IMNM), which primarily affects older males. IMNM presents with proximal muscle weakness, elevated CK levels, and specific antibodies. Case presentation We describe a 72-year-old patient with muscle weakness persisting for over 3 years after statin therapy. Initially suspected to have a genetic disorder, further testing revealed elevated anti-3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGCR) antibodies, indicating immune-mediated myopathy. Despite the absence of inflammatory changes on biopsy, the patient responded positively to immune therapy. Conclusion This case highlights challenges in diagnosing immune-mediated myopathy, especially in older patients with atypical presentations. Testing for HMGCR antibodies can aid in diagnosis, particularly when inflammatory markers are absent. Awareness of red flags, such as delayed symptom onset and response to prednisone, is crucial for accurate diagnosis and management.
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Affiliation(s)
- Andreas Albert Braun
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Monika Atiya
- Practice "Neurologie Männedorf", Männedorf, Switzerland
| | - Katja Göhner
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Tibor Hortobagyi
- Institute of Neuropathology, University Hospital Zurich, Zurich, Switzerland
| | | | - Bettina Schreiner
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
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2
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Zhai X, Wu W, Zeng S, Miao Y. Advance in the mechanism and clinical research of myalgia in long COVID. AMERICAN JOURNAL OF CLINICAL AND EXPERIMENTAL IMMUNOLOGY 2024; 13:142-164. [PMID: 39310121 PMCID: PMC11411160 DOI: 10.62347/txvo6284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 07/18/2024] [Indexed: 09/25/2024]
Abstract
As severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to evolve, mortality rates of coronavirus disease 2019 (COVID-19) have significantly decreased. However, a variable proportion of patients exhibit persistent prolonged symptoms of COVID-19 infection (long COVID). This virus primarily attacks respiratory system, but numerous individuals complain persistent skeletal muscle pain or worsening pre-existing muscle pain post COVID-19, which severely affects the quality of life and recovery. Currently, there is limited research on the skeletal muscle pain in long COVID. In this brief review, we review potential pathological mechanisms of skeletal muscle pain in long COVID, and summarize the various auxiliary examinations and treatments for skeletal muscle pain in long COVID. We consider abnormal activation of inflammatory response, myopathy, and neurological damages as pivotal pathological mechanisms of skeletal muscle pain in long COVID. A comprehensive examination is significantly important in order to work out effective treatment plans and relieve skeletal muscle pain. So far, rehabilitation interventions for myalgia in long COVID contain but are not limited to drug, nutraceutical therapy, gut microbiome-targeted therapy, interventional therapy and strength training. Our study provides a potential mechanism reference for clinical researches, highlighting the importance of comprehensive approach and management of skeletal muscle pain in long COVID. The relief of skeletal muscle pain will accelerate rehabilitation process, improve activities of daily living and enhance the quality of life, promoting individuals return to society with profound significance.
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Affiliation(s)
- Xiuyun Zhai
- Department of Rehabilitation, Shanghai General Hospital, Shanghai Jiaotong UniversityNo. 100, Haining Road, Shanghai 200080, China
| | - Weijun Wu
- Department of Rehabilitation, Shanghai General Hospital, Shanghai Jiaotong UniversityNo. 100, Haining Road, Shanghai 200080, China
| | - Siliang Zeng
- Department of Rehabilitation Therapy, School of Health, Shanghai Normal University Tianhua CollegeNo. 1661, North Shengxin Road, Shanghai 201815, China
| | - Yun Miao
- Department of Rehabilitation, Shanghai General Hospital, Shanghai Jiaotong UniversityNo. 100, Haining Road, Shanghai 200080, China
- Department of Rehabilitation, School of International Medical Technology, Shanghai Sanda UniversityNo. 2727, Jinhai Road, Shanghai 201209, China
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3
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Koumas C, Michelassi F. Immune-Mediated Necrotizing Myopathies: Current Landscape. Curr Neurol Neurosci Rep 2024; 24:141-150. [PMID: 38589696 DOI: 10.1007/s11910-024-01337-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 04/10/2024]
Abstract
PURPOSE OF REVIEW Immune-mediated necrotizing myopathy (IMNM), characterized by acute or subacute onset, severe weakness, and elevated creatine kinase levels, poses diagnostic and therapeutic challenges. This article provides a succinct overview of IMNM, including clinical features, diagnostic strategies, and treatment approaches. RECENT FINDINGS Recent insights highlight the different clinical presentations and therapeutic options of IMNM stratified by autoantibody positivity and type. Additionally, recent findings call into question the reported link between statin use and IMNM. This review synthesizes current knowledge on IMNM, emphasizing its distinct clinical features and challenging management. The evolving understanding of IMNM underscores the need for a comprehensive diagnostic approach that utilizes a growing range of modalities. Early and aggressive immunomodulatory therapy remains pivotal. Ongoing research aims to refine diagnostic tools and therapeutic interventions for this challenging muscle disorder, underscoring the importance of advancing our understanding to enhance patient outcomes.
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Affiliation(s)
- Christoforos Koumas
- Department of Neurology, Columbia University Medical Center, New York, NY, USA.
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Hague O, Thanopoulou V, Mangat P, Singh A, Stratton R, Malley T. Isotretinoin-induced myositis. Oxf Med Case Reports 2024; 2024:omae017. [PMID: 38532764 PMCID: PMC10962232 DOI: 10.1093/omcr/omae017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 03/28/2024] Open
Abstract
Retinoid-induced myositis is a phenomenon recognised in multiple case reports. We report a case of isotretinoin-induced myositis in an 18-year-old male patient. This case adds to the published literature as it demonstrates (i) myositis may occur after extended periods of isotretinoin use, (ii) should be considered as a differential diagnosis even when presenting asymmetrically and (iii) can continue to progress clinically and biochemically initially following the suspension of isotretinoin before being effectively treated with corticosteroids.
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Affiliation(s)
- Oliver Hague
- Department of Rheumatology, Royal Free Hospital, London NW3 2QG, United Kingdom
| | | | - Pamela Mangat
- Department of Rheumatology, Royal Free Hospital, London NW3 2QG, United Kingdom
| | - Animesh Singh
- Department of Rheumatology, Royal Free Hospital, London NW3 2QG, United Kingdom
| | - Richard Stratton
- Department of Rheumatology, Royal Free Hospital, London NW3 2QG, United Kingdom
| | - Tamir Malley
- Department of Rheumatology, Royal Free Hospital, London NW3 2QG, United Kingdom
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5
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Saito Y, Ishiyama A, Saito Y, Komaki H, Sasaki M. Myelin abnormalities in merosin-deficient congenital muscular dystrophy. Muscle Nerve 2024; 69:55-63. [PMID: 37933889 DOI: 10.1002/mus.28002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 10/19/2023] [Accepted: 10/21/2023] [Indexed: 11/08/2023]
Abstract
INTRODUCTION/AIMS Merosin is a protein complex located in the basement membrane of skeletal muscles and laminin α2-containing regions of the central and peripheral nervous systems. However, because of the prominence of muscle-related symptoms, peripheral neuropathy associated with merosin-deficient congenital muscular dystrophy type 1A (MDC1A) has received little clinical attention. This study aimed to present pathological changes in intramuscular nerves of three patients with MDC1A and discuss their relationship with electrophysiological findings to provide new evidence of peripheral nerve involvement in MDC1A. METHODS MDC1A was confirmed by clinical features, muscle biopsy, and genetic testing for variants in LAMA2. To clarify peripheral nerve involvement, we statistically evaluated electrophysiological and muscle pathology findings of intramuscular nerves. These findings were compared with those of age-matched boys with Duchenne muscular dystrophy (DMD) as controls with normal nerves. Nerve conduction studies (NCS) were performed before biopsy. Biopsied intramuscular nerves were examined with electron microscopy using g-ratio, which is the ratio of axon diameter to myelinated fiber diameter. RESULTS The myelin sheaths were significantly thinner in MDC1A patients than in age-matched DMD patients, with a mean g-ratio of 0.76 ± 0.07 in MDC1A patients and 0.65 ± 0.14 in DMD patients (p < .0001). No neuropathic changes were identified in muscle pathology. Low compound muscle action potential amplitudes, positive sharp waves and fibrillation potentials, and low-amplitude motor unit potentials with increased polyphasia indicated myopathic changes; no neurogenic changes were seen. DISCUSSION We postulate that the thin myelin associated with MDC1A reflects the role of merosin in myelin maturation.
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Affiliation(s)
- Yoshihiko Saito
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan
- Department of Neuromuscular Research, National Institute of Neuroscience, NCNP, Tokyo, Japan
| | - Akihiko Ishiyama
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan
- Department of Neuromuscular Research, National Institute of Neuroscience, NCNP, Tokyo, Japan
| | - Yuko Saito
- Department of Clinical Laboratory, National Center Hospital, NCNP, Tokyo, Japan
| | - Hirofumi Komaki
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan
| | - Masayuki Sasaki
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan
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Niezgoda A, Biegański G, Wachowiak J, Czarnota J, Siemionow K, Heydemann A, Ziemiecka A, Sikorska MH, Bożyk K, Siemionow M. Assessment of Motor Unit Potentials Duration as the Biomarker of DT-DEC01 Cell Therapy Efficacy in Duchenne Muscular Dystrophy Patients up to 12 Months After Systemic-Intraosseous Administration. Arch Immunol Ther Exp (Warsz) 2023; 71:24. [PMID: 37999748 PMCID: PMC10673998 DOI: 10.1007/s00005-023-00691-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 10/20/2023] [Indexed: 11/25/2023]
Abstract
Duchenne muscular dystrophy (DMD) is a lethal X-linked disease caused by mutations in the dystrophin gene, leading to muscle degeneration and wasting. Electromyography (EMG) is an objective electrophysiological biomarker of muscle fiber function in muscular dystrophies. A novel, DT-DEC01 therapy, consisting of Dystrophin Expressing Chimeric (DEC) cells created by fusing allogeneic myoblasts from normal donors with autologous myoblasts from DMD-affected patients, was assessed for safety and preliminary efficacy in boys of age 6-15 years old (n = 3). Assessments included EMG testing of selected muscles of upper (deltoideus, biceps brachii) and lower (rectus femoris and gastrocnemius) extremities at the screening visit and at 3, 6, and 12 months following systemic-intraosseous administration of a single low dose of DT-DEC01 therapy (Bioethics Committee approval no. 46/2019). No immunosuppression was administered. Safety of DT-DEC01 was confirmed by the lack of therapy-related Adverse Events or Serious Adverse Events up to 22 months following DT-DEC01 administration. EMG of selected muscles of both, ambulatory and non-ambulatory patients confirmed preliminary efficacy of DT-DEC01 therapy by an increase in motor unit potentials (MUP) duration, amplitudes, and polyphasic MUPs at 12 months. This study confirmed EMG as a reliable and objective biomarker of functional assessment in DMD patients after intraosseous administration of the novel DT-DEC01 therapy.
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Affiliation(s)
- Adam Niezgoda
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Grzegorz Biegański
- Department of Infectious Diseases and Child Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Krzysztof Siemionow
- Dystrogen Therapeutics Corp., Chicago, IL, USA
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, USA
| | - Ahlke Heydemann
- Department of Physiology and Biophysics, University of Illinois at Chicago, Chicago, IL, USA
- Center for Cardiovascular Research, University of Illinois at Chicago, Chicago, IL, USA
| | | | | | | | - Maria Siemionow
- Dystrogen Therapeutics Corp., Chicago, IL, USA.
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, USA.
- Chair and Department of Traumatology, Orthopedics and Surgery of the Hand, Poznan University of Medical Sciences, Poznan, Poland.
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Kanbayashi T, Kobayashi S, Hatanaka Y, Shimizu J, Sonoo M. Idiopathic Inflammatory Myopathy with Delayed Finger Opening Resembling Grip Myotonia. Intern Med 2023; 62:3397-3400. [PMID: 37032082 PMCID: PMC10713367 DOI: 10.2169/internalmedicine.1545-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/26/2023] [Indexed: 04/11/2023] Open
Abstract
Grip myotonia can be a clue for the diagnosis of myotonic disorders. However, several clinical conditions cause delayed finger opening mimicking grip myotonia. We herein report a 44-year-old man with idiopathic inflammatory myopathy who presented with delayed finger opening resembling grip myotonia. The delayed finger opening differed from grip myotonia given the absence of the warm-up phenomenon and percussion myotonia, relative sparing of the thumb extension, and pronounced weakness of the extensor digitorum. Focusing on the extension of the thumb and other fingers may aid in the differentiation between delayed finger opening and true grip myotonia.
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Affiliation(s)
| | | | - Yuki Hatanaka
- Department of Neurology, Teikyo University School of Medicine, Japan
| | - Jun Shimizu
- Department of Neurology, Graduate School of Medicine, University of Tokyo, Japan
- Department of Physical Therapy, School of Health Science, Tokyo University of Technology, Japan
| | - Masahiro Sonoo
- Department of Neurology, Teikyo University School of Medicine, Japan
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Yildiz H, Lepere C, Zorzi G, Gheysens O, Roodhans F, Pothen L. [ 18F]FDG-PET/CT in Idiopathic Inflammatory Myopathies: Retrospective Data from a Belgian Cohort. Diagnostics (Basel) 2023; 13:2316. [PMID: 37510060 PMCID: PMC10377909 DOI: 10.3390/diagnostics13142316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 06/26/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
[18F]FDG-PET/CT is a useful tool for diagnosis and cancer detection in idiopathic inflammatory myopathies (IIMs), especially polymyositis (PM) and dermatomyositis (DM). Data deriving from Europe are lacking. We describe [18F]FDG-PET/CT results in a Belgian cohort with IIMs, focusing on patients with PM and DM. All of the cases of IIMs admitted between December 2010 and January 2023 to the Cliniques Universitaires Saint-Luc (Belgium) were retrospectively reviewed. In total, 44 patients were identified with suspected IIMs; among them, 29 were retained for final analysis. The mean age of the retained patients was 48.7 years; 19 patients were female (65.5%). Twenty-two patients had DM and seven had PM. The mean serum creatinine kinase (CK) and the mean CRP levels were 3125 UI/L and 30.3 mg/L, respectively. [18F]FDG-PET/CT imaging was performed for 27 patients, detecting interstitial lung diseases (ILDs) in 7 patients (25.9%), cancer in 3 patients (11.1%), and abnormal muscle FDG uptake compatible with myositis in 13 patients (48.1%). All of the patients who were detected to have ILDs via PET/CT imaging were confirmed using a low-dose lung CT scan. Among the patients who were detected to have abnormal muscle FDG uptake via PET/CT scans (13/28), the EMG was positive in 12 patients (p = 0.004), while the MRI was positive in 8 patients (p = 0.02). We further observed that there was a significantly higher level of CK in the group with abnormal muscle FDG uptake (p = 0.008). Our study showed that PET/CT is useful for detecting cancer and ILDs. We showed that the detection of abnormal muscle uptake via PET/CT was in accordance with EMG and MRI results, as well as with the mean CK value, and that the presence of dyspnea was significantly associated with the presence of ILDs detected via PET/CT imaging (p = 0.002).
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Affiliation(s)
- Halil Yildiz
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, Institute of Clinical and Experimental Research (IREC), Université Catholique de Louvain (UCLouvain), Avenue Hippocrate 10, B-1200 Brussels, Belgium
| | - Charlotte Lepere
- Department of Internal Medicine, Hôpital d'Arlon (Vivalia), 6700 Arlon, Belgium
| | - Giulia Zorzi
- Department of Laboratory, Avenue Hippocrate 10, B-1200 Brussels, Belgium
| | - Olivier Gheysens
- Department of Nuclear Medicine, Cliniques Universitaires Saint-Luc, Institute of Clinical and Experimental Research (IREC), Université Catholique de Louvain (UCLouvain), Avenue Hippocrate 10, B-1200 Brussels, Belgium
| | - Fabien Roodhans
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, Institute of Clinical and Experimental Research (IREC), Université Catholique de Louvain (UCLouvain), Avenue Hippocrate 10, B-1200 Brussels, Belgium
| | - Lucie Pothen
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, Institute of Clinical and Experimental Research (IREC), Université Catholique de Louvain (UCLouvain), Avenue Hippocrate 10, B-1200 Brussels, Belgium
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Meldgaard M, Kristensen RS, Z'Graggen WJ, Tan SV, Søndergaard K, Qerama E, Andersen H, Fuglsang-Frederiksen A, Tankisi H. Muscle velocity recovery cycles in myopathy. Clin Neurophysiol 2023; 151:41-49. [PMID: 37148747 DOI: 10.1016/j.clinph.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/30/2023] [Accepted: 04/03/2023] [Indexed: 05/08/2023]
Abstract
OBJECTIVE To understand the pathophysiology of myopathies by using muscle velocity recovery cycles (MVRC) and frequency ramp (RAMP) methodologies. METHODS 42 patients with quantitative electromyography (qEMG) and biopsy or genetic verified myopathy and 42 healthy controls were examined with qEMG, MVRC and RAMP, all recorded from the anterior tibial muscle. RESULTS There were significant differences in the motor unit potential (MUP) duration, the early and late supernormalities of the MVRC and the RAMP latencies in myopathy patients compared to controls (p < 0.05 apart from muscle relatively refractory period (MRRP)). When dividing into subgroups, the above-mentioned changes in MVRC and RAMP parameters were increased for the patients with non-inflammatory myopathy, while there were no significant changes in the group of patients with inflammatory myopathy. CONCLUSIONS The MVRC and RAMP parameters can discriminate between healthy controls and myopathy patients, more significantly for non-inflammatory myopathy. MVRC differences with normal MRRP in myopathy differs from other conditions with membrane depolarisation. SIGNIFICANCE MVCR and RAMP may have a potential in understanding disease pathophysiology in myopathies. The pathogenesis in non-inflammatory myopathy does not seem to be caused by a depolarisation of the resting membrane potential but rather by the change in sodium channels of the muscle membrane.
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Affiliation(s)
- M Meldgaard
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - R S Kristensen
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - W J Z'Graggen
- Departments of Neurology and Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - S V Tan
- Department of Neurology and Neurophysiology, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - K Søndergaard
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - E Qerama
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - H Andersen
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - A Fuglsang-Frederiksen
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - H Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark.
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Monda E, Lioncino M, Caiazza M, Simonelli V, Nesti C, Rubino M, Perna A, Mauriello A, Budillon A, Pota V, Bruno G, Varone A, Nigro V, Santorelli FM, Pacileo G, Russo MG, Frisso G, Sampaolo S, Limongelli G. Clinical, Genetic, and Histological Characterization of Patients with Rare Neuromuscular and Mitochondrial Diseases Presenting with Different Cardiomyopathy Phenotypes. Int J Mol Sci 2023; 24:ijms24109108. [PMID: 37240454 DOI: 10.3390/ijms24109108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/15/2023] [Accepted: 05/20/2023] [Indexed: 05/28/2023] Open
Abstract
Cardiomyopathies are mostly determined by genetic mutations affecting either cardiac muscle cell structure or function. Nevertheless, cardiomyopathies may also be part of complex clinical phenotypes in the spectrum of neuromuscular (NMD) or mitochondrial diseases (MD). The aim of this study is to describe the clinical, molecular, and histological characteristics of a consecutive cohort of patients with cardiomyopathy associated with NMDs or MDs referred to a tertiary cardiomyopathy clinic. Consecutive patients with a definitive diagnosis of NMDs and MDs presenting with a cardiomyopathy phenotype were described. Seven patients were identified: two patients with ACAD9 deficiency (Patient 1 carried the c.1240C>T (p.Arg414Cys) homozygous variant in ACAD9; Patient 2 carried the c.1240C>T (p.Arg414Cys) and the c.1646G>A (p.Ar549Gln) variants in ACAD9); two patients with MYH7-related myopathy (Patient 3 carried the c.1325G>A (p.Arg442His) variant in MYH7; Patient 4 carried the c.1357C>T (p.Arg453Cys) variant in MYH7); one patient with desminopathy (Patient 5 carried the c.46C>T (p.Arg16Cys) variant in DES); two patients with mitochondrial myopathy (Patient 6 carried the m.3243A>G variant in MT-TL1; Patient 7 carried the c.253G>A (p.Gly85Arg) and the c.1055C>T (p.Thr352Met) variants in MTO1). All patients underwent a comprehensive cardiovascular and neuromuscular evaluation, including muscle biopsy and genetic testing. This study described the clinical phenotype of rare NMDs and MDs presenting as cardiomyopathies. A multidisciplinary evaluation, combined with genetic testing, plays a main role in the diagnosis of these rare diseases, and provides information about clinical expectations, and guides management.
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Affiliation(s)
- Emanuele Monda
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, AORN dei Colli, Monaldi Hospital, 81031 Naples, Italy
| | - Michele Lioncino
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, AORN dei Colli, Monaldi Hospital, 81031 Naples, Italy
| | - Martina Caiazza
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, AORN dei Colli, Monaldi Hospital, 81031 Naples, Italy
| | | | - Claudia Nesti
- Molecular Medicine, IRCCS Stella Maris Foundation, 56128 Pisa, Italy
| | - Marta Rubino
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, AORN dei Colli, Monaldi Hospital, 81031 Naples, Italy
| | - Alessia Perna
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, AORN dei Colli, Monaldi Hospital, 81031 Naples, Italy
| | - Alfredo Mauriello
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, AORN dei Colli, Monaldi Hospital, 81031 Naples, Italy
| | - Alberta Budillon
- Department of Advanced Medical and Surgical Sciences, 2nd Division of Neurology, Center for Rare Diseases and InterUniversity Center for Research in Neurosciences, University of Campania Luigi Vanvitelli, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Vincenzo Pota
- NeuroMuscular Omnicentre (NEMO), AORN dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Giorgia Bruno
- Pediatric Neurology Unit, Department of Neurosciences, Santobono-Pausilipon Children's Hospital, 80122 Naples, Italy
| | - Antonio Varone
- Pediatric Neurology Unit, Department of Neurosciences, Santobono-Pausilipon Children's Hospital, 80122 Naples, Italy
| | - Vincenzo Nigro
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Via Luigi De Crecchio 7, 80138 Naples, Italy
- Telethon Institute of Genetics and Medicine, Via Campi Flegrei 34, 80078 Pozzuoli, Italy
| | | | - Giuseppe Pacileo
- Heart Failure Unit, Department of Cardiology, AORN dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Maria Giovanna Russo
- Paediatric Cardiology Unit, University of Campania Luigi Vanvitelli, AORN dei Colli, Monaldi Hospital, 81100 Caserta, Italy
| | - Giulia Frisso
- Department of Molecular Medicine and Medical Biotechnology, University of Naples "Federico II", 80138 Naples, Italy
| | - Simone Sampaolo
- Department of Advanced Medical and Surgical Sciences, 2nd Division of Neurology, Center for Rare Diseases and InterUniversity Center for Research in Neurosciences, University of Campania Luigi Vanvitelli, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, AORN dei Colli, Monaldi Hospital, 81031 Naples, Italy
- NeuroMuscular Omnicentre (NEMO), AORN dei Colli, Monaldi Hospital, 80131 Naples, Italy
- Institute of Cardiovascular Sciences, University College of London and St. Bartholomew's Hospital, Gower St, London WC1E 6DD, UK
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11
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Melo AT, Dourado E, Campanilho-Marques R, Bandeira M, Barreira SC, Costa J, Pimenta R, Antunes-Duarte S, Cordeiro I, Fonseca JE. Myositis Multidisciplinary Clinic in a Tertiary Referral Center. J Multidiscip Healthc 2023; 16:1127-1139. [PMID: 37131932 PMCID: PMC10149065 DOI: 10.2147/jmdh.s404017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/28/2023] [Indexed: 05/04/2023] Open
Abstract
Background Idiopathic inflammatory myopathies (IIM) are a rare heterogeneous group of diseases characterised by chronic skeletal muscle inflammation, but other organs are also frequently involved. IMM represent a diagnostic challenge and a multidisciplinary approach is important to ensure successful diagnosis and adequate follow-up of these patients. Objective To describe the general functioning of our multidisciplinary myositis clinic, highlighting the benefits of multidisciplinary team management in patients with confirmed or suspected IIM and to characterise our clinical experience. Methods Description of the organization of a dedicated multidisciplinary myositis outpatient clinic, supported by IMM specific electronic assessment tools and protocols based on our Portuguese Register - Reuma.pt. In addition, an overview of our activity between 2017 and 2022 is provided. Results An IIM multidisciplinary care clinic, based on a close collaboration between Rheumatologists, Dermatologists and Physiatrist is detailed in this paper. One hundred and eighty-five patients were assessed in our myositis clinic; 138 (75%) of those were female, with a median age of 58 [45-70] years. At the last appointment, 130 patients had a confirmed IIM diagnosis, and the mean disease duration was 4 [2-6] years. The most frequent diagnosis was dermatomyositis (n = 34, 26.2%), followed by antisynthetase syndrome (n = 27, 20.8%) and clinically amyopathic/paucimyopathic dermatomyositis (n = 18, 13.8%). Twenty-four patients (18.5%) were on monotherapy and 94 (72.3%) were on combination therapy. Conclusion A multidisciplinary approach is important to ensure the correct diagnosis and follow-up of these patients. A myositis clinic, with a standardised practice at a tertiary hospital level, contributes to a standardization of care and opens research opportunities.
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Affiliation(s)
- Ana Teresa Melo
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Correspondence: Ana Teresa Melo, Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Hospital de Santa Maria, EPE, R. Prof. Egas Moniz, Lisboa, 1700, Portugal, Tel +351 217805139, Email
| | - Eduardo Dourado
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Raquel Campanilho-Marques
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Matilde Bandeira
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Sofia C Barreira
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - José Costa
- Physical Medicine and Rehabilitation Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Rita Pimenta
- Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Sofia Antunes-Duarte
- Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Inês Cordeiro
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - João E Fonseca
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
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12
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Weterman MAJ, Bronk M, Jongejan A, Hoogendijk JE, Krudde J, Karjosukarso D, Goebel HH, Aronica E, Jöbsis GJ, van Ruissen F, van Spaendonck-Zwarts KY, de Visser M, Baas F. Pathogenic variants in three families with distal muscle involvement. Neuromuscul Disord 2023; 33:58-64. [PMID: 36539320 DOI: 10.1016/j.nmd.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 11/23/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022]
Abstract
Three families suspected of distal hereditary motor neuropathy underwent genetic screening with the aim to identify the molecular defect underlying the disease. The description of the identification reflects the shift in molecular diagnostics that was made during the last decades. Our candidate gene approach yielded a known pathogenic variant in BSCL2 (p.Asn88Ser) in one family, and via a CMT-capture, in HSPB1 (p.Arg127Trp), in addition to five other variations in Charcot-Marie-Tooth-related genes in the proband of the second family. In the third family, using whole exome sequencing, followed by linkage-by-location, a three base pair deletion in exon 33 of MYH7 (p.Glu1508del) was found, a reported pathogenic allele albeit for a myopathy. After identification of the causative molecular defect, cardiac examination was performed for patients of the third family and this demonstrated abnormalities in three out of five affected family members. Heterogeneity and expansion of clinical phenotypes beyond known characteristics requires a wider set of genes to be screened. Whole exome/genome analysis with limited prior clinical information may therefore be used to precede a detailed clinical evaluation in cases of large families, preventing screening of a too narrow set of genes, and enabling the identification of novel disease-associated genes. In our cases, the variants had been reported, and co-segregation analysis confirmed the molecular diagnosis.
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Affiliation(s)
- Marian A J Weterman
- Department of Genome Analysis/Clinical Genetics, Amsterdam University Medical Center, Location Academic Medical Center, Amsterdam, the Netherlands; Dept Clinical Genetics, LUMC, Leiden, the Netherlands.
| | - Marieke Bronk
- Department of Neurology, University Medical Center Amsterdam, location Academic Medical Center, Amsterdam, the Netherlands
| | - Aldo Jongejan
- Department of Bio-informatics, University Medical Center Amsterdam, location Academic Medical Center, Amsterdam, the Netherlands
| | - Jessica E Hoogendijk
- Department of Neurology, UMC Brain Center, University Medical Center, Utrecht, the Netherlands
| | - Judith Krudde
- Department of Neurology, University Medical Center Amsterdam, location Academic Medical Center, Amsterdam, the Netherlands
| | - Dyah Karjosukarso
- Department of Genome Analysis/Clinical Genetics, Amsterdam University Medical Center, Location Academic Medical Center, Amsterdam, the Netherlands
| | - Hans H Goebel
- Department of Neurology, University Medical Center Amsterdam, location Academic Medical Center, Amsterdam, the Netherlands
| | - Eleonora Aronica
- Department of Pathology, Amsterdam University Medical Center, Location Academic Medical Center, Amsterdam, the Netherlands
| | - G Joost Jöbsis
- Department of Neurology, University Medical Center Amsterdam, location Academic Medical Center, Amsterdam, the Netherlands
| | - Fred van Ruissen
- Department of Genome Analysis/Clinical Genetics, Amsterdam University Medical Center, Location Academic Medical Center, Amsterdam, the Netherlands; Department of Human Genetics, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Karin Y van Spaendonck-Zwarts
- Department of Neurology, University Medical Center Amsterdam, location Academic Medical Center, Amsterdam, the Netherlands
| | - Marianne de Visser
- Department of Neurology, University Medical Center Amsterdam, location Academic Medical Center, Amsterdam, the Netherlands
| | - Frank Baas
- Department of Genome Analysis/Clinical Genetics, Amsterdam University Medical Center, Location Academic Medical Center, Amsterdam, the Netherlands; Dept Clinical Genetics, LUMC, Leiden, the Netherlands
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13
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Bodkin C, Comer A, Felker M, Gutmann L, Jones KA, Kincaid J, Payne KK, Skinner B. Challenging Neuromuscular Disease Cases. Semin Neurol 2022; 42:716-722. [PMID: 36417990 DOI: 10.1055/a-1985-0230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The diagnosis of neuromuscular disorders requires a thorough history including family history and examination, with the next steps broadened now beyond electromyography and neuropathology to include genetic testing. The challenge in diagnosis can often be putting all the information together. With advances in genetic testing, some diagnoses that adult patients may have received as children deserve a second look and may result in diagnoses better defined or alternative diagnoses made. Clearly defining or redefining a diagnosis can result in understanding of potential other systems involved, prognosis, or potential treatments. This article presents several cases and approach to diagnosis as well as potential treatment and prognostic concerns, including seipinopathy, congenital myasthenic syndrome, central core myopathy, and myotonic dystrophy type 2.
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Affiliation(s)
- Cynthia Bodkin
- Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Adam Comer
- Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Marcia Felker
- Division of Pediatric Neurology, Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Laurie Gutmann
- Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Karra A Jones
- Department of Pathology, Duke University Medical Center, Durham, North Carolina
| | - John Kincaid
- Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Katelyn K Payne
- Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana.,Department of Medical Genetics and Genomics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Blair Skinner
- Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana
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14
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Abstract
PURPOSE OF REVIEW The limb-girdle muscular dystrophies (LGMDs) are a group of inherited muscle disorders with a common feature of limb-girdle pattern of weakness, caused by over 29 individual genes. This article describes the classification scheme, common subtypes, and the management of individuals with LGMD. RECENT FINDINGS Advances in genetic testing and next-generation sequencing panels containing all of the LGMD genes have led to earlier genetic confirmation, but also to more individuals with variants of uncertain significance. The LGMDs include disorders with autosomal recessive inheritance, which are often due to loss-of-function mutations in muscle structural or repair proteins and typically have younger ages of onset and more rapidly progressive presentations, and those with autosomal dominant inheritance, which can have older ages of presentation and chronic progressive disease courses. All cause progressive disability and potential loss of ability to walk or maintain a job due to progressive muscle wasting. Certain mutations are associated with cardiac or respiratory involvement. No disease-altering therapies have been approved by the US Food and Drug Administration (FDA) for LGMDs and standard treatment uses a multidisciplinary clinic model, but recessive LGMDs are potentially amenable to systemic gene replacement therapies, which are already being tested in clinical trials for sarcoglycan and FKRP mutations. The dominant LGMDs may be amenable to RNA-based therapeutic approaches. SUMMARY International efforts are underway to better characterize LGMDs, help resolve variants of uncertain significance, provide consistent and improved standards of care, and prepare for future clinical trials.
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15
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Shetty ND, Dhande RP, Nagendra V, Unadkat BS, Shelar SS. Post-COVID-19 Myositis Based on Magnetic Resonance Imaging: A Case Report. Cureus 2022; 14:e30293. [PMID: 36407178 PMCID: PMC9657587 DOI: 10.7759/cureus.30293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
The severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) causes COVID-19, which is known to cause fever, dry cough, exhaustion, headache, and loss of taste and smell. Although fever, sore throat, and cough have historically been the utmost characteristic symptoms of the illness, published case reports have recently started to emphasize additional uncommon and unusual presentations of infection with the coronavirus. In COVID, the musculoskeletal system is seldomly involved. In addition to reviewing the causes and imaging characteristics of COVID-19-related illnesses of the musculoskeletal system, we elaborate on a case of a middle-aged man who developed myositis as sequelae to the COVID-19 infection.
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16
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Krenzke LR, Cameron S, Pritchard JC, Webb DB, Guo LT, Shelton GD. Glossitis in an older non-corgi dog: Diagnosis and long-term follow-up. THE CANADIAN VETERINARY JOURNAL = LA REVUE VETERINAIRE CANADIENNE 2022; 63:825-829. [PMID: 35919473 PMCID: PMC9281888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
A 9-year-old spayed female 18.8 kg mixed breed boxer dog was referred for evaluation of a 7-month history of difficulty swallowing and prehending food, regurgitation, hypersalivation, and an abnormal dorsiflexion of the tongue. Prior to referral, a barium study was performed, which revealed a mildly dilated esophagus. Treatment with sucralfate, cisapride, and prednisone was initiated. Physical examination revealed bilateral, symmetric atrophy of the temporalis muscles, dorsiflexion of the distal aspect of the tongue with concurrent muscle atrophy, and a reduced gag reflex. Electrodiagnostic examinations revealed spontaneous electrical activity in the muscles of mastication and tongue. Biopsies from the right temporalis, tongue, and biceps femoris muscles were collected. An immune-mediated myositis with fibrosis, scattered CD3, CD4, and CD8+ T-lymphocytes, and upregulation of markers for major histocompatibility antigens were observed in the tongue and temporalis muscles. The dog was treated with a tapering course of prednisone over 2 months and cyclosporine long-term. The dog was maintained on cyclosporine alone for > 2 years and clinical signs remained static, although multiple episodes of aspiration pneumonia occurred. Ultimately, euthanasia was performed due to chronic kidney disease with associated anemia, lethargy, and anorexia.
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Affiliation(s)
- Lucinda R Krenzke
- University of Wisconsin - Madison, School of Veterinary Medicine, Department of Medical Sciences, Madison, Wisconsin, USA (Krenzke, Cameron, Pritchard); Southeast Veterinary Neurology of Boynton Beach, Boynton Beach, Florida, USA (Webb); Comparative Neuromuscular Laboratory, University of California - San Diego, La Jolla, California, USA (Guo, Shelton)
| | - Starr Cameron
- University of Wisconsin - Madison, School of Veterinary Medicine, Department of Medical Sciences, Madison, Wisconsin, USA (Krenzke, Cameron, Pritchard); Southeast Veterinary Neurology of Boynton Beach, Boynton Beach, Florida, USA (Webb); Comparative Neuromuscular Laboratory, University of California - San Diego, La Jolla, California, USA (Guo, Shelton)
| | - Jessica C Pritchard
- University of Wisconsin - Madison, School of Veterinary Medicine, Department of Medical Sciences, Madison, Wisconsin, USA (Krenzke, Cameron, Pritchard); Southeast Veterinary Neurology of Boynton Beach, Boynton Beach, Florida, USA (Webb); Comparative Neuromuscular Laboratory, University of California - San Diego, La Jolla, California, USA (Guo, Shelton)
| | - D Blake Webb
- University of Wisconsin - Madison, School of Veterinary Medicine, Department of Medical Sciences, Madison, Wisconsin, USA (Krenzke, Cameron, Pritchard); Southeast Veterinary Neurology of Boynton Beach, Boynton Beach, Florida, USA (Webb); Comparative Neuromuscular Laboratory, University of California - San Diego, La Jolla, California, USA (Guo, Shelton)
| | - Ling T Guo
- University of Wisconsin - Madison, School of Veterinary Medicine, Department of Medical Sciences, Madison, Wisconsin, USA (Krenzke, Cameron, Pritchard); Southeast Veterinary Neurology of Boynton Beach, Boynton Beach, Florida, USA (Webb); Comparative Neuromuscular Laboratory, University of California - San Diego, La Jolla, California, USA (Guo, Shelton)
| | - G Diane Shelton
- University of Wisconsin - Madison, School of Veterinary Medicine, Department of Medical Sciences, Madison, Wisconsin, USA (Krenzke, Cameron, Pritchard); Southeast Veterinary Neurology of Boynton Beach, Boynton Beach, Florida, USA (Webb); Comparative Neuromuscular Laboratory, University of California - San Diego, La Jolla, California, USA (Guo, Shelton)
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17
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Clinical implication of denervation in sporadic inclusion body myositis. J Neurol Sci 2022; 439:120317. [PMID: 35709642 DOI: 10.1016/j.jns.2022.120317] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/08/2022] [Accepted: 06/03/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Sporadic inclusion body myositis (sIBM) is often accompanied by signs suggestive of denervation on electromyography (EMG), which mimics neurogenic disorders. Hence, the current study aimed to assess reinnervation after denervation in sIBM and its clinical impllcation. METHODS We retrospectively examined consecutive muscle biopsy specimens collected from 109 sIBM patients who were referred to our institution for diagnostic muscle biopsy from 2001 to 2018. Reinnervation after denervation in sIBM patients was assessed via muscle biopsy and EMG. The levels of acetylcholine receptor subunit γ (Chrng) and muscle-specific kinase (MuSK) mRNA, which are markers of denervation, were examined using real-time polymerase chain reaction. Response to treatment was defined as an increase of grade 1 or higher in two or more muscle groups as assessed using the Medical Research Council scale. RESULTS In total, 93 (85.3%) of 109 sIBM patients had reinnervation after denervation on histological examination and/or EMG. The mean disease duration before biopsy was significantly longer in patients with reinnervation after denervation than in those without (p < 0.00001). Patients with denervation had significantly higher levels of Chrng and MuSK mRNA than those without. The proportion of patients who responded to immunosuppressive therapies was smaller in the patients with denervation than those without (p < 0.05). However, there was no significant difference regarding time from onset to using a walking aid between the two groups. DISCUSSION Reinnervation after denervation is associated with disease duration and short-term response to therapy in individuals with sIBM.
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18
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Wu MJ, Liao WA, Lin PY, Sun YT. Muscle Biopsy: A Requirement for Precision Medicine in Adult-Onset Myopathy. J Clin Med 2022; 11:jcm11061580. [PMID: 35329906 PMCID: PMC8951002 DOI: 10.3390/jcm11061580] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/07/2022] [Accepted: 03/11/2022] [Indexed: 11/16/2022] Open
Abstract
Muscle biopsy is a fundamental procedure to assist the final diagnosis of myopathy. With the recent advances in molecular diagnosis, serology tests, and mechanism-based classification in myopathy, the précised diagnosis for myopathy required the applications of multiple tools. This study intends to reappraise the benefit of muscle biopsy in adult-onset myopathy under the setting of an optimized muscle biopsy protocol and comprehensive serology tests. A one-group pretest-posttest study design was used. The pre- and post-biopsy diagnoses and treatments in 69 adult patients were compared. Muscle biopsy yielded 85.5% of definitive diagnoses, including changes in pre-biopsy diagnoses (40.6%) and narrowing down the suspicious myopathies (49.3%). The demographic data and clinical parameters between the group “with change” and “without change” after biopsy were not different. Among those with changes in diagnosis, 39.3% also had a corresponding shift in treatment, which benefits the patients significantly. Regarding the most common adult-onset myopathy, idiopathic inflammatory myopathy (IIM), 41% of patients with pre-biopsy diagnosis as IIM had changes in their IIM subtype diagnosis, and 53% was finally not IIM after muscle biopsy. Although there have been advances in molecular diagnosis recently, muscle biopsy still undoubtedly critically guided the diagnosis and treatment of adult-onset myopathy in the era of precision medicine.
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Affiliation(s)
- Meng-Ju Wu
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (M.-J.W.); (P.-Y.L.)
| | - Wei-An Liao
- Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan;
| | - Po-Yu Lin
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (M.-J.W.); (P.-Y.L.)
| | - Yuan-Ting Sun
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (M.-J.W.); (P.-Y.L.)
- Department of Medical Genomics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
- Correspondence:
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19
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Kodintcev A. A clinical case of progressive hypokalemic myopathy due to Conn’s syndrome. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:149-154. [DOI: 10.17116/jnevro2022122111149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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20
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Abstract
Compound muscle action potential (CMAP) recordings provide a sensitive electromyographic approach to measure nerve conduction and assess neuromuscular junction functionality in humans and rodents. In humans, it represents a diagnostic tool for neuromuscular disorders. In rodents, this approach is widely employed to dissect the molecular mechanisms driving peripheral nerve degeneration/regeneration, as well as to evaluate the effect of candidate pro-regenerative compounds. The method described here allows recording CMAP from the gastrocnemius muscle of mice after sciatic nerve stimulation. We report some representative traces of CMAP recorded from adult, healthy mice, after sciatic nerve compression and during neurotransmission recovery stimulated by melatonin administration.
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Affiliation(s)
- Samuele Negro
- Department of Biomedical Sciences, University of Padua, Padua, Italy
| | - Marco Stazi
- Department of Biomedical Sciences, University of Padua, Padua, Italy
| | - Michela Rigoni
- Department of Biomedical Sciences, University of Padua, Padua, Italy.
- CIR-Myo, Centro Interdipartimentale di Ricerca di Miologia, University of Padua, Padova, Italy.
| | - Aram Megighian
- Department of Biomedical Sciences, University of Padua, Padua, Italy.
- Padova Neuroscience Center, Via Orus 2/B, University of Padua, Padova, Italy.
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21
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Lazovic M, Nikolic D, Boyer FC, Borg K, Ceravolo MG, Zampolini M, Kiekens C. Evidence based position paper on Physical and Rehabilitation Medicine practice for people with muscular dystrophies. Eur J Phys Rehabil Med 2021; 57:1036-1044. [PMID: 34823337 DOI: 10.23736/s1973-9087.21.07121-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Muscular dystrophies present a group of inherited degenerative disorder that are characterized by progressive muscular weakness. This evidence-based position paper represents the official position of the European Union through the UEMS PRM Section. The aim of the paper is to evaluate the role of the physical and rehabilitation medicine (PRM) physician and PRM practice for people with muscular dystrophies. A systematic review of the literature and a consensus procedure by means of a Delphi process have been performed involving the delegates of all European countries represented in the UEMS PRM Section. The systematic literature review is reported together with thirty-three recommendations resulting from the Delphi procedure. The role of the PRM physician is to assess the functional status of persons with muscular dystrophy and to plan, monitor and lead PRM program in an interdisciplinary setting within a multiprofessional team.
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Affiliation(s)
- Milica Lazovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia - .,Institute for Rehabilitation, Belgrade, Serbia -
| | - Dejan Nikolic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Physical Medicine and Rehabilitation, University Children's Hospital, Belgrade, Serbia
| | - François C Boyer
- PRM Department, Sebastopol Hospital, Reims Champagne Ardenne University, Reims, France
| | - Kristian Borg
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Maria G Ceravolo
- Department of Experimental and Clinical Medicine, Neurorehabilitation Clinic, University Hospital of Ancona, Politecnica delle Marche University, Ancona, Italy
| | - Mauro Zampolini
- Department of Rehabilitation, San Giovanni Battista Hospital, Foligno, Perugia, Italy
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22
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Tsamis KI, Boutsoras C, Kaltsonoudis E, Pelechas E, Nikas IP, Simos YV, Voulgari PV, Sarmas I. Clinical features and diagnostic tools in idiopathic inflammatory myopathies. Crit Rev Clin Lab Sci 2021; 59:219-240. [PMID: 34767470 DOI: 10.1080/10408363.2021.2000584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Idiopathic inflammatory myopathies (IIMs) are rare autoimmune disorders affecting primarily muscles, but other organs can be involved. This review describes the clinical features, diagnosis and treatment for IIMs, namely polymyositis (PM), dermatomyositis (DM), sporadic inclusion body myositis (sIBM), immune-mediated necrotizing myopathy (IMNM), and myositis associated with antisynthetase syndrome (ASS). The diagnostic approach has been updated recently based on the discovery of circulating autoantibodies, which has enhanced the management of patients. Currently, validated classification criteria for IIMs allow clinical studies with well-defined sets of patients but diagnostic criteria to guide the care of individual patients in routine clinical practice are still missing. This review analyzes the clinical manifestations and laboratory findings of IIMs, discusses the efficiency of modern and standard methods employed in their workup, and delineates optimal practice for clinical care. Α multidisciplinary diagnostic approach that combines clinical, neurologic and rheumatologic examination, evaluation of electrophysiologic and morphologic muscle characteristics, and assessment of autoantibody immunoassays has been determined to be the preferred approach for effective management of patients with suspected IIMs.
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Affiliation(s)
- Konstantinos I Tsamis
- Department of Neurology, University Hospital of Ioannina, Ioannina, Greece.,School of Medicine, European University Cyprus, Nicosia, Cyprus.,Department of Physiology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | | | | | | | - Ilias P Nikas
- School of Medicine, European University Cyprus, Nicosia, Cyprus
| | - Yannis V Simos
- Department of Physiology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | | | - Ioannis Sarmas
- Department of Neurology, University Hospital of Ioannina, Ioannina, Greece
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23
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Development and Preliminary Validation of an Electromyography-Scoring Protocol for the Assessment and Grading of Muscle Involvement in Patients With Juvenile Idiopathic Inflammatory Myopathies. Pediatr Neurol 2021; 124:6-10. [PMID: 34507251 DOI: 10.1016/j.pediatrneurol.2021.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/16/2021] [Accepted: 07/31/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION We performed a pilot study in order to investigate the feasibility of an electromyography (EMG)-scoring protocol for the assessment of disease activity in juvenile idiopathic inflammatory myopathies (JIIM). METHODS Children with JIIM followed up in a tertiary-level care center underwent standardized clinical, laboratory, and EMG assessment. An EMG-scoring protocol was devised by a consensus panel including a pediatric neurophysiologist and two pediatric rheumatologists, based on a combined score obtained as the sum of (1) the presence of denervation signs (fibrillation potentials) and (2) motor unit remodeling (mixed pattern of short- and long-duration motor unit action potentials). The EMG-scoring protocol was then validated following the Outcome Measures in Rheumatoid Arthritis Clinical Trials filter for outcome measures in rheumatology and the consensus-based standards for the selection of health measurement instruments methodology. RESULTS Thirteen children (77% females) were included in the study, with a median age of 10 years (interquartile range: 7-17 years) and median disease duration of 11.8 months (interquartile range: 2.1-44.5). A total of 39 EMG examinations were evaluated. A strong positive association between a standardized tool for muscle strength assessment and the combined score was observed. No significant associations were found with both creatine kinase and erythrocyte sedimentation rate levels. DISCUSSION Our EMG-scoring protocol is the first standardized and reproducible tool for the neurophysiologic evaluation and grading of muscle involvement in patients with JIIM and could provide relevant additional information in the assessment and follow-up of these rare conditions.
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Abstract
Electrodiagnostic testing is a useful tool in the evaluation of suspected myopathy and helps to confirm the presence of a myopathy and exclude disease mimickers. The electrodiagnostic pattern of findings during testing guides subsequent laboratory evaluation, genetic testing, and in identifying potential muscle biopsy targets. It also provides a baseline for subsequent assessment of disease progression or response to therapy. This article summarizes the approach to electrodiagnostic assessment in various myopathic disorders.
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25
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Ramani SL, Samet J, Franz CK, Hsieh C, Nguyen CV, Horbinski C, Deshmukh S. Musculoskeletal involvement of COVID-19: review of imaging. Skeletal Radiol 2021; 50:1763-1773. [PMID: 33598718 PMCID: PMC7889306 DOI: 10.1007/s00256-021-03734-7] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 02/02/2023]
Abstract
The global pandemic of coronavirus disease 2019 (COVID-19) has revealed a surprising number of extra-pulmonary manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. While myalgia is a common clinical feature of COVID-19, other musculoskeletal manifestations of COVID-19 were infrequently described early during the pandemic. There have been emerging reports, however, of an array of neuromuscular and rheumatologic complications related to COVID-19 infection and disease course including myositis, neuropathy, arthropathy, and soft tissue abnormalities. Multimodality imaging supports diagnosis and evaluation of musculoskeletal disorders in COVID-19 patients. This article aims to provide a first comprehensive summary of musculoskeletal manifestations of COVID-19 with review of imaging.
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Affiliation(s)
| | - Jonathan Samet
- Department of Radiology, Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL, 60611, USA
| | - Colin K Franz
- Shirley Ryan Ability Lab (Formerly the Rehabilitation Institute of Chicago), 355 E Erie St, Chicago, IL, 60611, USA
- Departments of Physical Medicine and Rehabilitation and Neurology, Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL, 60611, USA
| | - Christine Hsieh
- Department of Rheumatology, Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL, 60611, USA
| | - Cuong V Nguyen
- Department of Dermatology, Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL, 60611, USA
| | - Craig Horbinski
- Division of Pathology, Department of Medicine, Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL, 60611, USA
| | - Swati Deshmukh
- Department of Radiology, Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL, 60611, USA.
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26
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Villa D, Ardolino G, Borellini L, Cogiamanian F, Vergari M, Savojardo V, Peyvandi F, Barbieri S. Subclinical myopathic changes in COVID-19. Neurol Sci 2021; 42:3973-3979. [PMID: 34304328 PMCID: PMC8310558 DOI: 10.1007/s10072-021-05469-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 07/07/2021] [Indexed: 12/25/2022]
Abstract
Introduction Coronavirus disease 2019 (COVID-19) is associated to neuromuscular symptoms in up to 10.7% of hospitalized patients. Nevertheless, the extent of muscular involvement in infected subjects with no signs of myopathy has never been assessed with neurophysiological investigations. Methods Over a 3-week period — from April 30 through May 20, 2020 — a total of 70 patients were hospitalized in the Internal Medicine Ward of the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico in Milan, Italy. After excluding patients who underwent invasive ventilation and steroid treatment, 12 patients were evaluated. Nerve conduction studies (NCS) included the analysis of conduction velocity, amplitude, and latency for bilateral motor tibial, ulnar nerves, and sensory sural and radial nerves. Unilateral concentric-needle electromyography (EMG) was performed evaluating at least 4 areas of 8 selected muscles. For each muscle, spontaneous activity at rest, morphology, and recruitment of motor unit action potentials (MUAPs) were evaluated. Results While nerve conduction studies were unremarkable, needle electromyography showed myopathic changes in 6 out of 12 subjects. All patients were asymptomatic for muscular involvement. Clinical features and laboratory findings did not show relevant differences between patients with and without myopathic changes. Conclusion Our data show that in SARS-CoV-2 infection muscular involvement can occur despite the absence of clinical signs or symptoms and should be considered part of the disease spectrum. The application of muscle biopsy to unravel the mechanisms of myofiber damage on tissue specimens could help to clarify the pathogenesis and the treatment response of coronavirus-mediated injury. Supplementary Information The online version contains supplementary material available at 10.1007/s10072-021-05469-8.
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Affiliation(s)
- Davide Villa
- U.O. Neurofisiopatologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milan, Italy.,Dipartimento Di Fisiopatologia Medico-Chirurgica E Dei Trapianti, Università Degli Studi Di Milano, Milan, Italy
| | - Gianluca Ardolino
- U.O. Neurofisiopatologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milan, Italy
| | - Linda Borellini
- U.O. Neurofisiopatologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milan, Italy.
| | - Filippo Cogiamanian
- U.O. Neurofisiopatologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milan, Italy
| | - Maurizio Vergari
- U.O. Neurofisiopatologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milan, Italy
| | - Valeria Savojardo
- U.O. Medicina Generale Ad Alta Intensità Di Cura, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milan, Italy
| | - Flora Peyvandi
- Dipartimento Di Fisiopatologia Medico-Chirurgica E Dei Trapianti, Università Degli Studi Di Milano, Milan, Italy.,Centro Emofilia E Trombosi Angelo Bianchi Bonomi, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milan, Italy
| | - Sergio Barbieri
- U.O. Neurofisiopatologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milan, Italy
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27
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Nicolau S, Milone M, Liewluck T. Guidelines for genetic testing of muscle and neuromuscular junction disorders. Muscle Nerve 2021; 64:255-269. [PMID: 34133031 DOI: 10.1002/mus.27337] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 05/28/2021] [Indexed: 12/24/2022]
Abstract
Despite recent advances in the understanding of inherited muscle and neuromuscular junction diseases, as well as the advent of a wide range of genetic tests, patients continue to face delays in diagnosis of sometimes treatable disorders. These guidelines outline an approach to genetic testing in such disorders. Initially, a patient's phenotype is evaluated to identify myopathies requiring directed testing, including myotonic dystrophies, facioscapulohumeral muscular dystrophy, oculopharyngeal muscular dystrophy, mitochondrial myopathies, dystrophinopathies, and oculopharyngodistal myopathy. Initial investigation in the remaining patients is generally a comprehensive gene panel by next-generation sequencing. Broad panels have a higher diagnostic yield and can be cost-effective. Due to extensive phenotypic overlap and treatment implications, genes responsible for congenital myasthenic syndromes should be included when evaluating myopathy patients. For patients whose initial genetic testing is negative or inconclusive, phenotypic re-evaluation is warranted, along with consideration of genes and variants not included initially, as well as their acquired mimickers.
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Affiliation(s)
- Stefan Nicolau
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Teerin Liewluck
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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28
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Plesia M, Stevens OA, Lloyd GR, Kendall CA, Coldicott I, Kennerley AJ, Miller G, Shaw PJ, Mead RJ, Day JCC, Alix JJP. In Vivo Fiber Optic Raman Spectroscopy of Muscle in Preclinical Models of Amyotrophic Lateral Sclerosis and Duchenne Muscular Dystrophy. ACS Chem Neurosci 2021; 12:1768-1776. [PMID: 33950665 PMCID: PMC8154326 DOI: 10.1021/acschemneuro.0c00794] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 04/30/2021] [Indexed: 12/13/2022] Open
Abstract
Neuromuscular diseases result in muscle weakness, disability, and, in many instances, death. Preclinical models form the bedrock of research into these disorders, and the development of in vivo and potentially translational biomarkers for the accurate identification of disease is crucial. Spontaneous Raman spectroscopy can provide a rapid, label-free, and highly specific molecular fingerprint of tissue, making it an attractive potential biomarker. In this study, we have developed and tested an in vivo intramuscular fiber optic Raman technique in two mouse models of devastating human neuromuscular diseases, amyotrophic lateral sclerosis, and Duchenne muscular dystrophy (SOD1G93A and mdx, respectively). The method identified diseased and healthy muscle with high classification accuracies (area under the receiver operating characteristic curves (AUROC): 0.76-0.92). In addition, changes in diseased muscle over time were also identified (AUROCs 0.89-0.97). Key spectral changes related to proteins and the loss of α-helix protein structure. Importantly, in vivo recording did not cause functional motor impairment and only a limited, resolving tissue injury was seen on high-resolution magnetic resonance imaging. Lastly, we demonstrate that ex vivo muscle from human patients with these conditions produced similar spectra to those observed in mice. We conclude that spontaneous Raman spectroscopy of muscle shows promise as a translational research tool.
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Affiliation(s)
- Maria Plesia
- Sheffield
Institute for Translational Neuroscience, University of Sheffield, Sheffield S10 2HQ, UK
| | - Oliver A. Stevens
- Interface
Analysis Centre, School of Physics, University
of Bristol, Bristol BS8 1TL, UK
| | - Gavin R. Lloyd
- Phenome
Centre Birmingham, University of Birmingham, Birmingham B15 2TT, UK
- Biophotonics
Research Unit, Gloucestershire Hospitals
NHS Foundation Trust, Gloucester GL1 3NN, UK
| | - Catherine A. Kendall
- Biophotonics
Research Unit, Gloucestershire Hospitals
NHS Foundation Trust, Gloucester GL1 3NN, UK
| | - Ian Coldicott
- Sheffield
Institute for Translational Neuroscience, University of Sheffield, Sheffield S10 2HQ, UK
| | | | - Gaynor Miller
- Department
of Oncology and Metabolism, University of
Sheffield, Sheffield S10 2RX, UK
| | - Pamela J. Shaw
- Sheffield
Institute for Translational Neuroscience, University of Sheffield, Sheffield S10 2HQ, UK
- Cross-Faculty
Neuroscience Institute, University of Sheffield, Sheffield S10 2HQ, UK
| | - Richard J. Mead
- Sheffield
Institute for Translational Neuroscience, University of Sheffield, Sheffield S10 2HQ, UK
- Cross-Faculty
Neuroscience Institute, University of Sheffield, Sheffield S10 2HQ, UK
| | - John C. C. Day
- Interface
Analysis Centre, School of Physics, University
of Bristol, Bristol BS8 1TL, UK
| | - James J. P. Alix
- Sheffield
Institute for Translational Neuroscience, University of Sheffield, Sheffield S10 2HQ, UK
- Cross-Faculty
Neuroscience Institute, University of Sheffield, Sheffield S10 2HQ, UK
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29
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Triplett JD, Shelly S, Livne G, Milone M, Kassardjian CD, Liewluck T, Kelly C, Naddaf E, Laughlin RS, Lamb CJ, Rubin D, Dimberg EL, Dubey D, Mills JR, Mandrekar J, Klein CJ. Diagnostic modelling and therapeutic monitoring of immune-mediated necrotizing myopathy: role of electrical myotonia. Brain Commun 2020; 2:fcaa191. [PMID: 33364599 PMCID: PMC7749792 DOI: 10.1093/braincomms/fcaa191] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 09/19/2020] [Accepted: 09/28/2020] [Indexed: 12/11/2022] Open
Abstract
Delayed diagnosis of immune-mediated necrotizing myopathy leads to increased morbidity. Patients with the chronic course without 3-hydroxy-3-methylglutaryl-coenzyme-A reductase-IgG or signal recognition particle-IgG are often challenging to diagnose. Immunotherapy response can also be difficult to assess. We created a statistical model to assist immune-mediated necrotizing myopathy diagnosis. Electrical myotonia versus fibrillations were reviewed as biomarkers for immunotherapy treatment response. Identified were 119 immune-mediated necrotizing myopathy cases and 938 other myopathy patients. Inclusion criteria included all having electrophysiological evaluations, muscle biopsies showing inflammatory/necrotizing myopathies, comprehensively recorded neurological examinations, and creatine kinase values. Electrical myotonia was recorded in 56% (67/119) of retrospective and 67% (20/30) of our validation immune-mediated necrotizing myopathy cohorts, and significantly (P < 0.001) favoured immune-mediated necrotizing myopathy over other myopathies: sporadic inclusion body myositis (odds ratio = 4.78); dermatomyositis (odds ratio = 10.61); non-specific inflammatory myopathies (odds ratio = 8.46); limb-girdle muscular dystrophies (odds ratio = 5.34) or mitochondrial myopathies (odds ratio = 14.17). Electrical myotonia occurred in immune-mediated necrotizing myopathy seropositive (3-hydroxy-3-methylglutaryl-coenzyme-A reductase-IgG 70%, 37/53; signal recognition particle-IgG 29%, 5/17) and seronegative (51%, 25/49). Multivariate regression analysis of 20 variables identified 8 (including electrical myotonia) in combination accurately predicted immune-mediated necrotizing myopathy (97.1% area-under-curve). The model was validated in a separate cohort of 30 immune-mediated necrotizing myopathy cases. Delayed diagnosis of cases with electrical myotonia occurred in 24% (16/67, mean 8 months; range 0–194). Half (8/19) had a chronic course and were seronegative, with high model prediction (>86%) at the first visit. Inherited myopathies were commonly first suspected in them. Follow-up evaluation in patients with electrical myotonia on immunotherapy was available in 19 (median 21 months, range 2–124) which reduced from 36% (58/162) of muscles to 7% (8/121; P < 0.001). Reduced myotonia correlated with immunotherapy response in 64% (9/14) as well as with median creatine kinase reduction of 1779 U/l (range 401–9238, P < 0.001). Modelling clinical features with electrical myotonia is especially helpful in immune-mediated necrotizing myopathy diagnostic suspicion among chronic indolent and seronegative cases. Electrical myotonia favours immune-mediated necrotizing myopathy diagnosis and can serve as an adjuvant immunotherapy biomarker.
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Affiliation(s)
| | - Shahar Shelly
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Charles D Kassardjian
- Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Canada
| | | | - Cecilia Kelly
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Elie Naddaf
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Devon Rubin
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Divanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Jay Mandrekar
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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30
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Zimmermann M, Deininger N, Willikens S, Haack TB, Grundmann-Hauser K, Streubel B, Schreiber M, Lerche H, Grimm A. Tetraparesis and sensorimotor axonal polyneuropathy due to co-occurrence of Pompe disease and hereditary ATTR amyloidosis. Neurol Sci 2020; 42:1523-1525. [PMID: 33188503 PMCID: PMC7955998 DOI: 10.1007/s10072-020-04896-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/09/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION/AIMS Hereditary transthyretin amyloidosis with polyneuropathy (hATTRPN) is an autosomal dominant multi-organ disorder manifesting in the third to fifth decade with the key clinical features of distal and painful sensory loss of the lower limbs and autonomic dysregulation. Motor neuropathy and cardiomyopathy evolve in the course of the disease. Pompe disease is an autosomal recessive disease leading to decreased levels of lysosomal enzyme acid α-glucosidase and proximal muscle weakness. We report the clinical features and diagnostic workup in the rare case of a patient with ATTR amyloidosis and late-onset Pompe disease, both genetically confirmed. METHODS We performed a detailed clinical assessment, exome sequencing, and biochemical measurements. RESULTS The patient presented with a distal, painful hypaesthesia of both legs, a cardiomyopathy, and a muscle weakness in the form of a girdle-type pattern of the arms and legs at the beginning and a spreading to distal muscle groups in the course of disease. DISCUSSION This study highlights the importance of searching for co-occurrence of rare monogenetic neuromuscular diseases, especially in cases in which all clinical features can be readily explained by a single gene defect.
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Affiliation(s)
- Milan Zimmermann
- Department of Neurology and Hertie Institute for Clinical Brain Research and Center of Neurology, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany. .,German Center for Neurodegenerative Diseases (DZNE), 72076, Tübingen, Germany. .,Department of Neurodegenerative Diseases, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.
| | - Natalie Deininger
- Institute of Medical Genetics and Applied Genomics, University of Tübingen, 72076, Tübingen, Germany
| | - Sophia Willikens
- Department of Neurology and Hertie Institute for Clinical Brain Research and Center of Neurology, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Tobias B Haack
- Institute of Medical Genetics and Applied Genomics, University of Tübingen, 72076, Tübingen, Germany.,Center for Rare Diseases, University of Tübingen, Tübingen, 72076, Tübingen, Germany
| | - Kathrin Grundmann-Hauser
- Institute of Medical Genetics and Applied Genomics, University of Tübingen, 72076, Tübingen, Germany
| | - Berthold Streubel
- Institute for Pathology, Medical University of Wien, 1090, Wien, Austria
| | - Melanie Schreiber
- Department of Neurology and Hertie Institute for Clinical Brain Research and Center of Neurology, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,German Center for Neurodegenerative Diseases (DZNE), 72076, Tübingen, Germany
| | - Holger Lerche
- Department of Neurology and Hertie Institute for Clinical Brain Research and Center of Neurology, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,German Center for Neurodegenerative Diseases (DZNE), 72076, Tübingen, Germany
| | - Alexander Grimm
- Department of Neurology and Hertie Institute for Clinical Brain Research and Center of Neurology, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,German Center for Neurodegenerative Diseases (DZNE), 72076, Tübingen, Germany
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31
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Neuropathy in sporadic inclusion body myositis: A multi-modality neurophysiological study. Clin Neurophysiol 2020; 131:2766-2776. [PMID: 32928695 DOI: 10.1016/j.clinph.2020.07.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 07/09/2020] [Accepted: 07/22/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Sporadic inclusion body myositis (sIBM) has been associated with neuropathy. This study employs nerve excitability studies to re-examine this association and attempt to understand underlying pathophysiological mechanisms. METHODS Twenty patients with sIBM underwent median nerve motor and sensory excitability studies, clinical assessments, conventional nerve conduction testing (NCS) and quantitative thermal threshold studies. These results were compared to established normal controls, or results from a normal cohort of older control individuals. RESULTS Seven sIBM patients (35%) demonstrated abnormalities in conventional NCS, with ten patients (50%) demonstrating abnormalities in thermal thresholds. Median nerve motor and sensory excitability differed significantly in sIBM patients when compared to normal controls. None of these neurophysiological markers correlated significantly with clinical markers of sIBM severity. CONCLUSION A concurrent neuropathy exists in a significant proportion of sIBM patients, with nerve excitability studies revealing changes possibly consistent with axolemmal depolarization or concurrent neuronal adaptation to myopathy. Neuropathy in sIBM does not correlate with muscle disease severity and may reflect a differing tissue response to a common pathogenic factor. SIGNIFICANCE This study affirms the presence of a concurrent neuropathy in a large proportion of sIBM patients that appears independent of the severity of myopathy.
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32
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Mizus MC, Tiniakou E. Lipid-lowering Therapies in Myositis. Curr Rheumatol Rep 2020; 22:70. [PMID: 32845379 PMCID: PMC7986053 DOI: 10.1007/s11926-020-00942-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW The use of lipid-lowering therapies in patients with idiopathic inflammatory myopathies (IIM) is complicated and there are no guidelines for diagnosing, monitoring, or treating atherosclerotic cardiovascular disease (ASCVD) in this group of patients. RECENT FINDINGS The use of lipid-lowering therapies, especially statins, is recommended in patients with increased risk for ASCVD, which includes patients with inflammatory diseases, based on recent American College of Cardiology/American Heart Association (ACC/AHA) guidelines for ASCVD management. There is accumulating evidence that patients with IIM are at increased risk for ASCVD, similar to other inflammatory diseases. Lipid-lowering therapies have side effects that may be pronounced or confounding in myositis patients, potentially limiting their use. Statins are specifically contraindicated in patients with anti 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR) antibodies. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been shown to be safe and potentially beneficial in patients with IIM. Here, we propose a framework for (1) ASCVD risk assessment and treatment based on ACC/AHA ASCVD primary prevention guidelines; (2) myositis disease monitoring while undergoing lipid-lowering therapy; and (3) management of statin intolerance, including, indications for the use of PCSK9 inhibitors.
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Affiliation(s)
- Marisa C Mizus
- Department of Medicine, Division of Rheumatology, Mason Lord, Center Tower, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Baltimore, MD, 21224, USA.
| | - Eleni Tiniakou
- Department of Medicine, Division of Rheumatology, Mason Lord, Center Tower, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Baltimore, MD, 21224, USA.
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Pereira JA, Gerber J, Ghidinelli M, Gerber D, Tortola L, Ommer A, Bachofner S, Santarella F, Tinelli E, Lin S, Rüegg MA, Kopf M, Toyka KV, Suter U. Mice carrying an analogous heterozygous dynamin 2 K562E mutation that causes neuropathy in humans develop predominant characteristics of a primary myopathy. Hum Mol Genet 2020; 29:1253-1273. [PMID: 32129442 PMCID: PMC7254847 DOI: 10.1093/hmg/ddaa034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/21/2020] [Accepted: 02/25/2020] [Indexed: 12/13/2022] Open
Abstract
Some mutations affecting dynamin 2 (DNM2) can cause dominantly inherited Charcot-Marie-Tooth (CMT) neuropathy. Here, we describe the analysis of mice carrying the DNM2 K562E mutation which has been associated with dominant-intermediate CMT type B (CMTDIB). Contrary to our expectations, heterozygous DNM2 K562E mutant mice did not develop definitive signs of an axonal or demyelinating neuropathy. Rather, we found a primary myopathy-like phenotype in these mice. A likely interpretation of these results is that the lack of a neuropathy in this mouse model has allowed the unmasking of a primary myopathy due to the DNM2 K562E mutation which might be overshadowed by the neuropathy in humans. Consequently, we hypothesize that a primary myopathy may also contribute to the disease mechanism in some CMTDIB patients. We propose that these findings should be considered in the evaluation of patients, the determination of the underlying disease processes and the development of tailored potential treatment strategies.
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Affiliation(s)
- Jorge A Pereira
- Department of Biology, Institute of Molecular Health Sciences, Swiss Federal Institute of Technology, ETH Zurich, 8093 Zurich, Switzerland
| | - Joanne Gerber
- Department of Biology, Institute of Molecular Health Sciences, Swiss Federal Institute of Technology, ETH Zurich, 8093 Zurich, Switzerland
| | - Monica Ghidinelli
- Department of Biology, Institute of Molecular Health Sciences, Swiss Federal Institute of Technology, ETH Zurich, 8093 Zurich, Switzerland
| | - Daniel Gerber
- Department of Biology, Institute of Molecular Health Sciences, Swiss Federal Institute of Technology, ETH Zurich, 8093 Zurich, Switzerland
| | - Luigi Tortola
- Department of Biology, Institute of Molecular Health Sciences, Swiss Federal Institute of Technology, ETH Zurich, 8093 Zurich, Switzerland
| | - Andrea Ommer
- Department of Biology, Institute of Molecular Health Sciences, Swiss Federal Institute of Technology, ETH Zurich, 8093 Zurich, Switzerland
| | - Sven Bachofner
- Department of Biology, Institute of Molecular Health Sciences, Swiss Federal Institute of Technology, ETH Zurich, 8093 Zurich, Switzerland
| | - Francesco Santarella
- Department of Biology, Institute of Molecular Health Sciences, Swiss Federal Institute of Technology, ETH Zurich, 8093 Zurich, Switzerland
| | - Elisa Tinelli
- Department of Biology, Institute of Molecular Health Sciences, Swiss Federal Institute of Technology, ETH Zurich, 8093 Zurich, Switzerland
| | - Shuo Lin
- Biozentrum, University of Basel, Klingelbergstrasse 50/70, CH-4056 Basel, Switzerland
| | - Markus A Rüegg
- Biozentrum, University of Basel, Klingelbergstrasse 50/70, CH-4056 Basel, Switzerland
| | - Manfred Kopf
- Department of Biology, Institute of Molecular Health Sciences, Swiss Federal Institute of Technology, ETH Zurich, 8093 Zurich, Switzerland
| | - Klaus V Toyka
- Department of Neurology, University Hospital of Würzburg, University of Würzburg, 97080 Würzburg, Germany
| | - Ueli Suter
- Department of Biology, Institute of Molecular Health Sciences, Swiss Federal Institute of Technology, ETH Zurich, 8093 Zurich, Switzerland
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Dede HÖ, Sirin NG, Kocasoy-Orhan E, Idrisoglu HA, Baslo MB. Changes in motor unit bioelectrical activity recorded at two different sites in a muscle. Neurophysiol Clin 2020; 50:113-118. [PMID: 32171639 DOI: 10.1016/j.neucli.2020.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 02/10/2020] [Accepted: 02/11/2020] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION The objective of this study was to compare the properties of bioelectrical signals of motor units recorded at different sites in the muscles of controls, patients with myopathy and patients with motor neuron disease (MND). METHODS Five controls, 10 patients with myopathy and 11 patients with MND were included. Electrophysiologic tests were performed in the biceps brachii (BB) muscle from two recording sites. Site 1 was near the belly of the muscle and Site 2 was 5cm distal from Site 1, near the tendon. Multi-motor unit potential (MUP) analysis, jitter analysis, and peak number count were calculated from the signals recorded using a concentric needle electrode (CN). RESULTS At Site 2, duration was longer, number of phases was higher and amplitudes were smaller in MUPs compared with those recorded at Site 1. This significant difference between recording site and patient groups was related to neurogenic muscles. Jitter analysis showed no significant difference except an intergroup difference between the patient groups and controls. The peak number calculated using the CN was greater when recorded from Site 1 in concordance with MUP analysis. CONCLUSION Duration of MUP was longer and amplitude was smaller when the recording electrode was placed distally along the muscle near the tendon in neurogenic muscles, probably related to increased temporal dispersion. However, changing the position of the needle did not provide further information in distinguishing myogenic muscles.
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Affiliation(s)
- Hava Özlem Dede
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology, 34100 Istanbul Capa, Fatih Turkey.
| | - Nermin Gorkem Sirin
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology, 34100 Istanbul Capa, Fatih Turkey
| | - Elif Kocasoy-Orhan
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology, 34100 Istanbul Capa, Fatih Turkey
| | - Halil Atilla Idrisoglu
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology, 34100 Istanbul Capa, Fatih Turkey
| | - Mehmet Baris Baslo
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology, 34100 Istanbul Capa, Fatih Turkey
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Muscle involvement in myasthenia gravis: Expanding the clinical spectrum of Myasthenia-Myositis association from a large cohort of patients. Autoimmun Rev 2020; 19:102498. [PMID: 32062029 DOI: 10.1016/j.autrev.2020.102498] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 09/30/2019] [Indexed: 12/16/2022]
Abstract
Myastenia-Inflammatory Myopathy (MG-IM) association has been described in less than 50 cases, as isolated reports or in few case series. In most cases, MG and IM onset occur simultaneously even if the overlapping clinical manifestations could lead to delay the diagnosis in the early stage of disease. In these cases, thymic pathology is present in more than 50% of cases. Pathological findings can be consistent of polymyositis (63%), dermatomyositis (25%) or granulomatosis (12%). Accurate clinical manifestations and severity of IM in MG, including muscle specific antibodies (MSA) and muscle MRI, have not been systematically investigated and focal or mild subclinical myositis have not been reported. We observed that focal myositis or asymptomatic CK elevation can also occur in MG. In this review we have also retrospectively re-analyzed the clinical, serological, pathological and muscle imaging data from 13 patients with MG- IM from our cohort of 441 MG patients (2,9%). Clinical onset occurred simultaneously in 10/13 patients, whereas in 2 patients the IM appeared later in MG disease course (range 10-14 years) and conversely in 1 patient MG symptoms occurred later in IM disease course (4 years). Median age at disease onset was 51 year (range 24-73 years) regardless of clinical onset (MG or IM). Median clinical follow-up was 88 months (range 31-237 months). IM was suspected by CK elevation in all patients (ranging 800-3000 UI/L at first detection) and non-fatigable muscle weakness unresponsive to acetylcholinesterase inhibitors. All the patients presented mild to moderate MG symptoms. Three main categories of muscle involvement, sometimes overlapping, were recognizable: distal, proximal and subclinical myositits, leading to three main clinical groups (A,B,C) and two overlapping subgroups (A/B and B/C). Thymus pathology was present in 10/13 patients. Anti-AChR was detected in al all patients associated with anti-Titin and -RyR1 in those patients with thymoma. No MSA, nor MAA antibodies were detected. Muscle biopsy confirmed IM in all patients. In conclusion we redefined the clinical spectrum of muscle involvement in MG-IM association, which represent a continuum among 3 main clinical groups: distal, proximal and subclinical muscle involvement. Minimal muscle involvement and focal myositis could be underestimated among myasthenic patients and early aggressive immunotherapy could be required in focal group.
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Tran KT, Le VS, Vu CD, Nguyen LT. A novel de novo variant of LAMA2 contributes to merosin deficient congenital muscular dystrophy type 1A: Case report. Biomed Rep 2020; 12:46-50. [PMID: 31929873 PMCID: PMC6951223 DOI: 10.3892/br.2019.1260] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 10/25/2019] [Indexed: 12/30/2022] Open
Abstract
Merosin deficient congenital muscular dystrophy type 1A (MDC1A) is caused by defects in the LAMA2 gene. Patients with MDC1A exhibit severe symptoms, including congenital hypotonia, delayed motor development and contractures. The present case report describes a Vietnamese male child with clinical manifestations of delayed motor development, limb-girdle muscular dystrophy, severe scoliosis and white matter abnormality in the brain. Whole exome sequencing (WES) was performed with subsequent validation using Sanger sequencing, and a de novo missense variant (NM_000426.3:c.1964T>C, p.Leu655Pro) and a splice site variant (NG_008678.1:c.3556-13T>A) in the LAMA2 gene of the proband was detected. The missense variant located in exon 14 and has not been reported previously, to the best of our knowledge; whereas the splice site variant has been previously reported to cause premature termination of transcription in patients with MDC1A. In silico tools predicted that the missense variant was damaging. Phenotype-genotype analysis suggested that this proband was associated with classical early onset MDC1A. The co-existence of a de novo and a heterozygous variant in the LAMA2 gene suggested that the de novo variant contributed to the autosomal recessive manner of the disease. Careful consideration of this event by clinical confirmation of parental carrier status may help to accurately determine the risk of occurrence of this disease in future offspring. Additionally, WES is recommended as a powerful tool to assist in identifying potentially causative variants for heterogeneous diseases such as MDC1A.
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Affiliation(s)
- Kien Trung Tran
- Vinmec Research Institute of Stem Cell and Gene Technology, Vinmec International Hospital, Hanoi 100000, Vietnam
| | - Vinh Sy Le
- Vinmec Research Institute of Stem Cell and Gene Technology, Vinmec International Hospital, Hanoi 100000, Vietnam
- University of Engineering and Technology, Vietnam National University, Hanoi 100000, Vietnam
| | - Chinh Duy Vu
- Vinmec Times City International Hospital, Vinmec International Hospital, Hanoi 100000, Vietnam
| | - Liem Thanh Nguyen
- Vinmec Research Institute of Stem Cell and Gene Technology, Vinmec International Hospital, Hanoi 100000, Vietnam
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Janssen L, Allard NAE, Saris CGJ, Keijer J, Hopman MTE, Timmers S. Muscle Toxicity of Drugs: When Drugs Turn Physiology into Pathophysiology. Physiol Rev 2019; 100:633-672. [PMID: 31751166 DOI: 10.1152/physrev.00002.2019] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Drugs are prescribed to manage or prevent symptoms and diseases, but may sometimes cause unexpected toxicity to muscles. The symptomatology and clinical manifestations of the myotoxic reaction can vary significantly between drugs and between patients on the same drug. This poses a challenge on how to recognize and prevent the occurrence of drug-induced muscle toxicity. The key to appropriate management of myotoxicity is prompt recognition that symptoms of patients may be drug related and to be aware that inter-individual differences in susceptibility to drug-induced toxicity exist. The most prevalent and well-documented drug class with unintended myotoxicity are the statins, but even today new classes of drugs with unintended myotoxicity are being discovered. This review will start off by explaining the principles of drug-induced myotoxicity and the different terminologies used to distinguish between grades of toxicity. The main part of the review will focus on the most important pathogenic mechanisms by which drugs can cause muscle toxicity, which will be exemplified by drugs with high risk of muscle toxicity. This will be done by providing information on key clinical and laboratory aspects, muscle electromyography patterns and biopsy results, and pathological mechanism and management for a specific drug from each pathogenic classification. In addition, rather new classes of drugs with unintended myotoxicity will be highlighted. Furthermore, we will explain why it is so difficult to diagnose drug-induced myotoxicity, and which tests can be used as a diagnostic aid. Lastly, a brief description will be given of how to manage and treat drug-induced myotoxicity.
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Affiliation(s)
- Lando Janssen
- Departments of Physiology, Hematology, and Neurology, Radboud University Medical Center, Nijmegen, The Netherlands; and Human and Animal Physiology, Wageningen University & Research, Wageningen, The Netherlands
| | - Neeltje A E Allard
- Departments of Physiology, Hematology, and Neurology, Radboud University Medical Center, Nijmegen, The Netherlands; and Human and Animal Physiology, Wageningen University & Research, Wageningen, The Netherlands
| | - Christiaan G J Saris
- Departments of Physiology, Hematology, and Neurology, Radboud University Medical Center, Nijmegen, The Netherlands; and Human and Animal Physiology, Wageningen University & Research, Wageningen, The Netherlands
| | - Jaap Keijer
- Departments of Physiology, Hematology, and Neurology, Radboud University Medical Center, Nijmegen, The Netherlands; and Human and Animal Physiology, Wageningen University & Research, Wageningen, The Netherlands
| | - Maria T E Hopman
- Departments of Physiology, Hematology, and Neurology, Radboud University Medical Center, Nijmegen, The Netherlands; and Human and Animal Physiology, Wageningen University & Research, Wageningen, The Netherlands
| | - Silvie Timmers
- Departments of Physiology, Hematology, and Neurology, Radboud University Medical Center, Nijmegen, The Netherlands; and Human and Animal Physiology, Wageningen University & Research, Wageningen, The Netherlands
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Can G. İnflamatuar miyozitler: İdiyopatik mi? Çakışma mı? Paraneoplastik mi? EGE TIP DERGISI 2019. [DOI: 10.19161/etd.648954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Bromberg MB. The motor unit and quantitative electromyography. Muscle Nerve 2019; 61:131-142. [PMID: 31579956 DOI: 10.1002/mus.26718] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 09/10/2019] [Accepted: 09/11/2019] [Indexed: 12/13/2022]
Abstract
Electromyography (EMG) assesses the anatomic motor unit (A-MU), but knowledge of its anatomy, physiology, and changes with pathology is limited. The electrophysiological motor unit (E-MU) and its motor unit potential (E-MUP) represents a fraction of the A-MU. Routine EMG assesses a limited number of E-MUP waveform characteristics (metrics) and their magnitudes qualitatively scaled in a nonlinear manner. Another approach is quantitative EMG (QEMG), whereby 20+ E-MUPs are extracted and both basic and derived metrics obtained and values expressed quantitatively. In diseased muscle, many E-MUP metrics may be normal, which complicates diagnostic interpretation. In QEMG, E-MUP metrics can be clustered and statistical analyses performed to assign probabilities that E-MUPs (and the muscle) are normal, neuropathic, or myopathic. In this article we review what is known about the A-MU, the restricted E-MU, E-MUP metrics, and what QEMG offers currently and in the future.
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Affiliation(s)
- Mark B Bromberg
- Department of Neurology, University of Utah, Salt Lake City, Utah
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40
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Lamartine S Monteiro M, Remiche G. Late-onset Pompe disease associated with polyneuropathy. Neuromuscul Disord 2019; 29:968-972. [PMID: 31676142 DOI: 10.1016/j.nmd.2019.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/25/2019] [Accepted: 08/28/2019] [Indexed: 10/26/2022]
Abstract
Late-onset Pompe disease is caused by a glycogen deposition involving mainly striated muscle. It may also target many other tissues such as liver, smooth muscles or spine anterior horn. Glycogen accumulation in Schwann cells and in the perineurium of peripheral nerves was shown in Pompe's disease mouse models. Moreover two late-onset Pompe disease patients were reported as having a small fiber neuropathy. To the best of our knowledge an involvement of large nerve fibers was never depicted. We describe four late-onset Pompe disease patients having a concomitant polyneuropathy of undetermined etiology. Our observations reinforce the proof-of-concept supporting a potential involvement of peripheral nerves as additional organ targeted by late-onset Pompe disease. It has clinical care consequences since peripheral neuropathy in late-onset Pompe disease could worsen patient's disability and needs particular care such as proprioceptive physiotherapy.
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Affiliation(s)
- M Lamartine S Monteiro
- Centre de Référence Neuromusculaire, Department of Neurology, Service de Neurologie, Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070 Brussels, Belgium
| | - G Remiche
- Centre de Référence Neuromusculaire, Department of Neurology, Service de Neurologie, Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070 Brussels, Belgium.
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Freeman MW, Singh AK, Guidon AC, Arvikar SL, Goldstein RH, Clement NF. Case 22-2019: A 65-Year-Old Woman with Weakness, Dark Urine, and Dysphagia. N Engl J Med 2019; 381:275-283. [PMID: 31314973 DOI: 10.1056/nejmcpc1900589] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Mason W Freeman
- From the Departments of Medicine (M.W.F., S.L.A., R.H.G.), Radiology (A.K.S.), Neurology (A.C.G.), and Pathology (N.F.C.), Massachusetts General Hospital, and the Departments of Medicine (M.W.F., S.L.A., R.H.G.), Radiology (A.K.S.), Neurology (A.C.G.), and Pathology (N.F.C.), Harvard Medical School - both in Boston
| | - Ajay K Singh
- From the Departments of Medicine (M.W.F., S.L.A., R.H.G.), Radiology (A.K.S.), Neurology (A.C.G.), and Pathology (N.F.C.), Massachusetts General Hospital, and the Departments of Medicine (M.W.F., S.L.A., R.H.G.), Radiology (A.K.S.), Neurology (A.C.G.), and Pathology (N.F.C.), Harvard Medical School - both in Boston
| | - Amanda C Guidon
- From the Departments of Medicine (M.W.F., S.L.A., R.H.G.), Radiology (A.K.S.), Neurology (A.C.G.), and Pathology (N.F.C.), Massachusetts General Hospital, and the Departments of Medicine (M.W.F., S.L.A., R.H.G.), Radiology (A.K.S.), Neurology (A.C.G.), and Pathology (N.F.C.), Harvard Medical School - both in Boston
| | - Sheila L Arvikar
- From the Departments of Medicine (M.W.F., S.L.A., R.H.G.), Radiology (A.K.S.), Neurology (A.C.G.), and Pathology (N.F.C.), Massachusetts General Hospital, and the Departments of Medicine (M.W.F., S.L.A., R.H.G.), Radiology (A.K.S.), Neurology (A.C.G.), and Pathology (N.F.C.), Harvard Medical School - both in Boston
| | - Robert H Goldstein
- From the Departments of Medicine (M.W.F., S.L.A., R.H.G.), Radiology (A.K.S.), Neurology (A.C.G.), and Pathology (N.F.C.), Massachusetts General Hospital, and the Departments of Medicine (M.W.F., S.L.A., R.H.G.), Radiology (A.K.S.), Neurology (A.C.G.), and Pathology (N.F.C.), Harvard Medical School - both in Boston
| | - Nathan F Clement
- From the Departments of Medicine (M.W.F., S.L.A., R.H.G.), Radiology (A.K.S.), Neurology (A.C.G.), and Pathology (N.F.C.), Massachusetts General Hospital, and the Departments of Medicine (M.W.F., S.L.A., R.H.G.), Radiology (A.K.S.), Neurology (A.C.G.), and Pathology (N.F.C.), Harvard Medical School - both in Boston
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Selva-O'Callaghan A, Pinal-Fernandez I, Trallero-Araguás E, Milisenda JC, Grau-Junyent JM, Mammen AL. Classification and management of adult inflammatory myopathies. Lancet Neurol 2019; 17:816-828. [PMID: 30129477 DOI: 10.1016/s1474-4422(18)30254-0] [Citation(s) in RCA: 221] [Impact Index Per Article: 44.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 06/19/2018] [Accepted: 06/27/2018] [Indexed: 12/16/2022]
Abstract
Inflammatory myopathies, collectively known as myositis, are heterogeneous disorders characterised by muscle inflammation, and frequently accompanied by extramuscular manifestations that affect the skin, lung, and joints. Patients with inflammatory myopathies were previously classified as having dermatomyositis if characteristic rashes accompanied the muscle involvement, and as having polymyositis if no rashes were present. Five main types of inflammatory myopathies are now widely recognised: dermatomyositis, immune-mediated necrotising myopathy, sporadic inclusion-body myositis, overlap myositis (including antisynthetase syndrome), and polymyositis. The discovery of autoantibodies that are specifically associated with characteristic clinical phenotypes has been instrumental to the understanding of inflammatory myopathies. Treatment is still largely based on expert opinion, but several studies have shown effectiveness of different therapies in various subsets of inflammatory myopathies. These advances will undoubtedly improve the outcomes of patients with inflammatory myopathies.
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Affiliation(s)
- Albert Selva-O'Callaghan
- Systemic Autoimmune Diseases Unit, Vall d'Hebron General Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Iago Pinal-Fernandez
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulation, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ernesto Trallero-Araguás
- Rheumatology Unit, Vall d'Hebron General Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - José César Milisenda
- Internal Medicine Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Médica en Red Enfermedades Raras
| | - Josep Maria Grau-Junyent
- Internal Medicine Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Médica en Red Enfermedades Raras
| | - Andrew L Mammen
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulation, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Hazarika A, Barthakur M, Dutta L, Bhuyan M. F-SVD based algorithm for variability and stability measurement of bio-signals, feature extraction and fusion for pattern recognition. Biomed Signal Process Control 2019. [DOI: 10.1016/j.bspc.2018.08.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Prabhakar H, Ali Z. Intensive Care Management of the Neuromuscular Patient. TEXTBOOK OF NEUROANESTHESIA AND NEUROCRITICAL CARE 2019. [PMCID: PMC7120052 DOI: 10.1007/978-981-13-3390-3_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Neuromuscular emergencies are a distinct group of acute neurological diseases with distinct characteristic presentations. Patients who suffer from this group of diseases are at immediate risk of losing protection of their native airway as well as aspirating orogastric contents. This is secondary to weakness of the muscles of the oropharynx and respiratory muscles. Although some neuromuscular emergencies such as myasthenia gravis or Guillain-Barré syndrome are well understood, others such as critical illness myopathy and neuropathy are less well characterized. In this chapter, we have discussed the pathophysiology, diagnostic evaluation, and management options in patients who are admitted to the intensive care unit. We have also emphasized the importance of a thorough understanding of the use of pharmacological anesthetic agents in this patient population.
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Affiliation(s)
- Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Zulfiqar Ali
- Division of Neuroanesthesiology, Department of Anesthesiology, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir India
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Sener U, Martinez-Thompson J, Laughlin RS, Dimberg EL, Rubin DI. Needle electromyography and histopathologic correlation in myopathies. Muscle Nerve 2018; 59:315-320. [PMID: 30414326 DOI: 10.1002/mus.26381] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 11/02/2018] [Accepted: 11/06/2018] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Needle electromyography (EMG) findings help confirm myopathy and may indicate specific pathologic changes on muscle biopsy. METHODS We conducted a retrospective chart review of 218 consecutive patients referred for muscle biopsy. Presence of specific needle EMG findings was correlated with pathologic findings of inflammation, necrosis, splitting, and vacuolar changes. Sensitivity, specificity, and positive and negative predictive values of specific EMG findings for pathologic changes were calculated. RESULTS Short-duration motor unit potentials (MUP) were sensitive (83%-94%) but not specific (34%-49%) for pathologic changes. Fibrillation potentials were 65%-74% sensitive and 58%-81% specific for inflammation, necrosis, splitting, or vacuolar changes. The absence of fibrillation potentials had high negative predictive value (82%-93%) for inflammation, splitting, or vacuolar changes. DISCUSSION Fibrillation potentials and short-duration MUPs predict pathologic changes of muscle fiber necrosis, splitting, and/or vacuolar changes (as seen with inflammatory myopathies and muscular dystrophies). Absence of fibrillation potentials suggests other myopathologic changes (e.g., congenital myopathy). Muscle Nerve 59:315-320, 2019.
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Affiliation(s)
- Ugur Sener
- Mayo Clinic Neurology Department, 4500 San Pablo Road South, Jacksonville, Florida, 32224, USA
| | | | | | - Elliot L Dimberg
- Mayo Clinic Neurology Department, 4500 San Pablo Road South, Jacksonville, Florida, 32224, USA
| | - Devon I Rubin
- Mayo Clinic Neurology Department, 4500 San Pablo Road South, Jacksonville, Florida, 32224, USA
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Myositis Mimics—a Clinical Approach to a Diagnostic Challenge. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2018. [DOI: 10.1007/s40674-018-0108-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kwon H, Di Cristina JF, Rutkove SB, Sanchez B. Recording characteristics of electrical impedance-electromyography needle electrodes. Physiol Meas 2018; 39:055005. [PMID: 29616985 DOI: 10.1088/1361-6579/aabb8c] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Needle EMG remains the standard clinical test for neuromuscular disease (NMD) assessment, but it only characterizes myofiber membrane depolarization. On the other hand, electrical impedance provides non-electrically active structural and compositional data of tissues. Here, we designed a prototype of needle electrode integrating electrical impedance and EMG measurement capabilities, the so-called I-EMG needle electrode. APPROACH We use finite element method models to study the impedance recording characteristics of I-EMG needle electrodes. The simulated electrical and mechanical design specifications are then manufactured to create a prototype of an I-EMG needle electrode. We pilot these new needle electrodes by conducting in vivo impedance measurements with muscle at rest on healthy wild-type (wt, n = 5) and muscular dystrophy (mdx, n = 5) mice. Comparisons between wt and mdx mice are performed using Mann-Whitney test, two-tailed, p < 0.05. The electrical characterization of the EMG electrode in the developed I-EMG needles was performed in vitro on saline solution and through EMG detection in wt animal at rest and during voluntary contractions. RESULTS Muscle impedance demonstrate good repeatability (p < 0.05 and p < 0.005 for resistance and reactance at 50 kHz, respectively) and agreement between different I-EMG needles. Impedance data allows us to discriminate between mdx and wt muscle (p < 0.05 and p < 0.005 for resistance and reactance at 10 kHz, respectively). EMG broadband noise power and peak amplitude using the I-EMG needle were similar to that of a commercial monopolar EMG needle. EMG recordings using the I-EMG needle measured electrical activity similar to a standard monopolar needle with muscle at rest and during voluntary contraction. SIGNIFICANCE Needle I-EMG technology may offer the opportunity to enhance the diagnostic capability and quantification of NMD beyond that possible with either impedance or EMG techniques separately. Ultimately, needle I-EMG could serve as a new bedside tool to assess NMD without increasing the complexity or duration of the EMG test.
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Affiliation(s)
- H Kwon
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215-5491, United States of America
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Abstract
Chronic graft-versus-host disease is a potentially debilitating complication of allogeneic hematopoietic stem cell transplantation. Due to the direct inflammatory effects of the disease on tissue, and the impact on muscle and bone of the high-dose glucocorticoid immunosuppression used to treat the disease, patients are at risk of developing multifactorial functional impairment. This review outlines the clinical assessment and rehabilitation interventions to manage aspects of the disease that cause the most impairment: involvement of the skin/fascial and cardiopulmonary organ systems, as well as steroid-induced myopathy and bone and joint destruction.
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Affiliation(s)
- Sean Robinson Smith
- Department of Physical Medicine & Rehabilitation, University of Michigan, 325 East Eisenhower Pkwy, Suite 100, Ann Arbor, MI 48108, USA.
| | - Arash Asher
- Department of Physical Medicine & Rehabilitation, Samuel Oschin Comprehensive Cancer Institute at Cedars-Sinai Medical Center, Health Sciences, UCLA, 8700 Beverly Boulevard, AC 1109, Los Angeles, CA 90048, USA
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Meyer HJ, Emmer A, Kornhuber M, Surov A. Associations between apparent diffusion coefficient and electromyography parameters in myositis-A preliminary study. Brain Behav 2018; 8:e00958. [PMID: 29761011 PMCID: PMC5943752 DOI: 10.1002/brb3.958] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 02/05/2018] [Accepted: 02/21/2018] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE MRI is widely used in several muscle disorders. Diffusion-weighted imaging (DWI) is an emergent imaging modality sensitive to microstructural alterations in tissue. The apparent diffusion coefficient (ADC) is used to quantify the random motion of water molecules. Electromyography (EMG) is a clinically used diagnostic tool in myositis. The aim of this study was to elucidate possible associations between ADC values and EMG findings in myositis patients. METHOD Seven patients (eight investigated muscles) with myositis (mean age 51.43 ± 19 years) were included in this study. The diagnosis was confirmed by histopathology in every case. DWI was obtained with a 1.5-T scanner using two b-values 0 and 1000 s/mm². In all patients, a needle electromyography (EMG) was performed within 3 days to the MRI. The following EMG parameters were studied: motor unit action potential (MUAP) amplitudes and durations, as well as pathological spontaneous activity. Spearman's correlation coefficient was used to analyze associations between investigated parameters. RESULTS The estimated mean ADC mean value was 1.51 ± 0.29 × 10-3 mm²/s, mean ADC min was 1.28 ± 0.27 × 10-3 mm²/s, and mean ADC max was 1.73 ± 0.28 × 10-3 mm²/s. Correlation analysis identified significant associations between ADC mean and duration of the MUAP (p = .78 P = .0279) and between ADC min and duration of the MUAP (p = .85, P = .01). There were no significant differences according to pathological spontaneous activity. CONCLUSION ADC mean and ADC min showed strong positive correlations with the duration of the MUAP in myositis patients. Both modalities might similarly reflect muscle fiber loss in myositis patients.
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Affiliation(s)
- Hans-Jonas Meyer
- Department of Diagnostic and Interventional Radiology University of Leipzig Leipzig Germany
| | - Alexander Emmer
- Department of Neurology Martin-Luther University Halle-Wittenberg Halle Germany
| | - Malte Kornhuber
- Department of Neurology Martin-Luther University Halle-Wittenberg Halle Germany
| | - Alexey Surov
- Department of Diagnostic and Interventional Radiology University of Leipzig Leipzig Germany
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