Split Phenomenon of Fasciculation between Antagonistic Muscles in Amyotrophic Lateral Sclerosis: An Ultrasound Study

OBJECTIVE

Paresis of muscle groups in patients with amyotrophic lateral sclerosis (ALS) tends to present split phenomena. We explored the split phenomenon of fasciculation in multiple antagonistic muscle groups in ALS patients.

METHODS

One hundred and forty ALS patients and 66 non-ALS patients were included from a single ALS center. Muscle ultrasonography (MUS) was performed to detect fasciculation in elbow flexor-extensor, wrist flexor-extensor, knee flexor-extensor, and ankle flexor-extensor. Split phenomena of fasciculation between different antagonistic muscle groups were summarized, and the possible influence factors were analyzed through stratified analysis.

RESULTS

The frequency of split phenomenon of fasciculation intensity was significantly higher than those of muscle strength (26.1% vs. 7.1% for elbow flexor-extensor, 38.3% vs. 5.7% for wrist flexor-extensor, 37.9% vs. 3.0% for knee extensor-flexor, and 33.6% vs. 14.4% for ankle flexor-extensor) (P < 0.01). For muscles with 0-1 level of muscle strength (the Medical Research Council, MRC, score), significance difference in mean fasciculation intensity was observed only in ankle flexor-extensor. For muscles with 2-5 level of muscle strength, significant dissociation of fasciculation grade was common, especially among patients with slow rapid progression rate and both upper and lower motor neuron (UMN and LMN) involvement. As for non-ALS patients, no significant difference was observed in fasciculation intensity between antagonistic muscles.

CONCLUSION

Split phenomenon of fasciculation between antagonistic muscles was common and relatively specific in ALS patients. Muscle strength, progression rate, and UMN involvement were influence factors of the split phenomenon of fasciculation intensity.

[Cramps and fasciculations: is it amyotrophic lateral sclerosis?]

Amyotrophic lateral sclerosis (ALS) is the most common motor neuron disease of the adult age. It is an aggressive condition with a mean disease duration of only 3 to 5 years, characterized by progressive weakness and atrophy of limb, bulbar, and respiratory muscles. In general, death is caused by chronic hypoventilation due to respiratory insufficiency. No causal treatment is known today, but the two therapeutic agents authorized in Switzerland for the treatment of ALS can slow disease progression significantly. Other important therapeutic strategies include invasive/non-invasive ventilation, pain therapy, as well as physio-, ergo- and speech therapy on a regular basis.

Biochemical changes following succinylcholine administration after pretreatment with rocuronium at different intervals

OBJECTIVE

To evaluate the biochemical changes associated with succinylcholine administration after pretreatment with rocuronium at different time intervals.

METHOD

The prospective, randomised, single-blinded study was conducted at the Combined Military Hospital, Rawalpindi, from January to May 2010. Ninety male, aged 18-60 years, American Society of Anaesthesiology I or II patients undergoing elective inguinal herniotomy or external haemorrhoidectomy were included. The patients were randomly divided into three equal groups. Group A received a normal saline 5 ml as placebo 1 minute before succinylcholine; Group B received rocuronium 0.06 mg/kg 1 intravenously minute before succinylcholine, while Group C received intravenous injection of rocuronium 0.06 mg/kg 5 minute before succinylcholine. Venous blood samples for creatinine phosphokinase, lactate dehydrogenase and myoglobin plasma concentrations were obtained at 0, 30 minutes, 6 hours and 24 hours after succinylcholine administration.

RESULTS

Mean serum creatinine phosphokinase and myoglobin concentrations were significantly decreased in Groups B and C compared to Group A at 30 minutes and 24 hours (p < 0.05). However, no significant difference in the enzyme levels at any time interval was observed among the rocuronium groups. There was a significant rise in lactate dehydrogenase concentrations at 6 hours and 24 hours in Group A compared to Groups B and C (p < 0.05).

CONCLUSION

Pretreatment with rocuronium effectively reduces the biochemical changes associated with succinylcholine-induced muscle fasciculations. However, whether it is given 1 minute or 5 minutes before succinylcholine does not make much difference.

Unilateral myokymia of the tongue after radiation therapy for cervical nodal melanoma

Hypoglossal neuropathy with associated myokymia as a delayed effect of radiation is a rare occurrence, presumably due to the relative resistance of cranial nerves to injury from irradiation. The authors describe the first case of myokymia of the unilateral tongue with myokymic discharges on needle electromyography after hypofractionated radiation therapy for an extracranial melanoma of the neck. The earlier onset of myokymia than previous cases may represent more direct radiation exposure due to radiation site or the higher radiation dosage administered for treatment of melanomas.

ANCA-related vasculitic neuropathy mimicking motor neuron disease

Several conditions have been reported to mimic motor neuron disease (MND) and misdiagnosis remains a common clinical problem. Peripheral neuropathy is a classic feature of many vasculitic syndromes and in some patients it may be the only manifestation of vasculitis. We report a case of ANCA-related vasculitic neuropathy where the clinical presentation was suggestive of MND. A 42-year-old woman was admitted to our centre to confirm a diagnosis of MND made elsewhere. Clinical examination revealed postural tremor at the right hand, mild tongue atrophy with diffuse fasciculations and brisk tendon reflexes without other muscular weakness or atrophies. Electromyography demonstrated denervation in tongue and in the first dorsal interosseous of right hand ; motor evoked potentials disclosed normal central motor conduction time. Laboratory studies revealed only a mild increase of p-ANCA. A muscle biopsy showed a small inflammatory infiltrate around a vessel. The patient started high dosage of oral steroids. After one year of follow-up the patient suspended oral steroids, postural tremor of the right hand disappeared and tongue fasciculations were reduced. Vasculitis may mimic a MND, particularly in the absence of sensory involvement. Caution should be exercised in the clinical diagnosis of MND. Muscle biopsy is indicated in patient with atypical MND especially in those with an exclusive involvement of lower motor neuron.

Predictors of delay in the diagnosis and clinical trial entry of amyotrophic lateral sclerosis patients: A population-based study

BACKGROUND

The El Escorial and the revised Airlie House diagnostic criteria for amyotrophic lateral sclerosis (ALS) were introduced to select patients for clinical trials. Heterogeneity of clinical presentation at onset and delay in diagnosis may decrease the likelihood for trial entry.

OBJECTIVE

Identify risk factors for delay in the diagnosis and trial exclusion.

METHODS

ALS incident cases were identified with El Escorial (EEC) and Airlie House criteria (AHC) through a population-based registry established in Puglia, Southern Italy, in the years 1998-99.

RESULTS

130 ALS incident cases were diagnosed with a median interval between onset of symptoms and diagnosis of 9.3 months and not different across both EEC and AHC categories. Twenty percent of cases were not eligible for clinical trials according to the AHC. About 5% of subjects in this series died with only lower motor neuron signs. Predictors for delay in the diagnosis were age between 65 and 75 years and spinal onset while fasciculations and cramps as first symptoms were predictors of exclusion from trials.

CONCLUSIONS

In this population-based series, diagnostic delay was longer in subjects with spinal onset and age between 65 and 75 and fasciculation as first symptoms. About 80% of incident cases were trial eligible with AHC criteria. However, a significant number of subjects with ALS, characterized by a limited spread of signs, were not trial eligible while alive.

Usefulness of transcervical approach for surgical treatment of hypoglossal schwannoma with paraspinal extension: case report

BACKGROUND

Usefulness of transcervical approach to hypoglossal schwannoma with paraspinal extension is described herein.

CASE DESCRIPTION

A 54-year-old woman presented with gradually worsening left hypoglossal nerve palsy. The findings were of a tumor lying in the left hypoglossal canal and paraspinal region and were consistent with hypoglossal schwannoma. Subtotal intracapsular removal of the tumor was performed via transcervical approach. The symptoms improved, and no additional symptoms were noted.

CONCLUSION

The transcervical approach and intracapsular removal of the tumor under electrophysiological monitoring provided for successful minimally invasive surgery in this case of hypoglossal schwannoma.

Urticaria and lip fasciculation may be prodromal signs of brain malignancy

The association of urticaria and cancer usually is seen with lymphoreticular system malignancies. Recalcitrant intra-nostril pruritus has been associated with fourth-ventricle tumors of the brain. Rarely, urticaria has been described with cancer of the lung, usually small-cell adenocarcinoma. We describe a girl who suffered with chronic urticaria for 3 months before lip fasciculation began to be observed. CT scan revealed a brain tumor adjacent to the cerebellum, which was diagnosed as astrocytoma grade II. Because of the location, the tumor was not operable, but after one course of radiotherapy, both the urticaria and lip fasciculation disappeared.

Myasthenia gravis--a rare presentation with tongue atrophy and fasciculation

We report the case of an unusual presentation of myasthenia gravis with tongue atrophy and fasciculation. Myasthenia gravis is an autoimmune condition associated with weakness and fatigability of voluntary muscles. In >50%, the initial symptoms and signs are related to extraocular muscle weakness, such as diplopia or ptosis [Tsung K, Seggev JS. An unusual cause of dysphagia. West J Med 1995; 163: 159-60]. Rarely, it is known to affect bulbar muscles and can lead to dysphagia and respiratory compromise.

Immune-mediated rippling muscle disease

The authors report a 44-year-old man with rippling muscle disease (RMD) who does not have a mutation in the caveolin-3 gene. Immunohistochemistry of the muscle biopsy revealed a marked reduction of caveolin-3 and a mosaic pattern of dysferlin immunostaining. Ultrastructural studies showed a loss of caveolae and alterations of the triad. Autoantibodies were directed against the sarcolemma, triad, and several unknown muscle proteins.

Motor unit potential analysis in the cases with hemifacial spasm and postparalytic facial hyperactivity

This study seeks to find an answer to whether the damage caused by the focal demyelinated focus in hemifacial spasm (HFS) causes a deviation from normal in MUP's. The study evaluated MUP parameters of orbicularis oculi (o.oc) and orbicularis oris (o.or) muscles in the total of 76 cases, 41 of whom had a history of peripheral facial paralysis (PFP) and postparalytic facial hyperactivity (PPFHA) and 35 of whom had HFS. Control data was obtained from healthy sides 22 of 76 cases. "t test" and multiple comparisons were used for statistical evaluations. For o.oc muscle; when compared with the normal group, PPFHA group had significantly increased motor unit durations (p < 0.001), phase (p < 0.05), area (p < 0.05), turn (p < 0.05) and polyphasic potential numbers (p < 0.05) and HFS group had significantly increased amplitudes (p < 0.05), area (p < 0.05) and polyphasic potential numbers (p < 0.05). When patients groups were compared for the same muscle, PPFHA group had significantly increased MUP durations (p < 0.001) and number of turns (p < 0.05) as compared to HFS group. When o.or muscle values were compared with the normal group, PPFHA group had significantly increased durations (p < 0.001), phase (p < 0.05), area (p < 0.05) and turn numbers (p < 0.001) and polyphasic potential rates (p < 0.05) and area/amplitude values (p < 0.05), HFS group had significantly increased durations (p < 0.05), phase (p < 0.05), area (p < 0.05) and turn numbers (p < 0.05). When patient groups were compared for the same muscle, MUP duration was significantly increased (p < 0.05) in the PPFHA group as compared to HFS group. In conclusion, with the quantitative method, there is neurogenic involvement in the facial muscles of upper and lower halves in cases of HFS although lesser than PFP cases. This suggests that focal demyelination causes secondary axonal loss at least in some of the cases.

Cramps, muscle pain, and fasciculations: Not always benign?

Fasciculation and cramps without weakness or muscle atrophy are recognized as a benign syndrome. The authors report a patient with cramp and fasciculation, which persisted for 1 year without abnormal motor unit morphology on EMG before progressive weakness, muscle atrophy, and EMG abnormalities developed. This observation raises the possibility that lower motor neuron hyperexcitability may precede motor neuron death in motor neuron disease.

Adult onset Krabbe disease may mimic motor neurone disease

Krabbe's disease (galactocerebrosidase deficiency) rarely presents in adults, usually with predominantly upper motor neurone clinical features. We report a case in whom the clinical features were similar to motor neurone disease. Nerve conduction studies and neuroimaging were important in leading to the correct diagnosis. Differences in adult-onset presentations are described.

Acute femoral neuropathy secondary to an iliacus muscle hematoma

We present a patient with a spontaneous iliacus muscle hematoma, appearing immediately after a minor physical maneuver, presenting with pain and femoral neuropathy initially evidenced by massive quadriceps muscle fasciculations. A magnetic resonance imaging (MRI) study of the pelvic area confirmed the diagnosis, showing a hematoma secondary to a partial muscle tear. The patient was managed conservatively, and the continuous muscle activity ceased in 3 days, with progressive improvement of the pain and weakness. The recovery was complete. Femoral neuropathy is uncommon and usually due to compression from psoas muscle mass lesions of diverse nature, including hematomas. Usually subacute, femoral neuropathy may present acutely in cases of large or strategically placed compressive femoral nerve lesions, and may require surgical evacuation. The case presented herein is remarkable since the muscle hematoma appeared after a nonviolent maneuver, fasciculations were present at onset, and conservative management was sufficient for a full recovery.

Increased creatine kinase and spontaneous activity on electromyography, in amyotrophic lateral sclerosis

INTRODUCTION

Mild to moderate elevation of muscle creatine kinase (CK) is commonly observed in amyotrophic lateral sclerosis (ALS). Although the determinants of increased the CK in ALS remain uncertain, we hypothesize that fasciculations and muscle denervation can be involved by damaging the muscle fibre.

PATIENTS AND METHODS

We studied 87 ALS patients in whom CK determination was performed. In 47, a standardized EMG investigation was performed. In 22 patients a second CK determination was performed a mean of 5 months later. CK values were compared between different patients arranged in groups as determined by the number of regions with fasciculation as detected on the clinical examination, and the number of muscles with fasciculation or with fibrillation potentials as observed on EMG.

RESULTS

43% of our population had an increased CK value. Four out of 5 patients with suspected ALS had an increased CK value. The number of patients with increased CK value was not different between sexes, or between bulbar and spinal-onset patients. CK value was not related with disease duration, and did not change at the second measurement. CK value was not different between the groups studied.

CONCLUSION

The fasciculations,and the signs of denervation on EMG, are not determinants for high CK values in ALS patients, which are still unknown. Increased CK can be useful in the differential diagnosis of patients with lower motor neuron disorders.

[Juvenile asymmetrical segmental spinal muscular atrophy]

We report the case of a man who had an insidious onset of asymmetrical distal muscle weakness of the upper extremity at the age of 17. Objective findings were 1) muscular atrophy of calf and forearm flexor muscles and intrinsic hand muscles; 2) fasciculations; and 3) hand tremor. EMG and muscle biopsy showed neurogenic changes. MRI of the medulla and plasma creatine kinase were normal. Genetic testing for SMA-III was negative.

[Hereditary neuropathy with liability to pressure palsies: study of six Spanish families]

Hereditary neuropathy with liability to pressure palsies (HNPP) is an autosomal dominant inherited demyelinating neuropathy typically characterized by recurrent episodes of acute painless peripheral nerve palsies often preceded by minor trauma or compression at entrapment sites. However, less classical phenotypes have been reported. A 1.5 Mb deletion in chromosome 17 p11.2 has been shown to be the genetic basis of the disease in the majority of HNPP patients. The few families without this deletion harbored a mutation in the PMP22 gene. We performed a clinical, neurophysiological and molecular genetic study of 6 Spanish HNPP families. Five families (22 individuals) showed the classical chromosome 17 p11.2 deletion and one family (3 individuals) had a novel 3'splice-site mutation in PMP22. Neurophysiological abnormalities were detected in all symptomatic (n=21) and asymptomatic (n=4) deletion or mutation carriers, even in childhood. In addition to the typical presentation we observed other phenotypes: recurrent focal short-term sensory symptoms, a progressive mononeuropathy, a Charcot-Marie-Tooth (CMT) disease-like chronic progressive polyneuropathy, a chronic sensory polyneuropathy and a chronic inflammatory demyelinating polyneuropathy. We report new or very rare phenotypesThese atypical clinical aspects and intrafamilial heterogeneity are present in families with the HNPP deletion as well as in the family with the PMP22 mutation. However, the CMT disease-like chronic polyneuropathy was more common in the PMP22 mutation family. Intrafamilial heterogeneity also seemed to be more pronounced in this kinship. Patients in this family had a mild chronic motor and sensory polyneuropathy neurophysiologically characterized by delayed distal latencies, reduced nerve conduction velocities (NCV) within the demyelinating range, mildly decreased amplitudes of motor and sensory evoked potentials and absence of conduction blocks. In contrast, patients with the common HNPP deletion, regardless of their phenotype, had a diffuse increase in distal motor latencies contrasting with moderately reduced motor NCVs, preserved sensory nerve action potentials, slowing of NCVs at the common entrapment sites and occasionally conduction blocks. In this study we confirm the clinical and molecular heterogeneity of HNPP, emphasizing the need for a mutation analysis of the PMP22 gene when the common 17p11.2 deletion is not found in clinically suspected HNPP patients. We conclude that the 3'splice-site mutation in PMP22 and the common HNPP deletion have largely the same functional consequences although some clinical and neurophysiological differences were observed.

Progressive bulbar palsy: a case report diagnosed by lingual symptoms

The aim of this report is to show a case of Progressive Bulbar Palsy (PBP), diagnosed by oral medicine specialists, from oral symptoms of the disease. We have found no more than two published cases of PBP diagnosed by lingual alterations. We have followed the patient for almost four years, which is remarkable considering that the normal survival period for these patients is up to three years. We would like to emphasize the role of general dentists in the diagnosis of systemic conditions based on an oral examination that should include the oro-facial muscles.

Infant neurologic assessment

Infant neurologic assessment reflects the ongoing maturation of the central nervous system. Traditional approaches to assessment cannot be used. Key factors are accurate observation and flexibility in obtaining the data. A case example using a 4-month-old infant illustrates specific approaches to assessment.

A congenital dermal sinus presenting the muscle fasciculation and hypertrophy

OBJECTIVE

To report unique and unknown clinical features of muscle fasciculation and muscle hypertrophy in a case of congenital dermal sinus.

PATIENTS

A 16-year-old girl presented with continuous fasciculation, often cramp, and hypertrophy of the left calf muscle. The radiography showed spina bifida of L4, L5 and S1. MRI revealed dermal sinus tract from the skin dimple of the back to the dura mater, and connected to the intradural inclusion tumor. At surgery the inclusion tumor contained many short hairs, and the cauda equina were severely adherent. Microdissection of the tumor and the adhesion was performed. At 2 years after surgery fasciculation decreased but continued; however, painful cramps of the calf muscle do not occur.

CONCLUSIONS

Short hairs of dermoid and the adherence might be irritative to the cauda equina. The hyperactivity of the stimulated motor neuron may cause the muscle fasciculation leading to hypertrophy of the calf muscle.

HTLV-I-associated myelopathy (HAM)/tropical spastic paraparesis (TSP) with amyotrophic lateral sclerosis-like manifestations

To clarify the existence of HAM/TSP presenting amyotrophic lateral sclerosis (ALS)-like manifestations, we assayed HTLV-I proviral load in peripheral blood mononuclear cells (PBMC) in 15 patients with anti-HTLV-I antibody in serum and ALS-like manifestations (upper motor neuron involvement in at least one region and lower motor neuron involvement in at least two limbs) by quantitative PCR, and compared the proviral load with that of 233 HAM/TSP patients and of 213 HTLV-I carriers. Five of 15 patients with ALS-like manifestations had proviral loads as high as those in the 233 patients with HAM/TSP. Anti-HTLV-I antibody in cerebrospinal fluid (CSF) was present in all of five patients. The proviral load in the remaining 10 patients was similar to that in HTLV-I carriers. Four of five patients with a high proviral load met the diagnostic criterion of HAM/TSP except for lower motor neuron involvement. These four patients showed high neopterin levels in CSF. On the basis of HTLV-I proviral load in PBMC and the clinical symptoms, our tentative conclusion is that these four patients are HAM/TSP presenting ALS-like manifestations.

Complex fasciculations and their origin in amyotrophic lateral sclerosis and Kennedy's disease

Complex fasciculations are common in patients with amyotrophic lateral sclerosis (ALS). Combined fasciculations, defined as a complex fasciculation consisting of two or more components that occur independently but also in combination with another component, also occur in ALS. To test the hypothesis that combined fasciculations originate at the supraspinal level, we analyzed 2681 fasciculation potentials from 17 patients with definite or probable ALS by the El Escorial criteria. Results were compared with 304 fasciculation potentials recorded from 6 patients with Kennedy's disease, in which the upper motoneurons are spared. The mean firing frequency of the fasciculations was 24.4 +/- 25.6 per minute in ALS, significantly higher than the 2.9 +/- 3.4 per minute found in Kennedy's disease (P < 0.0001). In ALS, the mean combination ratio (the number of times that a combined fasciculation occurred divided by the total number of fasciculations) was 4.6 +/- 8.3% (range 0-33). Fourteen of 17 ALS patients had combined fasciculations, but only one combined fasciculation was found in a patient with Kennedy's disease. Combined fasciculations are distinctive in ALS, and we hypothesize that they are triggered by a supraspinal mechanism reflecting dysfunction of descending motor pathways.

Pains, strains, and fasciculations: lower extremity muscle disorders

Muscle injuries that were suspected only on the basis of clinical examination are now readily demonstrated and characterized using MR imaging. Imaging is used not only for assessment of location, type, and severity of muscle injuries; it plays an important role in treatment planning, and the detection of complications. MR imaging also is useful in nontraumatic muscle disorders including congenital, inflammatory, and infectious myositis, and in cases of denervation, MR imaging is valuable for diagnosis, staging, and prognostication. In cases where the origin of myopathy is unknown, MR imaging can direct biopsy to increase diagnostic yield.

Clinical neurophysiology in the diagnosis of amyotrophic lateral sclerosis: the Lambert and the El Escorial criteria

For many years, the only published criteria for the electrodiagnostic (EDX) recognition of amyotrophic lateral sclerosis (ALS) were those formulated by Lambert (1957; 1969). In 1990, different EDX guidelines were incorporated in the all-inclusive diagnostic criteria formulated by a subcommittee on ALS of the World Federation of Neurology, which met in El Escorial, Spain. Unfortunately, particularly in regard to the EDX requirements, the 'El Escorial criteria' have several flaws which compromise their usefulness. These include: (1) they ignore the fact that whenever upper and lower motor neuron disorders co-exist, as they characteristically do with ALS, the motor unit potential firing pattern is controlled by the upper motor neuron lesion; (2) they markedly devalue the usefulness of detecting fasciculations and, through presumably typographical error, state that the 'absence' rather than the 'presence' of fasciculations supports the diagnosis of ALS; this view is in direct conflict with the opinions expressed by most electromyographers; (3) they contain a statement regarding how the diagnosis of ALS is confirmed by the EDX studies which is confusing and, for two of the body regions (bulbar; thoracic), unrealistic; (4) finally, many of the EDX features they listed supporting the recognition of possible LMN degeneration appear to be mislabeled, while a few features in the EDX criteria are incorrect.

Surface EMG and myosonography in the detection of fasciculations: a comparative study

Surface electromyography (EMG) and muscle sonography both facilitate the detection of fasciculations. This study was conducted to evaluate the prevalence of fasciculations in 10 lower extremity muscles in 58 subjects 47 +/- 18 years of age without and 54 patients 52 +/- 15 years of age with various neuromuscular diseases (3 with inflammatory myopathy, 15 with lower motor neuron disease, 22 with acquired and 11 with hereditary motor and sensory neuropathy (HMSN), and 3 with adrenomyeloneuropathy). When each muscle was screened by means of myosonography for 10 seconds, fasciculations were found in up to 8 muscles in 11 control subjects (19%) and in up to 10 muscles in 41 patients (76%). Within the same recording period surface EMG revealed fasciculations in 5 control subjects (9%) and 30 patients (56%), whereas during a recording time of 20 minutes fasciculations were detected in 55 (95%) control subjects and all patients. An amplitude of 400 microV proved to be the optimum cutoff between fasciculations for healthy subjects and patients with neuromuscular disease (accuracy, 74%). Myosonography allowed differentiation of both groups with an accuracy of 79%. Surface EMG was more liable to artifacts than myosonography. The average interval between subsequent fasciculations cannot be used to differentiate patients with acquired and hereditary polyneuropathy and with lower motor neuron disease. Long-term surface EMG recording indicates fasciculations to occur in almost all patients with neuromuscular disease and the vast majority of healthy subjects. Muscle ultrasonography was more convenient and reliable than surface EMG in differentiating patients and healthy subjects.

[A case of Isaacs' syndrome preceding the recurrence of malignant thymoma--generating site of ectopic activity and therapy]

We described a-44-year old male patient with Isaacs' syndrome occurring 8 months before the recurrence of malignant thymoma. Electrophysiological examination suggested that spontaneous muscle activities were generated at the distal terminals of the motor nerves. Double filtration plasmapheresis alleviated the symptoms of neuromyotonia for a short term. Administration of valproic acid had more prolonged effects lasting for 2 months until his death from relapsed thymoma. Our results support that autoimmune mechanisms, especially humoral factors, are playing an important role in the pathogenesis of Isaacs' syndrome and that anti-convulsants therapy is important.

Motor neuron disease following generalized fasciculations and cramps

We report a case of motor neuron disease in which fasciculations and cramps progressed generally before the development of muscle wasting. After involvement of the upper and lower motor neurons became clinically manifest, widespread fasciculations and cramps persisted and accompanied pseudotetany. The present case suggests that spinal cord pathology of motor neuron disease can cause the abnormal excitability of the motor neurons, resulting in the development of generalized fasciculations and cramps.

Muscle pain, fatigue, and fasiculations

This article discusses muscle pain, fatigue, and fasiculations. Muscle pain and fatigue are common problems in general medicine and in neurology, while fasiculations raise concern about a potentially ominous disease. The author reviews the conditions that cause pain and similar conditions arising from nonmuscular soft tissues. The article includes a general evaluation to be used for each of these clinical problems.