MRI-negative myeloradiculoneuropathy following Covid-19 infection: An index case

Covid-19 associated several neurological manifestation in the form of Post-infectious transverse myelitis(TM) and para-infectious TM has been reported. A 54 years old female patient presented to us with acute retention of urine and upper motor neuron type of bilateral lower limb weakness in shock stage, after 12 days of covid-19 infection. MRI (3T) brain and spine showed no abnormality and Nerve conduction study showed acquired motor axonal polyradiculoneuropathy in bilateral lower limbs. We herein present an index case of MRI-negative myeloradiculoneuropathy following covid-19 infection.

Tat-p27 Ameliorates Neuronal Damage Reducing α-Synuclein and Inflammatory Responses in Motor Neurons After Spinal Cord Ischemia

p27^Kip1 (p27) regulates the cell cycle by inhibiting G1 progression in cells. Several studies have shown conflicting results on the effects of p27 against cell death in various insults. In the present study, we examined the neuroprotective effects of p27 against H₂O₂-induced oxidative stress in NSC34 cells and against spinal cord ischemia-induced neuronal damage in rabbits. To promote delivery into NSC34 cells and motor neurons in the spinal cord, Tat-p27 fusion protein and its control protein (Control-p27) were synthesized with or without Tat peptide, respectively. Tat-p27, but not Control-27, was efficiently introduced into NSC34 cells in a concentration- and time-dependent manner, and the protein was detected in the cytoplasm. Tat-p27 showed neuroprotective effects against oxidative stress induced by H₂O₂ treatment and reduced the formation of reactive oxygen species, DNA fragmentation, and lipid peroxidation in NSC34 cells. Tat-p27, but not Control-p27, ameliorated ischemia-induced neurological deficits and cell damage in the rabbit spinal cord. In addition, Tat-p27 treatment reduced the expression of α-synuclein, activation of microglia, and release of pro-inflammatory cytokines such as interleukin-1β and tumor necrosis factor-α in the spinal cord. Taken together, these results suggest that Tat-p27 inhibits neuronal damage by decreasing oxidative stress, α-synuclein expression, and inflammatory responses after ischemia.

Multi-phaseted problems of TDP-43 in selective neuronal vulnerability in ALS

Transactive response DNA-binding protein 43 kDa (TDP-43) encoded by the TARDBP gene is an evolutionarily conserved heterogeneous nuclear ribonucleoprotein (hnRNP) that regulates multiple steps of RNA metabolism, and its cytoplasmic aggregation characterizes degenerating motor neurons in amyotrophic lateral sclerosis (ALS). In most ALS cases, cytoplasmic TDP-43 aggregation occurs in the absence of mutations in the coding sequence of TARDBP. Thus, a major challenge in ALS research is to understand the nature of pathological changes occurring in wild-type TDP-43 and to explore upstream events in intracellular and extracellular milieu that promote the pathological transition of TDP-43. Despite the inherent obstacles to analyzing TDP-43 dynamics in in vivo motor neurons due to their anatomical complexity and inaccessibility, recent studies using cellular and animal models have provided important mechanistic insights into potential links between TDP-43 and motor neuron vulnerability in ALS. This review is intended to provide an overview of the current literature on the function and regulation of TDP-43-containing RNP granules or membraneless organelles, as revealed by various models, and to discuss the potential mechanisms by which TDP-43 can cause selective vulnerability of motor neurons in ALS.

Stress-related over-enhancement of the hypothalamic-pituitary-adrenal axis causes experimental neurolathyrism in rats

Neurolathyrism is a motor neuron disease that is caused by the overconsumption of grass peas (Lathyrus sativus L.) under stressful conditions. The neuro-excitatory β-N-oxalyl-L-α,β-diaminopropionic acid present in grass peas was proposed the causative agent of spastic paraparesis of the legs. Historical reports of neurolathyrism epidemics, studies of neurolathyrism animal models, and in vitro studies on the mechanism of β-N-oxalyl-L-α,β-diaminopropionic acid toxicity support the hypothesis that stress increases susceptibility to neurolathyrism. To elucidate the role of stress in neurolathyrism-induced motor dysfunction, we focused on the hypothalamic-pituitary-adrenal axis in a rodent model of neurolathyrism. Our results implicated increased glucocorticoid and neuroinflammation in the motor dysfunction (paraparesis) exhibited by the stress loaded rat models of neurolathyrism.

The Clinical Efficacy of Botulinum Toxin Injections to the Upper Lumbrical Muscles for Clenched Fist Deformity in Chronic Stroke Patients

OBJECTIVE

Post-stroke hemiplegic patients with a spastic clenched fist deformity that was caused by upper motor neuron syndrome often have problems with hygiene and nursing. Botulinum toxin-A (BTX-A) had been given for treatment of such patients to relieve spasticity by targeting finger joint muscles, such as the flexor digitorum superficialis and flexor digitorum profundus. However, some of these patients do not have satisfactory outcomes. Therefore, we aimed to examine the clinical efficacy and outcome of BTX-A treatment that targeted the upper lumbrical muscles (ULM) in patients with spastic clenched fist deformity caused by stoke.

METHODS

Chronic stroke patients with spastic clenched fist deformity who received BTX-A treatment were evaluated retrospectively. We obtained data from medical records before and at 4 weeks after BTX-A injection to the ULM. The clinical data and outcome measures analyzed included range of motion, the Modified Ashworth Scale, the numeric graphic rating scale for pain, and 2 items from the disability assessment scale (ease of cleaning palm and trimming nail).

RESULTS

Wilcoxon signed rank test showed that BTX-A treatment significantly improved all measures.

CONCLUSION

BTX-A therapy to the ULM provided satisfactory outcomes in improving spastic clenched fist.

A Temporal Association between Accumulated Petrol (Gasoline) Lead Emissions and Motor Neuron Disease in Australia

Background: The age standardised death rate from motor neuron disease (MND) has increased from 1.29 to 2.74 per 100,000, an increase of 112.4% between 1959 and 2013. It is clear that genetics could not have played a causal role in the increased rate of MND deaths over such a short time span. We postulate that environmental factors are responsible for this rate increase. We focus on lead additives in Australian petrol as a possible contributing environmental factor. Methods: The associations between historical petrol lead emissions and MND death trends in Australia between 1962 and 2013 were examined using linear regressions. Results: Regression results indicate best fit correlations between a 20 year lag of petrol lead emissions and age-standardised female death rate (R² = 0.86, p = 4.88 × 10⁻²³), male age standardised death rate (R² = 0.86, p = 9.4 × 10⁻²³) and percent all cause death attributed to MND (R² = 0.98, p = 2.6 × 10⁻⁴⁴). Conclusion: Legacy petrol lead emissions are associated with increased MND death trends in Australia. Further examination of the 20 year lag between exposure to petrol lead and the onset of MND is warranted.

[A case of motor dominant neuropathy and focal segmental glomerulosclerosis associated with Sjögren's syndrome]

A 49-year-old woman was admitted to our hospital with gradually progressive weakness of the limbs for about 20 days. She presented with weakness of the limbs, predominantly in the proximal portion, and slight dysesthesia of the limbs, predominantly in the distal portion. Repeated nerve conduction examination revealed axonopathy dominantly in the motor neurons. Therefore, we suspected her as having Guillain-Barré syndrome, and initiated intravenous administration of high-dose immunoglobulin. However, her symptoms progressed gradually and finally she found it difficult to walk. Her urine analysis simultaneously demonstrated albuminuria, and a kidney biopsy indicated focal segmental glomerulosclerosis. At that point, laboratory examination showed high levels of anti SS-A antibody and salivary gland biopsy revealed infiltration of a significant number of lymphocytes around the gland, which led to the diagnosis of Sjögren's syndrome. We considered the etiology of the neural and renal dysfunction as due to the inflammatory mechanism associated with Sjögren's syndrome. Therefore, we administered a second course of immunoglobulin therapy and steroid therapy, which included both pulse and oral administration. Her neurologic symptoms and albuminuria improved rapidly after steroid therapy. The present case indicates that both motor dominant neuropathy and focal segmental glomerulosclerosis can occur in patients with Sjögren's syndrome.

Immunological profiles determine neurological involvement in Sjögren's syndrome

BACKGROUND

Up to 68% of patients with primary Sjögren's syndrome (pSS) undergo neurological complications, and evidence for distinct immunological subgroups is emerging. We sought to determine systemic and immunological profiles associated with neurological manifestations.

METHODS

420 patients fulfilling the 2002 American-European pSS criteria were retrospectively analyzed. Neurological manifestations were diagnosed through clinical, biological, electrophysiological, and imaging findings. Biographical, clinical, and laboratory data were compared.

RESULTS

Within 93 (22%) patients with neurological manifestations, peripheral and central nervous systems were involved in 66% and 44%, respectively. Raynaud's phenomenon, cutaneous vasculitis, renal involvement, and cryoglobulinemia were associated with sensorimotor neuropathy and mononeuritis multiplex (p<0.05). Conversely, pure sensory neuropathy occurred without extraglandular manifestation, and without anti-Ro/SSA antibodies (p<0.05). All neurological manifestations were associated with increased use of corticosteroids and immunosuppressive drugs (p<0.05).

CONCLUSIONS

In pSS, patients with sensorimotor neuropathies and pure sensory neuropathies have distinct extraglandular and immunological profiles.

Outcome measures for clinical trials in Parkinson’s disease: achievements and shortcomings

Three areas of intense investigation in Parkinson's disease clinical trials include symptomatic treatment of Parkinsonism, disease-modifying therapy (or neuroprotection), and the prevention and treatment of motor complications of dopaminergic therapy. Difficulty interpreting the results of many studies in recent years has been attributed to problems with the chosen outcome measures. This article reviews the most common outcome measures used, assesses their positive attributes and proposes needs for future research. The Unified Parkinson's disease Rating Scale has been extensively validated and is by far the most common outcome measure used in trials of symptomatic therapy. Ambiguities in the response scale descriptors, poor inter-rater reliability of some items and a lack of items addressing nonmotor features of the disease are being addressed in a revision of the scale. Quality of life outcomes are being used in the minority of clinical trials, and no single generic or disease-specific quality of life measure is being used most frequently. Additional work validating several of the disease-specific instruments is needed. When a generic measure is used, its validity for use in Parkinson's disease must be critically assessed despite its previously established validity in other diseases. With respect to measuring motor complications, significant unmet needs include a consensus as to the best way to define the first motor complication and validating time to the first occurrence of motor complications as a surrogate of future disability and quality of life. Measuring the effectiveness of a potential neuroprotective agent presents unique challenges, particularly since symptomatic effects of the experimental agent or concomitant treatment can obscure any neuroprotective effects. Study designs and biomarkers are being developed that may overcome this problem. Currently, neuroimaging techniques that reflect function of the dopaminergic system are the most promising biomarkers but still require additional validation.

Transient Reversal of HIV-Associated Motor Neuron Disease Following the Introduction of Highly Active Antiretroviral Therapy

Neurological diseases occur frequently in patients with human immunodeficiency virus (HIV) infection, and include a variety of neuromuscular disorders. On the other hand, only a few cases of motor neuron disease (MND) have been reported to date in HIV-positive patients, even though this neurological complication occurs with a 27-fold greater frequency in these subjects compared with the general population. A retroviral etiology for MND has long been hypothesized, and epidemiological and experimental data suggest a pathogenetic link between HIV infection and MND, because retroviral infections may cause motor neuron damage in both laboratory animals and humans, as a result of various pathways. Furthermore, the introduction of potent, protease inhibitor-based antiretroviral combinations has had a great impact on the natural history of HIV disease and produced a dramatic improvement in some patients with HIV-associated MND, but optimal treatment for this progressive neurological complication has not been well defined. A case of MND in a male HIV-infected patient with significant but transient reversal of neurological symptoms after the use of protease inhibitor-containing antiretroviral regimen is described.

Lower motor neuron syndrome due to cauda equina hypertrophy with onion bulbs

INTRODUCTION

Hypertrophy of the nerve roots of the cauda equina may occur with both acquired and inherited neuropathies. Although selective nerve root involvement of the sensory roots has been described and termed chronic inflammatory sensory polyradiculoneuropathy (CISP), selective involvement of the proximal motor roots has not been described.

METHODS

Clinical, electrophysiological, MRI, and pathological findings are reported.

RESULTS

Here, we report a patient with cauda equina hypertrophy presenting with a pure lower motor neuron syndrome without clinical or electrophysiological evidence of sensory fiber involvement. Bowel and bladder functions were spared. Nerve root biopsy demonstrated abundant onion bulb formations. The patient experienced improvement in motor function with immunomodulatory treatment.

CONCLUSIONS

We suggest the term chronic immune demyelinating motor polyradiculopathy (CIMP) to describe this particular form of CIDP, thereby expanding the clinical spectrum of CIDP.

Retroviral-vector-mediated gene therapy to mucopolysaccharidosis I mice improves sensorimotor impairments and other behavioral deficits

Mucopolysaccharidosis I (MPS I) is a lysosomal storage disease due to α-L-iduronidase (IDUA) deficiency that results in the accumulation of glycosaminoglycans (GAG). Systemic gene therapy to MPS I mice can reduce lysosomal storage in the brain, but few data are available regarding the effect upon behavioral function. We investigated the effect of gene therapy with a long-terminal-repeat (LTR)-intact retroviral vector or a self-inactivating (SIN) vector on behavioral function in MPS I mice. The LTR vector was injected intravenously to 6-week-old MPS I mice, and the SIN vector was given to neonatal or 6-week-old mice. Adult-LTR, neonatal-SIN, and adult-SIN-treated mice achieved serum IDUA activity of 235 ± 20 (84-fold normal), 127 ± 10, and 71 ± 7 U/ml, respectively. All groups had reduction in histochemical evidence of lysosomal storage in the brain, with the adult-LTR group showing the best response, while adult-LTR mice had reductions in lysosomal storage in the cristae of the vestibular system. Behavioral evaluation was performed at 8 months. Untreated MPS I mice had a markedly reduced ability to hold onto an inverted screen or climb down a pole. LTR-vector-treated mice had marked improvements on both of these tests, whereas neonatal-SIN mice showed improvement in the pole test. We conclude that both vectors can reduce brain disease in MPS I mice, with the LTR vector achieving higher serum IDUA levels and better correction. Vestibular abnormalities may contribute to mobility problems in patients with MPS I, and gene therapy may reduce symptoms.

[A case of acute motor acsonal neuropathy in patient after removal of giant adenoma of hypophysis]

Authors described a case of development of Acute Motor Acsonal Neuropathy (AMAN)--the one of variations of Guillian-Barre syndrome. They discuss clinical and diagnostic peculiarities of AMAN. Treatment by specific immunoglobulins is a method of choice for patients with this pathology.

Control of konzo in DRC using the wetting method on cassava flour

Fifty konzo cases were identified in four villages in Popokabaka Health Zone, DRC. One third of people had only one meal per day, mainly of cassava flour consumed as a thick porridge (fufu) and pounded, boiled cassava leaves. Retention of cyanogens in flour resulted from short soaking of cassava roots. A 1.5 years intervention was made in the largest village Kay Kalenge, where the wetting method was taught to all women of the village, who accepted it willingly. The total cyanide content of cassava flour was reduced to below 10 ppm. Fufu from treated flour tasted and stored better than fufu from untreated flour. The mean urinary thiocyanate content of 100 school children reduced from 332 to 130 μmole/L and the number of samples exceeding 350 μmole/L decreased from 26 to 0 during the intervention. No new konzo cases occurred, which included two dry seasons when konzo peaks. Konzo was first identified by Dr. Trolli in 1938 in Popokabaka Health Zone and it has now been prevented for the first time in the same area. The methodology is now in use in Boko Health Zone and we believe it is the most effective way to control konzo in tropical Africa.

Neuromuscular complications

Although direct neoplastic involvement of muscle tis-sue is surprisingly rare, considering the large amount of body mass that is represented by muscle tissue, the most important and unresolved muscle effect is muscle cachexia.Other associations, such as inflammatory, paraneo-plastic, toxic, and several extremely rare associations,have been described. Drug-induced toxicity and radiation recall syndrome need to be taken into consideration when muscle symptoms appear in patients with cancer.

The prevalence of peripheral neuropathy in a population-based study of patients with type 2 diabetes in Sweden

AIMS

To assess peripheral neuropathy following a standardized foot examination protocol in a representative population-based cohort of subjects with type 2 diabetes.

METHODS

In a geographically defined population, aged 40-70 years with diabetes prevalence of 3.5% according to medical records, we investigated 156 type 2 diabetic subjects, 95% Caucasian, mean age 61.7±7.2 years, duration of diabetes 7.0±5.7 years, and HbA(1c) 7.3±2.4% (6.4% Mono-S), by questionnaires, clinical examinations, blood sampling, and review of medical records. Foot examination included clinical signs of peripheral neuropathy and tests of sensibility with monofilament, tuning fork, and assessments of the vibration perception thresholds (VPT).

RESULTS

Peripheral autonomic neuropathy (PAN) as judged by two or more signs of dysfunction was the most common and affected 43%. The prevalence of peripheral sensory neuropathy (PSN) was 15% by monofilament, 24% by tuning fork, and 28% by VPT expressed as ZscoreVPT ≥2.0 S.D. Twenty-nine percent had a VPT ≥25 V. Signs of peripheral motor neuropathy (PMN) affected 15%. Peripheral neuropathy, at least one variable, affected 67%, whereas 25% were affected by more than one variable of neuropathy, i.e., polyneuropathy. Exclusion of other identified causes for neuropathy than diabetes reduced the prevalence of diabetic polyneuropathy to 23%. Concurrent diabetic complications were 29% for retinopathy, 14% for incipient nephropathy, and 8% for overt nephropathy. The prevalence of macrovascular complications was 62% for CVD, 26% for PVD, and 11% for cerebrovascular lesion (CVL).

CONCLUSION

Peripheral neuropathy was common in this representative type 2 diabetes population. Clinical signs of PAN were the most frequent followed by diminished perception of vibration and touch.

Acute transverse myelitis and acute motor axonal neuropathy developed after vaccinations against seasonal and 2009 A/H1N1 influenza

Acute transverse myelitis (ATM) has been described as an uncommon complication of vaccinations and is rarely accompanied by inflammatory peripheral neuropathy. We report a case of a 77-year-old woman who developed ATM and acute motor axonal neuropathy (AMAN) following vaccinations against seasonal and 2009 A/H1N1 influenza. She manifested ophthalmoplegia, quadriparesis and sensory impairment. MR imaging showed a longitudinally-extensive spinal cord lesion, and nerve conduction study revealed motor axonal polyneuropathy. Despite prompt treatment, her symptoms poorly recovered. While concurrent ATM and AMAN may suggest the presence of a common antigen, their scarcity indicates the importance of other factors causing immunologic disruptions.

Insulin-induced hypoglycemic peripheral motor neuropathy in spontaneously diabetic WBN/Kob rats

Intensive insulin therapy can lead to hypoglycemia, with patients sometimes developing hypoglycemic neuropathy. Spontaneously diabetic Wistar Bonn Kobori (WBN/Kob) rats develop diabetic peripheral motor neuropathy characterized by segmental demyelination and axonal degeneration. We examined the short-term effects of hypoglycemia on neuropathic changes in these rats. Spontaneous diabetic WBN/Kob rats received insulin implants for 40 d and were divided into 3 groups based on blood glucose levels: group N, normoglycemic to slightly hyperglycemic (150 to 250 mg/dL); group H, hypoglycemic to slightly hyperglycemic (50 to 200 mg/dL); and group D, nontreated spontaneously diabetic (350 to 420 mg/dL). Conduction velocity was measured in sciatic-tibial motor nerves; these nerves also underwent qualitative and quantitative histomorphologic analysis. Conduction velocity was not significantly different in N, D, and H groups. Morphologic analysis of the sciatic nerves of H rats showed severe changes, including axonal degeneration, myelin distention, and endoneurial fibrosis, that tended to occur in large, myelinated fibers. N and D rats showed relatively mild changes. The degree and distribution of degenerated nerve fibers in H rats were significantly higher than in N and D rats. These results suggest that hypoglycemia of less than 50 mg/dL induced severe peripheral neuropathy. Hypoglycemic lesions differed from the hyperglycemic lesions in diabetic WBN/Kob rats. This rat strain is an appropriate model for investigating the hypoglycemic peripheral neuropathy that can be associated with a diabetic condition.

[FUNCTIONAL STATUS OF THE LOWER EXTREMITY NEUROMOTOR APPARATUS DURING SURGICAL TREATMENT FOR TUBERCULOUS SPONDYLITIS]

The functional status of the lower extremity neuromuscular apparatus has been studied in patients with tuberculous spondylitis. The importance of an electroneuromyographic study is shown at different stages of surgical treatment in patients with neurological complications.

[New evidence of the prion nature of amyotrophic leukospongiosis]

We described 2 cases and presented new experimental data on the study of the etiopathogenesis of amyotrophic leukospongiosis (AL) using Western blot, electronic and atomic force microscopy. AL is characterized by the gradual and steady progression of flaccid paralysis of extremities and muscles of the trunk without the expressed atrophy with an inevitable fatal outcome resulting in breathing disorders of spinal type, degenerative changes of the central nervous system and, first of all, spongiosis of the white matter of the brain. Several lines of evidence suggest that the accumulation of pathological prion protein (PrPAL) in the human brain is a critical event for the development of the disease. The new findings add knowledge of the AL etiopathogenesis and support the evidence that the disease is caused by prion infection and refers to the group of transmissible spongiform encephalopathies.

A patient with progressive weakness and cramping of right arm and both legs. Diagnosis: persistent, multifocal, partial conduction blocks (CB) of motor axons outside the common sites of nerve entrapment

A 44-year-old man presented with a 1-year history of progressive muscle weakness and cramping. Neurophysiology study, along with clinical presentation, was diagnostic. The differential diagnosis, diagnostic testing, treatment, and prognosis of this rare disease are discussed.

Inborn errors of metabolism and motor disturbances in children

Motor disturbances are very common in paediatric neurology. Often families can be reassured that these are just variants of normal development. However, abnormal movements can also be the hallmark of severe brain dysfunction of different and complex origins. This review concentrates on motor disturbances as frequent and important symptoms of inborn errors of metabolism. A structured diagnostic approach is developed taking into account age-dependent physiological developments and pathophysiological responses of gross and fine motor functions. A series of investigations are presented with the primary aim of early diagnosis of treatable conditions. The correct recognition and differentiation of movement disorders (ataxia, rigid akinetic syndrome (Fparkinsonism_), dystonia, athetosis, tremor,and others), spasticity, and neuromuscular disorders, requires profound neurological expertise. A high level of suspicion and close interaction between paediatric neurologists and specialists in inborn errors of metabolism are indispensable to effectively and timely identify patients in whom motor disturbances are the presenting and/or main symptom of an inborn error.

Motor unit number estimate as a predictor of motor dysfunction in an animal model of type 1 diabetes

Peripheral neuropathy is a common complication of diabetes that leads to severe morbidity. In this study, we investigated the sensitivity of motor unit number estimate (MUNE) to detect early motor axon dysfunction in streptozotocin (STZ)-treated mice. We compared the findings with in vitro changes in the morphology and electrophysiology of the neuromuscular junction. Adult Thy1-YFP and Swiss Webster mice were made diabetic following three interdaily intraperitoneal STZ injections. Splay testing and rotarod performance assessed motor activity for 6 wk. Electromyography was carried out in the same time course, and compound muscle action potential (CMAP) amplitude, latency, and MUNE were estimated. Two-electrode voltage clamp was used to calculate quantal content (QC) of evoked transmitter release. We found that an early reduction in MUNE was evident before a detectable decline of motor activity. CMAP amplitude was not altered. MUNE decrease accompanied a drop of end-plate current amplitude and QC. We also observed small axonal loss, sprouting of nerve endings, and fragmentation of acetylcholine receptor clusters at the motor end plate. Our results suggest an early remodeling of motor units through the course of diabetic neuropathy, which can be readily detected by the MUNE technique. The early detection of MUNE anomalies is significant because it suggests that molecular changes associated with pathology and leading to neurodegeneration might already be occurring at this stage. Therefore, trials of interventions to prevent motor axon dysfunction in diabetic neuropathy should be administered at early stages of the disorder.

[Case of pure motor Guillain-Barré syndrome with motor conduction block and anti-GM1/GalNAc-GD1a antibody]

A 38-year-old man presented with distal-dominant limb weakness two weeks after an upper respiratory infection. He had no sensory and autonomic signs and no cranial nerve involvement during the course of the disease. Tendon reflexes were preserved except for an absent Achilles' tendon reflex. His disability at nadir was grade 2 on the Hughes functional scale. Cerebrospinal fluid analysis showed albuminocytologic dissociation and he was diagnosed with pure motor Guillain-Barré syndrome (GBS). Thin-layer chromatography immunostaining and an enzyme-linked immunosorbent assay revealed an immunoglobulin G antibody to the ganglioside complex GM1/GalNAc-GD1a in his acute phase serum. A serial nerve conduction study revealed conduction block in the median and ulnar nerve trunks and temporal dispersion in the tibial nerve, without an evident remyelination pattern during the course of the disease. A sensory nerve conduction study was normal. According to Hadden's criteria, the electrodiagnostic findings were judged as a primary demyelinating pattern. Weakness and abnormal motor nerve conduction recovered rapidly after intravenous immunoglobulin therapy. In view of the localization of GM1 and GalNAc-GD1a on the axolemma of the motor nerves, the clinical course and electrophysiological features may have resulted from functional conduction failure at the nodes of Ranvier of the motor nerves, rather than primary demyelination or axonal degeneration. The illness resembled acute motor conduction block neuropathy characterized by preserved sensory function, an early conduction block at intermediate nerve segments, and good recovery. GM1 and GalNAc-GD1a may form a complex in the axolemma at the nodes of Ranvier or paranodes of the motor nerves, and may be a target antigen in pure motor GBS; especially in the form with acute motor conduction block neuropathy. The present case is the first description of a GBS patient with an IgG anti-GM1/GalNAc-GD1a antibody.

Neurological presentation and long-term outcome following operative intervention in patients with meningocele manqué

We review and describe the neurological presentation and long-term outcome of patients with meningocele manqué, and describe the dysraphic features associated with this entity. Our series of patients was collected over a 25-year period with a mean follow-up of 11.5 years. The mean age of presentation was 10.4 years and 72% of the patients presented with an abnormal neurological examination. At most recent follow-up, symptoms were stable, improved, and progressed in 47, 37 and 16%, respectively. Meningocele manqué was associated with focal hirsutism in 37% of the cases. These bands were primarily found in the lumbar spine and involved two sequential vertebral levels in 42% of cases. Sectioning of meningocele manqué has good long-term results in the majority of patients. These bands should be sought in the evaluation of patients with spinal dysraphism and surgically transected.

Paraneoplastic motor neuron disease resembling amyotrophic lateral sclerosis in a patient with renal cell carcinoma

OBJECTIVE

To report an unusual paraneoplastic syndrome, amyotrophic lateral sclerosis, associated with renal cell carcinoma.

CASE PRESENTATION AND INTERVENTION

A 59-year-old man presented with muscle weakness and fasciculations in the upper extremities. Neurological examination showed that the fasciculations arose spontaneously in the upper limbs. Electrodiagnostic studies revealed an active neurogenic disorder. The patient was diagnosed with a motor neuron disease mimicking amyotrophic lateral sclerosis. Urine analysis revealed microscopic hematuria. Abdominal computerized tomography scans showed a 9.5 x 8 cm renal mass in the lower pole of the right kidney. Curative right radical nephrectomy was performed. Pathologic examination showed a clear cell adenocarcinoma. After nephrectomy, the muscle weakness and fasciculations disappeared spontaneously within 2 months. The patient was disease-free for 58 months after right radical nephrectomy. He complained of muscle weakness and fasciculation at the last follow-up again. Physical examination revealed fasciculation in the upper limbs. Abdominal tomography showed a 22 x 20 mm solid mass in the lower pole of the left kidney. Kidney-saving surgery was performed and the diagnosis of renal cell carcinoma was confirmed pathologically. Following surgery, fasciculations completely disappeared and muscle weakness diminished within 3 months.

CONCLUSION

This case highlights motor neuron disease as a rare paraneoplastic syndrome in association with renal cell carcinoma and resolution after removal of the tumor.

Delayed reversible motor neuronopathy caused by electrical injury

Electrical injury may cause central nervous system (CNS) complications and peripheral nerve disorders. Delayed neurologic complications are rarely reported. A case of delayed reversible motor neuronopathy caused by low-voltage electrical injury is reported due to its rarity. A 22-year-old female received an electric shock of 110 volts while pushing up a metal gate during a rainy morning on April 16, 2005. She initially suffered loss of consciousness for several hours, and then became quadriplegic, from which she completely recovered 10 days later. After return to work for 1 month, she developed weakness and numbness of bilateral upper limbs. Nerve conduction velocity study and bilateral median nerve somatosensory evoked potential were normal. Magnetic resonance imaging of the brain and cervical spine were also normal. Electromyography showed mild denervation, reduced interference and polyphasia over the upper arms, suggestive of anterior horn cell lesion. After rest and rehabilitation for 2 weeks, the patient completely recovered her muscle power over proximal upper limbs and partially over the distal upper limbs. Follow-up at the outpatient clinic 4 months later showed total recovery of muscle power. Low-voltage electrical current can cause acute transient quadriplegia and delayed motor neuronopathy. The mechanism of this patient's recovery from electric shock, followed by deterioration 1 month later, and then recovery after rest is unclear. We considered whether the mechanism of weakness after electric injury, with initial recovery followed later by the development of weakness, might be due to overuse, just like in post-poliomyelitis syndrome. This needs further investigation.

Change in blood antioxidant status of horses moved from a stable following diagnosis of equine motor neuron disease

The antioxidant status of 10 horses living in stable 1 where 2 cases of equine motor neuron disease had previously been diagnosed was assessed before and 9 weeks after moving to another stable. Duration of residence in stable 1, subsequent moving, or both, significantly affected several parameters of the antioxidant status.

Impaired Motor Competence in School-aged Children With Complex Congenital Heart Disease

OBJECTIVE

To explore the extent and type of motor problems in children with complex congenital heart disease (CHD) compared with schoolchildren without any documented heart failure.

DESIGN

Cohort study.

SETTING

Biomechanical Laboratory, Rikshospitalet-Radiumhospitalet Medical Centre.

PARTICIPANTS

One hundred twenty children aged 7 to 12 years with complex CHD and 387 healthy schoolchildren in the same age range (control group).

INTERVENTIONS

All children with CHD were surgically treated with multiple corrections within the first year of life.

MAIN OUTCOME MEASURES

Movement Assessment Battery for Children, grip strength, quadriceps muscle strength, and balance.

RESULTS

Compared with the control group, children with CHD had a risk of having any degree of impaired motor competence of 5.8 (95% confidence interval, 3.8-8.8). The risk for having severe motor problems was 11.0 (95% confidence interval, 5.4-22.5). There were highly significant differences between the groups for manual dexterity, ball skills, grip strength, quadriceps muscle strength, and static and dynamic balance (P<.001).

CONCLUSIONS

Children with CHD have a risk of severe motor problems 11-fold that of schoolchildren without any known heart failure. This suggests that primary health care providers should screen the motor competence in children with CHD at an early age to initiate therapeutic actions for children who show incipient motor problems. Optimal rehabilitative, social, and environmental support may improve the children's motor competence and prevent future health problems.

Peripheral neuropathy and inborn errors of metabolism in adults

Although they are classically viewed as paediatric diseases, it is now recognized that inborn errors of metabolism (IEMs) can present at any age from childhood to adulthood. IEMs can involve the peripheral nervous system, mostly as part of a more diffuse neurological or systemic clinical picture. However, in some cases, the neuropathy can be the unique initial sign. Here, based on our personal experience and on a comprehensive literature analysis, we review IEMs causing neuropathies in adults. Diseases were classified according to the predominant type of neuropathies into (1) acute neuropathies, (2) mononeuropathy multiplex, (3) chronic axonal polyneuropathies, (4) chronic demyelinating polyneuropathies, (5) small-fibre neuropathies, and (6) lower motor neuron disease.

Motor neuron disease and model systems: aetiologies, mechanisms and therapies

The phenotypes of many neurological diseases, including motor neuron disease (amyotrophic lateral sclerosis; ALS) and Alzheimer's disease (AD), are determined by the vulnerabilities of populations of nerve cells and the character/ evolution of cellular abnormalities. Because different cell types respond selectively to individual trophic factors, these factors may be useful in ameliorating pathology in cells that express their cognate receptors. To test therapies for ALS and AD, investigators require model systems. Although there are a variety of models of ALS, two models are particularly attractive: transgenic mice that express human superoxide dismutase 1 (SOD-1) mutations linked to familial ALS develop paralysis associated with a gain of adverse property of the mutant SOD; and axotomy of facial axons in neonatal rats, a manipulation that causes retrograde cell degeneration, which can be ameliorated by several trophic factors.

Acute intermittent porphyria with peripheral neuropathy: A follow-up study after hematin treatment

We report a patient with acute intermittent porphyria who presented with progressive motor neuropathy, particularly in the upper limbs. The electrophysiological studies showed an asymmetric motor neuropathy with a prominent involvement of both the radial and left peroneal nerves. During the 1-year follow-up period, 6 courses of hematin infusion, with 150 mg daily for 4 consecutive days every month, were administrated. The motor neuropathy showed a steady and gradual improvement following the hematin treatment. Molecular analysis of the porphobilinogen deaminase gene revealed a short segment deletion (1008-1019delCAGCCTGGCCAA) resulting in a truncated protein. The findings suggest that early hematin treatment is temporally associated with interval improvement of the patient's porphyric motor neuropathy.

Human retinal pigment epithelial cell implants ameliorate motor deficits in two rat models of Parkinson disease

Intrastriatal transplantation of gelatin microcarrier-attached human retinal pigment epithelial cells (hRPE-GM) may represent an alternative source for cell therapy in Parkinson disease (PD). The use of human retinal pigment epithelial (hRPE) cells in PD relies on the capacity of these cells to produce l-dopa as an intermediate product in the eumelanin synthesis pathway. We investigated the behavioral effects of hRPE-GM implants on forelimb use asymmetries and hindlimb motor deficits in unilateral and bilateral 6-hydroxydopamine (6-OHDA) rat models of PD. We report that intrastriatal unilateral implantation of hRPE-GM in rats with 6-OHDA nigrostriatal lesions produce an amelioration of the contralateral forelimb disuse and the contralateral hindlimb deficits. These results further support the possibility that implantation of cultured hRPE cells may be a promising therapeutic option for patients with PD.

[A forty-five-years-old woman suffered from Sjögren syndrome with progressive tetraparesis]

We herein report the finding of a 45-year-old woman suffered from Sjögren syndrome with progressive tetraparesis, who later developed systemic muscle atrophy and respiratory failure with a one-year clinical history. Neurological examinations revealed progressive tetraparesis with absent deep tendon reflexes, whereas no upper motor neuron signs were observed. The motor and sensory nerve conduction velocity and sensory nerve action potential (SNAP) were both completely normal, but the prolongation of distal motor latency in the median nerve and a decrease in the compound muscle action potential (CMAP) amplitude were observed. We ascertained that a spontaneous discharge was detected in her upper and lower limbs on electromyography (EMG). Her neurological findings as well as the EMG findings closely correlated with those of motor neuron disease; however, she showed a motor paralytic bladder and also demonstrated a serum antibody reaction with 50 kDa spinal cord protein of the rat. A lumbar MR image showed an increased signal intensity of the cauda equina on a gadolinium-enhanced T1 weighted image. We consider the immune-mediated impairment of the motor nerve associated with Sjögren syndrome to be the cardinal pathogenesis of the present patient, even though treatment with oral corticosteroids did not ameliorate her symptoms.

Impact of the endoplasmic reticulum stress response in spinal cord after transient ischemia

BACKGROUND

Delayed paraplegia after operation of the thoracic aorta is considered to be related to vulnerability of motor neurons to ischemia. Recently, endoplasmic reticulum (ER) stress has been reported to participate in neuronal cell death. In the present study, we investigate the expression of ER stress-related molecules and discuss the relationship between neuronal vulnerability and ER stress after transient ischemia in the spinal cord.

METHODS

A rabbit spinal cord ischemia model was generated using a balloon catheter. In this model, spinal motor neurons show selectively delayed neuronal death whereas other spinal neuron, such as interneurons, survive. Immunohistochemical analysis and Western blotting for ER stress-related molecules, including phosphorylated eukaryotic initiation factor 2 alpha (p-eIF2alpha), activating transcription factor 4 (ATF4), glucose-regulated protein 78 (GRP78) and inositol-requiring ER transmembrane RNAse alpha isoform (IRE1alpha), were examined.

RESULTS

P-eIF2alpha, which inhibits protein synthesis and modulates ER stress, was induced only in interneurons after 6 h of reperfusion. ATF4, which is specifically activated by PERK-eIF2alpha, was induced only in interneurons between 6 h and 1 day after reperfusion. GRP78 was induced strongly both in interneurons and motor neurons at an early stage of reperfusion, but prolonged expression was observed only in interneurons. IRE1alpha, which is supposed to transduce an ER stress-related death signal, was expressed more strongly and over a more prolonged period in motor neurons.

CONCLUSIONS

These results indicate that the vulnerability of motor neurons in the spinal cord might be partially attributed to an ER stress response to transient ischemia.

Vitamin E deficiency and risk of equine motor neuron disease

BACKGROUND

Equine motor neuron disease (EMND) is a spontaneous neurologic disorder of adult horses which results from the degeneration of motor neurons in the spinal cord and brain stem. Clinical manifestations, pathological findings, and epidemiologic attributes resemble those of human motor neuron disease (MND). As in MND the etiology of the disease is not known. We evaluated the predisposition role of vitamin E deficiency on the risk of EMND.

METHODS

Eleven horses at risk of EMND were identified and enrolled in a field trial at different times. The horses were maintained on a diet deficient in vitamin E and monitored periodically for levels of antioxidants--alpha-tocopherols, vitamins A, C, beta-carotene, glutathione peroxidase (GSH-Px), and erythrocytic superoxide dismutase (SOD1). In addition to the self-control another parallel control group was included. Survival analysis was used to assess the probability of developing EMND past a specific period of time.

RESULTS

There was large variability in the levels of vitamins A and C, beta-carotene, GSH-Px, and SOD1. Plasma vitamin E levels dropped significantly over time. Ten horses developed EMND within 44 months of enrollment. The median time to develop EMND was 38.5 months. None of the controls developed EMND.

CONCLUSION

The study elucidated the role of vitamin E deficiency on the risk of EMND. Reproducing this disease in a natural animal model for the first time will enable us to carry out studies to test specific hypotheses regarding the mechanism by which the disease occurs.