A diagnosis challenge-L4 nerve root compression as the initial presentation of chronic inflammatory demyelinating polyneuropathy

The authors present the case of a 65-year-old woman who was admitted for paraparesis and paresthesias in the inferior limbs. The neurological examination revealed the difficulty in extension of the right foot and of the right toe, accompanied by paresthesias located in the anterolateral area of the right leg, dorsum and plantar area of the foot, the reduction of the right knee jerk, and of the ankle tendon jerk both sides. The vertebro-spinal MRI showed lumbar canal stenosis with L4 intraforaminal compression on the right, and L2-L3 on the left. CSF examination revealed mild increase in protein concentration. The morphological picture of the sural nerve biopsy was compatible with a chronic inflammatory neuropathy and severe muscular lesions of neurogenic origin were observed on right gastrocnemius muscle biopsy. The diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP) was established. Solu-medrol (0.5 g/d)-5 days, then medrol (prednisolone) was done, followed by improving of the symptomatology. For the relapse of the disease intravenous immunoglobulins (IVIG)-0.4 g/kg/d-5 days was the elective treatment. Six months later she presented a new relapse. IVIG were administered with the remission of the sensitive symptoms. A chronic treatment with medrol was recommended. The diagnosis of L4 disc herniation was obvious in the studied case, but the electroneurographic examination brought extra data for the associated diagnosis of CIDP whose onset was asymmetrical and initially paucisymptomatic. Neither the electroneurographic examination nor the CSF examination were total relevant for CIDP, imposing the sural nerve biopsy. The diagnosis of CIDP involves a team-work composed of neurologist, electroneurophysiologist and neuropathologist.

Carnitine deficiency

We present the case of a female patient, aged 12 years, with fatigability and exertional myalgias, progressively developed within the last two years. Negative family history, as well as negative personal medical history, were found. At physical examination, short stature, proximal muscle weakness and mild hepatomegaly were noted. Urine ketones level was slightly decreased, serum transaminases, creatine kinase and lactate dehydrogenase levels were increased. Electromyographical examination showed a myopathic non-specific pattern. Deltoid muscle biopsy revealed: small, clear vesicles are present on Hematoxylin-Eosin and modified Gömöri trichrome stains; modified Gömöri trichrome stain also revealed muscle fibers (especially type I of muscle fibers) having mild to moderate mitochondrial proliferation (red rim and speckled sarcoplasm). The lipid storage has been well demonstrated by Sudan Black stain, which revealed small lipid droplets in type I muscle fibers. Abnormal internal architecture with a punctate pattern was showed by adenine dinucleotide tetrazolium reductase and succinate dehydrogenase stains. Electron microscopy showed small inter-myofibrillar accumulations of round, amorphous, homogeneous acellular substances that are not membrane bounded. These features indicate that these are neutral fat (lipid) droplets. Subsarcolemmal accumulations of mitochondria were also revealed. The differential diagnosis of this case is discussed, and the up to date general data concerning carnitine deficiency are presented. The aim of our case-report is to emphasize the role of muscle biopsy in carnitine deficiency, as well as to remind the necessity of keeping in mind such metabolic disorders when doing the differential diagnostic of a muscular weakness.

Value of immunohistochemical investigation in the diagnosis of neuromuscular diseases in children

Neuromuscular diseases represent an important group in pediatric pathology. Immunohistochemistry together with clinical examination and morphologic exam are very important in the diagnosis of neuromuscular disorders.

PATIENTS AND METHODS

One hundred children diagnosed with neuromuscular disorders were included in a prospective-retrospective study in 25 years.

RESULTS

There were 58 neurogenic diseases and 42 muscular dystrophies. In positive and differential diagnosis very important were the morphologic and immunohistochemical investigations. Seventy-three percent had positive family history and 27% of dystrophic patients had "de novo" mutations. The most part of the neurogenic disorders were spinal motor atrophies, 91.38%.

CONCLUSIONS

Neurogenic muscular diseases were the most common neuromuscular diseases in our patient group. The immunohistochemical investigation was very useful in diagnosing some of these cases.

Dermatomyositis and polyradiculoneuritis, a rare association

The association between dermatomyositis and polyradiculoneuritis is rarely citated in the speciality literature. Our patient had at first a disorder that looked like dermatomyositis, then she associated polyradiculoneuritis. At the presentation to our hospital the two diseases were combined, being very difficult to differentiate. The discrimination between these two had been made by performing a muscular biopsy and EMG studies. This emphasizes once again their importance in defining the muscular impairment from the neurogenic one.

Mitochondrial myopathies: current diagnosis (I)

Mitochondrial diseases can present at any age and include a combination of multisystemic symptoms. Major manifestations of muscle involvement include infantile hypotonia, weakness, and lactic acidosis; severe exercise intolerance and easy fatigability, variable fixed weakness, often involving the extraocular muscles. Additionally, infantile or childhood encephalomyopathies have been identified in which CNS (e.g., seizures, ataxia, stroke-like episodes) and muscle symptoms coexist. Paraclinical investigations support the diagnosis and help in categorizing the mitochondrial myopathies (MM). Serum CK level may be mildly elevated in MM but are often normal; blood lactate concentration is usually elevated at rest. Electroneuromyographic features are not pathognomonic: myopathic EMG findings and reduced sensory response amplitudes. Muscle biopsy is a more specific test of mitochondrial myopathies, typically showing the presence of ragged red fibers, COX negative and SDH positive, with ultrastructural abnormal mitochondria (electron microscopy). Enzymatic and genetic tests are sometimes useful. After overviewing the current literature, a brief clinical case report is presented.

Amyloid neuropathy

Amyloidosis is the name given to a group of diseases characterized by the extracellular deposition of insoluble amyloid fibrils in different tissues and organs like kidneys, heart, liver, skin, nerves etc. Clinical manifestations of amyloidosis are determined by the amyloid precursor protein type, by the tissue containing amyloid deposits, and by the quantity of stored amyloid. We present here the data of a patient with sensory polyneuropathy, orthostatic hypotension, nephritic syndrome and benign IgG monoclonal gammopathy, in which we diagnosed amyloid neuropathy.

Management of malignant extrinsic compression of the ureter by simultaneous placement of two ipsilateral ureteral stents

BACKGROUND AND PURPOSE

Extrinsic ureteral obstruction caused by various malignancies often necessitates urinary diversion. The use of single ureteral stents as a form of urinary diversion results in a high failure rate, while the use of two ipsilateral stents has shown promising results. We report our experience using the latter technique.

PATIENTS AND METHODS

Between 1996 and 2001, four male and three female patients with a mean age of 65 years (range 37-95 years) who had extrinsic compression of the ureters underwent single stent management to relieve obstruction. Ureteral obstruction was secondary to prostate cancer (N = 3), cervical cancer (2), non-Hodgkin's lymphoma (1), and transitional-cell cancer of the bladder and ureter (1). After failure of such management, two 7F stents or a combination of 8F/6F double-J ureteral stents were placed. The stents were changed every 4 to 6 months. Follow-up included serial renal ultrasound scans and serum creatinine measurements.

RESULTS

Ureteral stricture length ranged from 2 to 4 cm. Insertion of two double-J ureteral stents in a single ureter was successful in all cases. During the mean follow-up of 16 months (range 1-38 months), the ureteral stents were tolerated by all patients, without significant discomfort. Marked improvement of hydronephrosis and alleviation of flank pain was noted in all patients. Three patients have died at 1 to 3 months. Renal function improved, with a mean decline in the serum creatinine concentration from 3.2 mg/dL to 1.48 mg/dL in the five patients tested.

CONCLUSION

Simultaneous placement of two double-J ureteral stents for the management of ureteral obstruction secondary to a malignancy is a safe and effective technique.

Laparoscopic ureteral reconstruction with small intestinal submucosa

PURPOSE

To evaluate the feasibility of laparoscopic ureteral reconstruction with small intestinal submucosa (SIS) in the pig ureter.

MATERIALS AND METHODS

Eight female pigs weighing between 25 and 30 kg were enrolled. After anesthesia was administered, a double-pigtail stent was inserted, the animals were moved to a lateral decubitus position, pneumoperitoneum was established, and three 10-mm ports were positioned. The ureter was opened longitudinally for 7 cm, and two thirds of the periphery of the upper third of the left ureter was excised. The SIS was anastomosed to the upper and distal ureteral segments with chromic 4-0 sutures. The double-pigtail stent was removed 6 weeks after the initial procedure, and retrograde pyelography was performed a week later to confirm the viability of the pelvicaliceal system.

RESULTS

The average duration of the procedures was 210 minutes (range 125-250 minutes). All animals survived the entire follow-up period of 7 weeks. Retrograde pyelography revealed a patent ureteral lumen, and no obstructive phenomena were observed. Histologically, the SIS-regenerated ureteral segments were remarkably similar to normal porcine ureters and were indistinguishable from neighboring tissue.

CONCLUSION

Laparoscopic ureteral reconstruction with SIS proved to be effective and technically feasible. The SIS seems to be an effective biodegradable scaffold, facilitating regeneration of host tissue.

Merosin-deficient congenital muscular dystrophy: neuropathology case reports

The aims of our study were: to present cases of congenital muscular dystrophy (CMD) with deficiency in merosin and the importance of immunohistochemistry in the diagnosis of merosin-deficient CMD. In four years (1997-2000), we found three patients with merosin-deficient CMD, one of them having an unusual clinical and pathological manifestation of the disease. Muscle biopsies of gastrocnemius or quadriceps muscles were investigated. In addition with the conventional HE staining, indirect immunohistochemistry for merosin, dystrophin, utrophin and for the proteins of the dystrophin associated complex (alpha-, beta-, gamma- sarcoglycans; beta-dystroglycan) was performed on cryosections. The findings suggest that there is no correlation between the clinical and histological picture of the disease and the expression of merosin in skeletal muscles. The degree of muscle involvment (assessed by histology) is parallel with the clinical neuromotor deficiency, but not with expression of merosin, which can be absent even in mild cases. The clinical investigations as well as current morphological techniques, only together with immunohistochemistry can differentiate between merosin - deficient CMD and other muscular dystrophy forms.

Cloacal exstrophy: a unified management plan

BACKGROUND/PURPOSE

The belief that patients with cloacal exstrophy have a short and therefore useless colon is all too common. Frequently, the colon is used for urinary or vaginal reconstruction, and the possibility of a pull-through is lost. In the authors' experience, the use of a unified management plan allowed most patients to undergo pull-through and avoid a permanent stoma.

METHODS

Twenty-five patients were treated for cloacal exstrophy in the authors' institution from 1985 through 1999. In all patients, bladder closure, omphalocele repair, and creation of a colostomy were performed at birth. All available colon, no matter how small, was incorporated into the fecal stream. After at least 1 year, patients were assessed for the ability to form solid stool through their stoma. Normal colonic length, capacity to form solid stool, or success with a bowel management regimen through the stoma were considered indications for pull-through. Genitourinary reconstruction was contingent on the colorectal plan.

RESULTS

Colonic length ranged from normal in 12 patients, 40 to 70 cm in 3 patients, 10 to 30 cm in 4 patients, and less than 10 cm in 2 patients. All 25 patients underwent pull-through. Three are totally continent, 4 are continent with occasional soiling, 11 remain clean with a bowel management regimen, and 4 are too young to assess. One patient was clean, but now refuses bowel management. Two early patients, both with less than 10 cm of colon, now have ileostomies.

CONCLUSIONS

During neonatal repair, a colostomy should be formed incorporating all pieces of colon, no matter how small. With time, most patients will be able to form solid stool, and a pull-through should be undertaken if that ability exists. Decisions regarding genitourinary reconstruction should be made only after the gastrointestinal plan is established to achieve the optimal use of available bowel.

Radical prostatectomy versus brachytherapy for early-stage prostate cancer

BACKGROUND AND PURPOSE

The considerations in choosing a treatment for prostate cancer are potential for cure, acute toxicity, long-term morbidity, quality of life, and direct and indirect costs. The classic options are radical prostatectomy, external-beam radiation, and watchful waiting. During the last decade, technological advances have fostered another: brachytherapy.

METHODS

This article compares brachytherapy and radical prostatectomy in terms of cancer control, complications, and cost using series from medical centers that have pioneered and advocated particular procedures.

RESULTS

In the surgical series from Johns Hopkins, the 7-year success rate (no PSA >0.2 ng/mL) of anatomic radical prostatectomy was 97.8% in patients with stage T(2c) or lower disease and a Gleason score of < or =6. In the brachytherapy series from Seattle, the 7-year success rate (PSA < or =0.5 ng/mL) was 79%. Postoperatively, 68% of the patients who were potent preoperatively maintained erectile function, and 92% were fully continent. Urethral toxicity is slightly more common in patients treated by brachytherapy, but in the authors' series, no patient remained incontinent after 6 months. Some patients became impotent during follow-up. The cost of brachytherapy ($16,200) is less than that of ($27,000), although the difference may be reduced by the use of neoadjuvant hormonal therapy with the former.

CONCLUSION

Patients receiving brachytherapy appear to have a slightly higher rate of disease progression. The side effects generally are acceptable and may be less severe than those of surgery. Further follow-up data are needed to define the roles of these two treatments for early-stage prostate cancer.

Cell death induced by beta-amyloid 1-40 in MES 23.5 hybrid clone: the role of nitric oxide and NMDA-gated channel activation leading to apoptosis

The molecular events associated with beta-amyloid-induced neuronal injury remain incompletely characterized. Using a substantia nigra/neuroblastoma hybrid cell line (MES 23.5) synthetic beta-amyloid 1-40 induced a time and dose-dependent apoptotic cell death which was characterized by cell shrinkage and fragmentation of DNA, and was inhibited by aurintricarboxylic acid (ATA), and cycloheximide (CHX). Following beta-amyloid 1-40 treatment, cyclic GMP, an index of NO synthesis, was increased in MES 23.5 cells. The NO scavenger hemoglobin, as well as the NO synthase inhibitors NG-monomethyl-L-arginine acetate (L-NMMA) and L-N5-(1-iminoethyl)ornithine hydrochloride (L-NI0) attenuated such increases. These same inhibitors and scavengers also significantly prevented cytotoxicity. beta-Amyloid also induced an early and transient increase in intracellular calcium as monitored with laser scanning confocal microscopy and Fluo-3 imaging. These induced calcium transients could be significantly blocked by the N-methyl-D-aspartic acid (NMDA) receptor antagonist MK-801. Pretreatment with MK-801 or removal of extracellular Ca2+ also reduced beta-amyloid-induced NO production and neurotoxicity. Furthermore, beta-amyloid neurotoxicity was greatly enhanced in the absence of Mg2+ or in the presence of glutamate or NMDA. These data suggest that beta-amyloid can lead to apoptotic cell death through a NO mediated process possibly triggered by Ca2+ entry through activated NMDA-gated channels.

Tomaculous neuropathy with unusual clinical aspects

Tomaculous neuropathy represents the morphological substrate of the recurrent familial neuropathy with liability to pressure palsies. Some ultrastructural changes characterizing the tomaculous neuropathy can occur as incidental aspects in other different neuropathies. Few tomaculous neuropathy cases with clinical aspect of chronic polyneuropathy without paretic episodes have been mentioned in the literature. In the present work, we report four cases who offered the morphological surprise of a true tomaculous neuropathy with 15-37% of the teased fibres bearing tomaculae sized: 55-106 microns/20-23 microns, on the background of a demyelinating neuropathy with 25-56% of the teased fibres showing segmental de- or remyelination. The clinical and electrophysiological diagnoses of these 4 patients were: HSMN type I (2 cases), HSMN type VIII (polyneuropathy associated with a cerebello-extrapyramidal syndrome -1 case), and a neurogenic scapuloperoneal syndrome (1 case). The specificity of the tomaculous neuropathy is discussed.

Increased intracellular calcium triggered by immune mechanisms in amyotrophic lateral sclerosis

Although the causes of motor neuron degeneration and death in amyotrophic lateral sclerosis (ALS) is unknown, recent evidence suggests a prominent role for increased intracellular calcium, possibly triggered by autoimmune mechanisms. The presence in ALS patients of paraproteinemias, lymphomas, lymphoid cells in the central nervous system (CNS) and the availability of animal models of immune-mediated motor neuron disease provide circumstantial evidence for autoimmunity. Direct evidence derives from the demonstration that ALS IgGs bind to voltage-gated calcium channels in 75% of sporadic cases, but not in familial ALS cases, and that ALS IgGs increase N-type and P-type calcium currents in neuronal cells and in lipid bilayers. These same ALS IgGs are cytotoxic for a motor neuron cell line (VSC 4.1) in vitro. In addition, following passive transfer to mice in vivo, ALS IgGs produce ultrastructural and calcium changes in synaptic vesicles and mitochondria of motor axon terminals, as well as in rough endoplasmic reticulum and Golgi complex of motor neuron perikarya, but not in sensory neurons or Purkinje cells. The reason for the selective vulnerability of motor neurons is not clearly defined, but a prominent possibility is the physiological absence in motor neurons of the calcium-binding proteins calbindin-D28k and parvalbumin. These studies emphasize the central role of increased intracellular calcium in motor neuron cell death in sporadic ALS, and the role of autoimmunity in triggering such increases.

Structural modifications of intracerebral small vessels in various types of dementia

Previous and recent studies stress the importance of small intracerebral vessel lesions in the pathogeny of some forms of dementia. The observations on this subject and included in our study refer to adult patients (32-86 years) selected only on the criterion of clinical diagnosis of dementia. To diagnose most of the cases, clinical experimental data and clinico-psychomotor tests were used. Classical neuropathological techniques were performed for the morphological study of their brains. All types of cerebral vessels were affected in various percentages by the different types of lesions. Vessel wall sclerosis of all types of intracerebral vessels was noticed in 50% of the cases, the thickening of the arteriolar wall with or without sclerosis in 25% of cases and exclusively capillary fibrosis in 21.4% of cases. Other types of vascular changes were present in a small number of cases. No correlation could be made between a certain type of vascular lesion and the age or diagnosis of the patient. Nevertheless, we could observe that wall sclerosis was more frequently found in groups with the oldest patients with vascular diseases (VD, MD), the thickening of the arteriolar wall in patients aged 60-74 years with vascular diseases, and capillary changes in older patients with dementia of Alzheimer type. No preferential location of the vascular lesions could be observed in our group of patients.

Degenerative neuromuscular diseases with a late onset. Clinical, electrophysiological and morphological study

This study carried out clinical, electrophysiological and morphological investigations (sural nerve and gastrocnemius muscle biopsies) in a group of 47 patients with neuromuscular disease of a certain or supposed degenerative origin and a late onset (over the age of 30 yrs.). It aimed the evidence of the eventual particularities of such diseases with a delayed onset. The equal involvement of sexes, the insidious onset, the clinical picture similar to that of the corresponding diseases with an onset at the usual age were observed. Regardless of the age, some interesting associations of the polyneuropathy with other diseases or its presence with in these diseases (Parkinsonism, Addison's disease, multiple symmetrical lipomatosis, etc.) were noticed, too. Electrophysiological examinations showed no particularities. Neither did the muscular morphological picture in most of the cases presenting neurogenic lesions with a moderate intensity. The sural nerve biopsy evidenced in 70% of the cases a moderately intense neuropathy of an axonal type ("dying back"), with or without secondary lesions of segmental demyelination and with the signs of a live regenerative activity.

Chronic sensorimotor polyneuropathy associated with cerebello-extrapyramidal manifestations in a patient with tomaculous neuropathy

Clinical, electrophysiological and morphological (sural nerve and gastrocnemius muscle biopsies) data of a 57-year-old man with a chronic sensorimotor polyneuropathy of Charcot-Marie-Tooth type associated with a progressive cerebello-extrapyramidal syndrome are reported. Patient's family data were negative. Nerve structural and ultrastructural examinations revealed the morphological picture of a tomaculous neuropathy. The association of different clinical syndromes and the specificity of the tomaculous neuropathy are discussed.

[Preliminary results in treating superficial bladder tumors by the local instillation of Calmette-Guérin bacilli]

Post-resection complementary immunotherapy was applied to 55 patients with superficial urinary bladder tumours (Ta, TI) with Calmette-Guérin bacilli (Pasteur strain) prepared by the "Cantacuzino" Institute. The treatment consisted initially in scarification and instillation in 19 patients, and in instillation alone inside the urinary bladder in 43 patients, according to Morales, and respectively Brosman protocols. In 7 patients only Morales immunotherapy was applied initially but after recidive and resection they too were treated according to the Brosman protocol. One should note that most of these tumours were of the recurring type, with multiple recidives in the antecedents in 60% of the patients, and that the surgical treatment, as well as instillation of cytostatic drugs had failed. In the present protocol transurethral resection was carried out in 93% of the cases. After immunotherapy the following aspects were noted: in 75.8% of the patients there were no recidives 25 months in the average after the start of the treatment. In the average 13 months elapsed between the start of the treatment and the occurrence of the first recidive, as compared with 7 months in the average for the controls. Most of the recidives in patients with instillations occurred in those in whom the tumour had gone beyond the basal membrane. In 2 patients with infiltrative recidives total cystectomy was carried out. With regard to degree of anaplasia following BCG instillation there was a down-grading in 43% of the cases. There was no fatality ascribable to BCG treatment in our series, and both general and local complications were insignificant considering the therapeutic benefit.

The importance of cerebral lesions of vascular origin in the morphopathologic picture of old age dementia

Our study refers to the complex neuropathologic examination of 70 demented patients (40 males and 30 females) above 60 years of age. Proportion of different types of cerebral damage with vascular pathogeny showed that 78% of the vascular dementia cases had as morphological background various aspects of multi-infarct dementia; softenings of variable size and lacunae, associated or not with myelinic rarefactions and pallor specific to subcortical arteriosclerotic encephalopathy; the remaining cases pointed to single anoxic lesion and/or subcortical encephalopathy. Perfect clinico-morphological diagnostic concordance has not always been reached in our sample--as in literature cases--often due to the dementia subtypes overlapping, and to the fact that the same clinical syndrome may show in different cerebral lesions. Likewise, no correlation has been found between lesion type, site or size and clinical picture or dementia course, which was also reported by other authors. On a morphopathogenic basis, we support the view that necrotic lesions of ischemic origin--multi-infarct and lacunar dementias--should be distinguished from myelinic rarefactions and pallor in the white matter, whose pathogeny is still controversial. Due attention is paid to the importance of the venous factor in the development of subcortical encephalopathy.

Polyneuropathy with lipid deposits in Schwann cells and axonal degeneration in cerebrotendinous xanthomatosis

The present paper is a histological, histochemical and electron microscopic study of biopsied specimens from both right and left Achilles tendon, sural nerve and gastrocnemius muscle in a case of peripheral neuropathy with decreased sensory conduction velocity within a cerebrotendinous xanthomatosis confirmed biochemically in a 29-year-old woman. The tendon specimens contained large deposits of complex, non-homogeneous lipids, distributed intra- and extracellularly. The right sural nerve specimen showed a very severe neuropathy with massive diffuse myelinated fiber loss, presence of foamy macrophages and lipid droplets in Schwann cells. Segmental de- and remyelination was noted in 17% of the teased myelinated fibers. No onion bulbs were observed. Two years later, the left sural nerve specimen revealed a mild diffuse myelinated fiber loss, a more active segmental de- and remyelination (23%) without onion bulbs, and an active regeneration. Lipid storage aspects were absent. The gastrocnemius muscle specimens exhibited slight alterations of neurogenic origin. The pathogenesis of this neuropathy is discussed.

Muscle hypertrophy and a syndrome of continuous motor unit activity in prednisone-responsive Guillain-Barré polyneuropathy

The clinical, electrophysiological and morphological findings (light and electron microscopy of the sural nerve and gastrocnemius muscle) are reported in an unusual case of Guillain-Barré polyneuropathy with an association of muscle hypertrophy and a syndrome of continuous motor unit activity. Fasciculation, muscle stiffness, cramps, myokymia, impaired muscle relaxation and percussion myotonia, with their electromyographic accompaniments, were abolished by peripheral nerve blocking, carbamazepine, valproic acid or prednisone therapy. Muscle hypertrophy, which was confirmed by morphometric data, diminished 2 months after the beginning of prednisone therapy. Electrophysiological and nerve biopsy findings revealed a mixed process of axonal degeneration and segmental demyelination. Muscle biopsy specimen showed a marked predominance and hypertrophy of type-I fibres and atrophy, especially of type-II fibres.

Delayed neuropathy after organophosphorus insecticide (Dipterex) poisoning: a clinical, electrophysiological and nerve biopsy study

Clinical, electrophysiological and histological findings in four patients accidentally poisoned with the organophosphorus insecticide Dipterex are reported. Three to five weeks after insecticide ingestion signs of a distal sensorimotor (preponderantly motor) neuropathy occurred. The patients complained of paraesthesia in the lower limbs, and two of them of very disagreeable pricking sensation in the soles of the feet, responsive to carbamazepine. They showed distal weakness mainly of the legs, footdrop , difficult gait and muscle hypotonia. Ankle jerk was abolished while other tendon reflexes persisted. Two months or even later after poisoning, knee jerks in all the patients were very brisk and more and less accompanied by other pyramidal signs (patellar clonus, abolishment of abdominal cutaneous reflexes, Babinski's sign). Clinical, electrophysiological and nerve biopsy data revealed a "dying-back" neuropathy in our patients. Distal muscle fatigue was confirmed by failure of neuromuscular transmission on repetitive nerve stimulation.

Neuronal type of Charcot-Marie-Tooth disease with a syndrome of continuous motor unit activity

The clinical, genetic and electrophysiological study of 3 patients with an association of a neuronal form of Charcot-Marie-Tooth Disease (CMTD) with a syndrome of continuous motor unit activity (CMUA) are reported, with light and electron microscopy of muscle and sural nerve biopsies in 2 patients. The unusual clinical features of CMTD were associated with fasciculation, cramps, myokymia, impaired muscular relaxation and percussion myotonia with their electromyographic (EMG) correspondent, responsive to valproic acid (VPA) therapy. In Case 3, an important muscle hypertrophy which was confirmed by morphometric data, was noted in addition. Nerve biopsy and electrophysiological findings indicated that axonal degeneration with secondary demyelination and remyelination underlie the hereditary motor and sensory neuropathy (HMSN) in our patients. The hyperexcitability and hyperactivity of peripheral motor axons probably induced by the hereditary neuropathy may, in this instance, be the causative condition of the syndrome of CMUA in our patients.

Sensorimotor neuropathy in a patient with Marinesco-Sjögren syndrome

A case of Marinesco-Sjögren syndrome, displaying the characteristic signs (ataxia, congenital cataract and mental retardation) is presented. Electrophysiological examination pointed to the presence of a sensorimotor peripheral neuropathy with an underlying mixed process of segmental demyelination and axonal degeneration (probably secondary). The sural nerve and gastrocnemius biopsy confirmed these data, showing that in this case the segmental demyelination process was accompanied by axonal degeneration.