成人型脊髓性肌萎缩症临床分析(附46例报告)

目的总结分析成人型脊髓性肌萎缩症(SMA4)的临床特征。方法收集46例经肌肉活检证实的SMA4病例进行临床资料回顾性分析。结果SMA4起病隐袭,进展缓慢,肌无力以四肢近端为主,无锥体束受累。约四分之一患者血清CPK轻度升高;EMG示神经源性损害;肌活检主要为小群性肌萎缩,ATP酶染色见同型肌群化及肌纤维代偿性肥大。结论SMA4是病变影响下运动神经元的一组独立性疾病,并非为肌萎缩侧索硬化的某一发展阶段。预后相对良好。     

Intestinal pseudo-obstruction in adult spinal muscular atrophy

A 42-Year-old woman sith negative family history had the insidious onset of weakness in her lower extremities 8 years before, in 1983. The disorder slowly progressed to include cramps and muscle twitches. The diagnosis of adult spinal muscular atrophy (SMA) was made when electromyography showed large rapidly firing motor unit potentials, positive waves, and fibrillation potentials, and when muscle biopsy of the quadriceps revealed severe alterations consistent with neurogenic atrophy. The patient also had severe chronic constipation for many years. More recently she had developed unremitting diarrhea. Gastrointestinal studies showed no evidence of peristaltic contractions in the rectum, delayed gastric emptying, and abnormal jejunal manometry with altered propagation of the migrating myoelectrical complex. © 1994 John Wiley & Sons, Inc.     

Accuracy of muscle fasciculations for the diagnosis of later-onset spinal muscle atrophy

Diagnosis of later-onset spinal muscular atrophy (SMA) can be challenging. This study aimed to evaluate the diagnostic properties of the detection of muscle fasciculations for SMA diagnosis in adolescents and adults with proximal muscle weakness. A cross-sectional diagnostic accuracy study was performed, in which 10 subjects with SMA (5 with type II and 5 with type III) and 9 subjects with genetic muscle diseases were evaluated by physical examination, muscle ultrasound (MUS) and electromyography (EMG). Inter-rater reliability of MUS was higher than physical examination and in a sensitivity analysis of MUS, all SMA subjects and a single patient with genetic muscle disease presented fasciculations in at least 2 different muscle groups, resulting in a sensitivity of 1 (95% CI: 0.69 to 1) and a specificity of 0.89 (95% CI: 0.52 to 1) for SMA diagnosis. Forty-two percent of evaluated subjects did not agree to perform EMG, limiting this method results. Muscle ultrasound presented the best diagnostic accuracy and physical examination combined with MUS seemed to be a good strategy for screening adolescents and adults with proximal muscle weakness for SMA. These results might improve diagnostic guidelines for later-onset SMA, leading to earlier diagnosis, treatment and specific care.     

Genetically confirmed spinal muscular atrophy type III with epilepsy, cerebral hypoperfusion, and parahippocampal gyrus atrophy]

We report a 37-year-old female with spinal muscular atrophy (SMA) type III and central nervous system (CNS) involvement. She showed gait disturbance at the age of 12 years, and difficulty of squatting at the age of 19. On examination at the age of 22, she had proximal muscle weakness and atrophy, fasciculation, normal sensory system and elevated creatine kinase in the serum. She was diagnosed as having SMA type III based on clinical, electrophysiological, and muscle biopsy findings. She suffered from subacute necrotizing lymphadenitis at the age of 23 and from epilepsy at the age of 33. Magnetic resonance imaging showed atrophy of parahippocampal gyrus with right side predominance. Single photon emission computed tomography (SPECT) using I123-IMP showed decreased accumulations of I123-IMP in the temporal lobes with left side predominance. Electroencephalogram showed theta wave without epileptic burst. SMA gene analysis revealed deletion of exon 7 and 8 in survival motor neuron (SMN) gene. A few patients with SMA and CNS involvement have been reported without genetic diagnosis. This is the first report of genetically confirmed SMA patient with CNS involvement. SMN gene is distributed not only in spinal cord but also in brain. The CNS involvement detected in this patient may be related to the loss of SMN gene function, although coincidental association of SMA and the CNS abnormalities is still considered in this atypical case.     

X-linked spinal and bulbar muscular atrophy without proximal atrophy

We report on a case of genetically proven X-linked spinal and bulbar muscular atrophy (X-SBMA) with prominent distal muscle atrophy and without proximal muscle involvement. The patient was a 35-year-old man who had a history of slow progressive hand and distal leg muscle weakness and wasting for 10 years. Motor nerve conduction velocities were normal with reduced compound muscle action potential amplitudes of hand and foot muscles. Sensory action potential amplitudes were small. Needle EMG revealed a chronic partial denervation with reduced interference in hand and distal leg muscles but with normal heading in all tested proximal muscles. Genetic studied showed an expansion of CAG repeat in the first exon of the androgen receptor gene, which suggests diagnosis of X-SBMA. The importance of genetic studies in this patient with unusual clinical presentation is emphasized.     

Acute onset spinal muscular atrophy in siblings

We describe two sisters who each presented in infancy with acute, severe, generalised weakness and are-flexia in association with an intercurrent infection. The clinical picture resembled acute polyneuritis, but EMG findings and the later clinical features were consistent with a diagnosis of spinal muscular atrophy. Although symptoms in SMA may be exacerbated by infection, immunisation or trauma, this unusual presentation of the condition in siblings suggests that this may constitute a genetically distinct subgroup of the disorder.     

慢性脊髓性肌萎缩症的临床和肌活检

文章报道２４例慢性脊髓性肌萎缩症，其中婴儿型、少年型、成年型慢性近端型分别为５例、２例及１３例，面肩肱型２例，远端型和肩腓型各１例。本病主要临床表现为肌无力、肌萎缩和不同程度的肌束震颤，锥体束和周围神经一般不受累。各型肌萎缩的部位不同。３例患者伴有ＣＰＫ浓度增高。除２例肌电图正常外，其余表现为失神经性改变。光镜提示神经原性萎缩。电镜下见肌原纤维数量减少，Ｚ线变粗或波浪状以及线粒体和内质网肿胀。     

Leg muscle function and fatigue during walking in spinal muscular atrophy type 3

Introduction: Spinal muscular atrophy (SMA) causes muscle weakness and fatigue. Better understanding of the relationship between weakness and fatigue may help identify potential targets for rehabilitation. Methods: Gait and surface electromyography (EMG) from 4 muscle groups were measured during the Six‐Minute Walk Test (6MWT) in 10 ambulatory participants, aged 9–49 years. Average root mean square amplitude (RMS) of muscle activity was calculated. Strength was assessed using manual and quantitative methods. Results: RMS, stride length, and velocity decreased during the 6MWT. Knee flexor and hip abductor strength was associated with fatigue‐related changes; overall strength correlated with disease duration; and leg strength was associated with 6MWT distance. Conclusions: Clinical measures are valid in assessing fatigue and function in SMA, and these assessments can be enhanced by use of gait analysis and EMG. Disease duration and strength measures may represent further stratification refinements when enrolling patients in clinical trials. Muscle Nerve 50 : 34–39, 2014     

婴儿型脊髓性肌萎缩症的临床及电生理特点

目的 探讨婴儿型脊髓性肌萎缩症(SMA)的临床和电生理特点.方法 回顾性分析20例婴儿型SMA患儿的临床资料.结果 20例SMA患儿临床表现为出生后进行性加重的四肢弛缓性瘫痪,肌张力低下,腱反射消失.肌电图表现为神经源性损害,所检测的50条运动神经均示神经肌肉复合动作电位波幅衰减,其中10条合并末端潜伏期延长及传导速度轻度减慢;所检测的25条感觉神经传导速度在正常范围.肌肉活检为典型的神经源性肌萎缩.结论 婴儿型SMA的临床特点为出生后进行性加重的四肢弛缓性瘫痪,肌电图检查显示为神经源性损害.     

进行性脊肌萎缩症129例临床分析

目的探讨进行性脊肌萎缩症(PSMA)的临床特点、诊断与鉴别诊断。方法回顾性分析129例PSMA患者的临床资料。结果本组患者均隐袭起病,逐渐加重,男性多见,发病年龄65.9%患者>50岁。首发症状以单侧上肢无力和肌萎缩为多见(65.9%),均表现为下运动神经元损害的症状和体征,51.9%患者出现延髓麻痹症状;肌电图检查均提示神经源性损害;易误诊为颈或腰椎病。结论本病是一组慢性进行性下运动神经元疾病,病变可累及延髓。诊断主要依据临床表现和肌电图。     

Inclusion body myositis in post-poliomyelitis muscular atrophy

A 38-year-old male developed a new muscle weakness in his left thigh 35 years after having acute paralytic poliomyelitis with residual right distal leg weakness and atrophy. EMG studies showed widespread denervation in proximal and distal muscles regardless the clinical involvement. Muscle biopsy from an affected muscle showed the findings of inclusion-body myositis consisting of perivascular and interstitial mononuclear infiltration, sarcoplasmic granular inclusions with membranous whorls and typical filamentous inclusions in several myonuclei. This raises the possibility of inclusion body myositis in other cases of progressive post-poliomyelitis muscular atrophy, especially those with perivascular infiltration of mononuclear cells in the muscle biopsy.     

Head tremor in dentatorubral-pallidoluysian atrophy

Dentatorubral-pallidoluysian atrophy (DRPLA) is a rare autosomal-dominant neurodegenerative disorder characterized by variable combination of clinical manifestations including ataxia, myoclonus, seizures, dementia, and choreic movements. Head tremor has been rarely reported. We report a 66-year-old-woman with genetically determined DRPLA who presented with head tremor. A "no-no" type head tremor was the initial and the most prominent symptom, and mild cerebellar signs and choreic movements were also observed later. Neither hand tremor nor dystonia was noted. The patient did not show dementia, myoclonus, or seizures. Surface electromyogram (EMG) revealed 3.5-4 Hz rhythmic EMG bursts in both sternocleidomastoid muscles. DNA analysis disclosed expanded trinucleotide repeats (n = 54) in the DRPLA gene. We suggest that isolated head tremor can be a clinical manifestation of DRPLA.     

Evaluation of cerebrospinal fluid biomarkers in pediatric patients with spinal muscular atrophy

BackgroundSpinal muscular atrophy (SMA) is a rare neuromuscular disorder characterised by muscle weakness and muscle atrophy and classified into five known subtypes based on clinical features. The recent development of novel drugs to treat SMA has been encouraging, and nusinersen is the first drug approved to treat SMA.ObjectiveTo explore cerebrospinal fluid (CSF) biomarkers of SMA and investigate their relationship with symptoms and the treatment response in pediatric patients.MethodsWe analyzed the CSF levels of chitotriosidase 1 (CHIT1) and inflammatory cytokines (tumor necrosis factor [TNF]-α and interferon [INF]-γ) using enzyme-linked immunosorbent assays in pediatric SMA patients treated at Hiroshima University Hospital over 2 years.ResultsThis study analyzed pediatric SMA patients. While the CSF inflammatory cytokines (TNF-α and INF-γ) in these SMA children were unchanged, the CHIT1 levels decreased significantly from year 1 to 2 of treatment. We also found a trend toward an inverse correlation between the motor function score (HINE-2 scores) and CHIT1 level from year 1 to 2 of treatment.ConclusionsCHIT1 may be a CSF biomarker of the treatment response in pediatric SMA.     

Striatonigral degeneration and sporadic olivopontocerebellar atrophy: a consideration of the clinical entity of multiple system atrophy]

Striatonigral degeneration (SND) and sporadic olivopontocerebellar atrophy (sOPCA) are categorized under multiple system atrophy (MSA), since these disorders have common clinical and pathological features. However, it is still uncertain whether these disorders are manifestation of the same disease. In this study, we performed both clinical and neuroradiological studies on patients with SND or sOPCA in whom clinical diagnosis was based on a criteria during eight years in our hospital. A total of forty patients had SND and thirty-one patients had sOPCA. The onset ages of patients with SND (60.7 +/- 8.7, mean +/- SD) were significantly higher than those with sOPCA (55.4 +/- 7.9). In both SND and sOPCA patients, about 20% had clinical symptoms suggesting the involvement of multiple systems: pyramidal, cerebellar, extrapyramidal and autonomic symptoms. In 55% of the SND patients, cerebellar symptoms could be observed, and the same percentage of sOPCA patients had parkinsonism. Although, as defined, cerebellar symptoms were predominant in sOPCA patients and parkinsonism was predominant in SND patients, the SND patient group was particularly homogeneous with respect to clinical characteristics. The initial symptoms of SND were parkinsonian gait or tremors. Almost all patients exhibited asymmetrical appearance of the parkinsonian symptoms, such as rigidity, tremors, and bradykinesia. Tremors at rest were observed in two-thirds of the patients with SND during the course of their illness, but dementia was infrequently observed. There was no detectable limitation in horizontal eye movements in patients with SND. The progression of the disability of patients with SND was rapid; according to the clinical rating scale of parkinsonism, the average level of disability deteriorated to Hoehn-Yahr's stage III after three years from disease onset, and then deteriorated to stage IV after four years. Neuroradiologically, only a small proportion of patients with SND (27%) showed magnetic resonance image (MRI) findings suggesting OPCA pathology, such as volume loss in the brainstem or cerebellum with/without T2-high signaling of transverse fibers of pons or T2-high signaling of the middle cerebellar peduncle. Simultaneously, a small proportion of the patients with sOPCA (20%) showed MRI findings suggesting putaminal pathology, such as T2-low intensity signals of the putamen with linear T2-high intensity signals around the lateral putamen. Our results suggest that SND and sOPCA can be clearly differentiated, at least from clinical or neuroradiological aspects. Since there is still no evidence indicating that each disorder is a clinical variant of a single disease caused by the same etiology, a differentiation might be important for future pathogenetical studies.     

Pontocerebellar hypoplasia type 1

Pontocerebellar hypoplasias are heterogeneous disorders that share a reduction in the size of brainstem and cerebellum. We describe a patient with features of the rare combination of pontocerebellar hypoplasia and spinal motor neuron disease. Parental consanguinity, low Apgar scores, facial weakness, dysphagia, tongue fasciculations, stridor, generalized hypotonia, severe muscle weakness, areflexia, and congenital joint contractures were evident. Cranial magnetic resonance imaging revealed a small cerebellum and brainstem, and a muscle biopsy revealed neurogenic changes. These abnormalities suggested pontocerebellar hypoplasia type 1.     

Nonprogressive juvenile-onset spinal muscular atrophy: A clinico-radiological and CAG repeat study of androgen receptor gene

BACKGROUND: Occurrence of nonprogressive juvenile-onset spinal muscular atrophy (SMA) predominantly in males suggests a possibility of X-linked disorder but there is no such report addressing this problem. AIMS: To evaluate CAG repeat expansion of androgen receptor (AR) gene in patients with nonprogressive juvenile-onset SMA. SETTING: Tertiary medical teaching institute. SUBJECTS AND METHODS: Patients fulfilling the diagnostic criteria of nonprogressive juvenile-onset SMA were included. Detailed clinical evaluation and pedigree charting were done in all. Nerve conduction study, electromyography and cervical spinal MRI were carried out. From peripheral venous blood, DNA was separated and AR gene CAG repeat exon polymorphism was assayed using polymerase chain reaction (PCR) in conjugation with genotyping and Gene scan soft ware. Number of CAG repeats was compared with normal controls. RESULTS: 25 patients with nonprogressive juvenile-onset SMA from 24 families were included and their mean age was 22.2 years. Age at the time of disease onset ranged between 15 and 30 years with a mean duration of illness 2.6 years. None of the patients had testicular atrophy or gynecomastia. C7-T1 myotomal wasting and weakness although was unilateral to begin with but became bilateral in 16 and 4 more patients had evidences of subclinical involvement of the other side as revealed by EMG. Spinal MRI revealed cord atrophy at C6-8 vertebral level in 16 patients. CAG repeat study of AR gene was carried out in 16 patients. The number of CAG repeats in patients ranged between 15 and 39 (median 21) which were within the normal range. CONCLUSION: Abnormal CAG repeat expansion of AR gene is not found in patients with nonprogressive juvenile-onset SMA.     

Pregnancy and spinal muscular atrophy

Summary We investigated the course and outcome of pregnancy and its influence on muscle weakness in 12 females with proximal spinal muscular atrophy (SMA) who delivered a total of 17 infants when aged 18–32 years. In 4 females the SMA clearly followed an autosomal recessive mode of inheritance. The disease was autosomal dominantly inherited in 2 patients; the other 6 were sporadic cases. Ages of onset of SMA ranged from 8 months to 29 years; all the females learned to walk, and 10 out of 12 are still ambulatory aged 30–60 years. Pregnancy and delivery were complicated in 10 out of 12 patients by premature labour (4), prolonged labour (3) and delayed postpartum recovery (6). Caesarean section was performed in 3 cases. No deleterious effects on fetal outcome could be detected. Exacerbation of muscle weakness after the second trimester of pregnancy was experienced by 8 females: 5 noticed a persistent deterioration of SMA; in 3 muscle weakness worsened temporarily during pregnancy and was followed by marked improvement in the puerperium. The psychological perceptions, in retrospect, of 10 females concerning their decision to have children were evaluated.     

Pontocerebellar hypoplasia type 3 with tetralogy of Fallot

We report a male infant with pontocerebellar hypoplasia type 3 and tetralogy of Fallot. He showed optic nerve atrophy, progressive microcephaly, severe psychomotor developmental delay, and vesicoureteral reflux. Magnetic resonance imaging revealed severe hypoplasia of the cerebellar vermis and hemisphere, and of the brainstem including the pons, and simplified gyral patterns in bilateral frontal lobes. An unknown etiology differing from other cases of PCH type 3 might have caused not only optic nerve atrophy and hypoplasia of the cerebellum and brainstem, but also cerebral and visceral malformations. To the best of our knowledge, this represents the first report of pontocerebellar hypoplasia with congenital cardiac malformation.