A family of juvenile proximal spinal muscular atrophy with dominant inheritance

Childhood progressive spinal muscular atrophy with facioscapulo-humeral predominance, sensory and autonomic involvement and optic atrophy

A female child of healthy parents developed rotary nystagmus at the age of 15 months. Ophthalmoscopy disclosed incomplete optic atrophy. Blood tests, EEG and CT scans were normal. At 20 months progressive muscular weakness and wasting with limb-girdle distribution commenced, followed later by disturbance of gait. From muscle and nerve biopsy the diagnosis of a peripheral neuropathy with neurogenic muscular atrophy was made. No mental change occurred. At 23 months she sustained cardiac arrest and was resuscitated; thereafter, she remained in a vegetative state and expired 9 months later. Her brain was markedly atrophic and firm. Diffuse old ischemic necroses and neuronal loss with gliosis were found in the cortex, the neostriatum, the thalamus, parts of the lower brainstem, and the cerebellum. Her optic nerves and tracts showed complete atrophy. The spinal cord exhibited degeneration and loss of motor neurons with cervical accentuation. The intermediolateral nuclei, the dorsal nuclei and the spinal ganglia were also involved. There was demyelination of the posterior funiculi, the pyramidal tracts, and the sciatic, peroneal, sural, and superior frontal nerve. The voluntary muscles exhibited large group atrophy with liposclerotic change and limb-girdle predominance. The neck, tongue and ocular muscles were also involved, as were, to a less extent, the lower limbs. Although the loss of motor neurons in the spinal cord and at the bulbar level with the typical pattern of neurogenic muscular atrophy, as well as its distribution, resemble the facioscapulo-humoral type of heredity motor neuropathy (HMN), early onset, rapid course, sensory and autonomic involvement, and atrophy of the optic nerve do not fit this or any one type of HMN.

Clinical variability of autosomal dominant spinal muscular atrophy

Autosomal dominant spinal muscular atrophy (SMA) is generally classified into a juvenile and an adult onset form. Clinical data of 20 affected members out of 6 families with autosomal dominant proximal SMA are reported. Three families could largely be classified as the adult onset form (onset after 20 years of life). They showed a benign course, most of them remaining ambulatory 10-40 years after clinical onset. Intrafamilial variability of onset was small, the progression of weakness within one family appeared to be very similar. Three patients of the other 3 families suffered from the juvenile onset form (first symptoms before the age of 12 years) with walking difficulties throughout life, whereas other family members would have been classified as adult onset SMA. The latter had an onset between age 17 and 28 years, and were only moderately handicapped when last examined (aged 38-60 years). The great intrafamilial variability in at least some of the families with autosomal dominant SMA is not compatible with the distinction of two clinically defined genetic entities. This observation is important with respect to a reliable prediction in clinical practice and genetic counselling.

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

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