Progressive encephalomyelitis with rigidity: a case report

A case report of rigidity and recurrent lower limb myoclonus: progressive encephalomyelitis rigidity and myoclonus syndrome, a chameleon

BACKGROUND

Progressive encephalomyelitis with rigidity and myoclonus (PERM) syndrome is a rare neurological condition. Its clinical characteristics include axial and limb muscle rigidity, myoclonus, painful spasms and hyperekplexia. Diagnosis of this disease can be very challenging and optimal long-term treatment is unclear.

CASE PRESENTATION

We report a case of a 62 year old patient admitted for repetitive myoclonus and rigidity in the lower limbs progressing since 10 years, associated with a fluctuating encephalopathy requiring stays in Intensive Care Unit. Multiple diagnostics and treatment were proposed, unsuccessfully, before the diagnosis of PERM syndrome was established. In association with the clinical presentation, a strong positive result for GAD (glutamic acid decarboxylase) antibodies lead to the diagnosis of PERM syndrome.

CONCLUSIONS

PERM syndrome is a rare disease and its diagnosis is not easy. Once the diagnosis is established, the correct treatment should follow and could be lifesaving, regardless of a delayed diagnosis. Maintenance of long-term oral corticotherapy is suggested to prevent relapses.

Differential diagnosis and treatment of muscle hypertonia as practiced in Zagreb's Centre/Institute for Neuromuscular Diseases

Because I am a neuromyologist that has dealt for many years with muscle hypertonia, I decided to write my memories in order to motivate younger researchers to try to duplicate the same observations and experiences. We defined a whole range of conditions and symptoms, partly or in full. That is the first crucial step on the way to suppressing or relieving suffering. In some cases there was nothing we could do. In the other cases, we managed to diminish the uncomfortable symptoms. In still other cases, we cured the diseases, at least for a while. My conclusion is that great and systematic effort is always worth the trial. Maybe someone will follow us?! Always again, i used to repeat to myself and to the others that, when approaching the patient, always the following rules should be respected: watch, listen and use your own common sense to evaluate what you observe; analyse why the symptoms occur in a concrete case; include the therapy in the logic of symptom development; continue to follow the patient and ask questions of yourself and of your colleagues; consult the literature; find the differences; ask again and again what else could be done ... and the solutions will appear unexpectedly.

Introducing corticosteroids therapy from 1969 to 1990 at the Centre/Institute for Neuromuscular Diseases, KBC Rebro, Zagreb, Croatia

The author presents the chronological development of therapy by corticosteroids in myasthenia gravis (MG), as well as dilemmas connected to this kind of treatment at the Centre/Institute Zagreb, she founded. The improvement of postoperative prognosis of thymectomy with corticosteroids is described and transfer of positive experiences to other neurological diseases. The side effects can be reduced significantly by respecting the basic rules: the choice of corticosteroids (fluocortolone, methyprednisolone, no dexamethasone), single dose administered in the morning, not later than 8 a.m. (respecting the circadian rhythm of concentration of cortisol in blood). Initially, the high dose is administered daily, until the stabilisation of signs and symptoms improvement. Then, in my early modification, the initial dose, administered every other day, becames gradually lowered. The diet is similar to diabetic, with the potassium added. In the period from 1973 to 1990, 212 myasthenia gravis and 37 polymyositis patients were treated that way.We recommend to continue endocrinological research, on which we already reported, now with contemporary methods. The value of the "pulse therapy" should be analysed in more details, with peroral corticosteroids added afterwards.