Difficulties in the neonatal diagnosis of Menkes' kinky hair syndrome--trichopoliodystrophy

The recognition of Menkes' kinky hair syndrome, trichopoliodystrophy, may present problems in the early neonatal period. The serum copper, and ceruloplasmin levels are within the range of normal infants in the first week of life; they are higher than normal in the cord blood of affected infants and fall gradually. Pili torti may only develop later, as the primary fetal hair is normal. The baby may appear bald, or both normal and abnormal hair may be found in different areas of the skull. The roentgenographic signs of wormian bones in the skull, metaphyseal spurring of the long bones, and diverticuli of the bladder develop progressively and may not be seen until after 6 weeks of age. However, diagnosis is possible in the neonatal period, if male infants with unexplained hypothermia, hypotonia, septicemia, or seizures are investigated by serum copper and ceruloplasmin levels after 1 month of age.

Optiz trigonocephaly syndrome: report of two cases

We report two patients with Opitz trigonocephaly syndrome. Both children showed the pattern of abnormal findings characteristic of this syndrome, including trigonocephaly, upslanted palpebral fissures, inner epicanthic folds, broad alveolar ridges, small chin, short neck with loose skin, muscular hypotonia and cardiac defect. An 8-week-old girl had multiple gingival frenula, brachydactyly, syndactyly of toes and anal stenosis in addition, while a boy who died at 28 h from cardiac failure showed multiple joint contractures, cryptorchidism and renal cortical cysts.

Rett syndrome--clinical studies and pathophysiological consideration

Eleven female patients with Rett syndrome were evaluated for detecting the pathogenesis. Clinical symptoms were characterized by their orderly sequence of occurrence of particular symptoms at particular ages starting from early infancy, and their progression. Increment of head circumference tapered from late infancy, resulting in microcephalus which corresponded with the clinical features. Surface EMG revealed the tremulous rhythmic discharge underlying the characteristic stereotyped movement of the hands. Serial polysomnographical examinations showed abnormalities of the tonic and phasic components of sleep and increment of % REM stage with age. The results of these clinical, laboratory and polysomnographical examinations were discussed, comparing with other neurological diseases and knowledge of animal experiments. From these findings the pathophysiology of Rett syndrome could be explained by the early and progressive lesions in the brain stem nuclei, which influence the maturation and function of particular parts of the higher central nervous system. Serotonergic and catecholaminergic neurons might have important roles in the pathophysiology of this syndrome. However, biochemical and histochemical examinations of the brain are necessary for detecting the pathogenesis and etiology. And the cause of gynecopathy also remains to be clarified.

[Value of electromyography in the child. Apropos of 1,624 examinations performed over a 3 year period]

EMG and nerve conduction studies have limitations and require particular consideration in children. The indications and the main results are considered from the study of 1624 EMGs in 1385 children under 15 years old seen over a period of 3 years. Classification of cases was based on clinical criteria. The diagnostic yield of EMG is emphasized in the evaluation of 122 children with hypotonia and weakness (all under 3 years old); abnormalities were demonstrated in 48% leading to the diagnosis of spinal muscular atrophy in 16%, of congenital myopathies in 11%, and of peripheral neuropathies in 8%. In 103 children with hypotonia associated with mental deficiency and/or seizures, evidence of a peripheral neuropathy was shown in 20%. EMG abnormalities allowing the diagnosis of hereditary motor and sensory neuropathies or myopathies were demonstrated in a wide range of clinical conditions. EMG appears to be useful for the early detection of hereditary myopathies or neuropathies in asymptomatic children. It may have also a prognostic value as in adults, especially in nerve traumas.

Congenital autonomic dysfunction with universal pain loss

Three patients who appear to have a previously undescribed congenital neuropathy are described. None is of Ashkenazi Jewish extraction, but each seems to fulfill the clinical diagnostic criteria for familial dysautonomia. All lack overflow tears, fungiform papillae, and deep-tendon reflexes; intradermal administration of histamine did not produce an axon flare. Intraocular instillation of dilute mecholyl produced miosis in the one patient tested. In contrast to patients with familial dysautonomia, the three patients had universal loss of pain sensation, profound hypotonia, and unusual facies. Pathologic examination of the sural nerve in one patient was not consistent with the usual findings in familial dysautonomia. These patients are believed to have a previously undescribed congenital neuropathy.

Hand weakness in the elderly

Hand weakness is an important but frequently overlooked problem in the elderly. The exact diagnosis is often difficult because of the complexities of innervation and muscle function. An anatomic approach to the diagnosis of isolated hand weakness in the elderly is presented. Causes, evaluation, and therapy for various forms of this symptom are reviewed.

A method for detecting functional weakness

A simple electrophysiological method is described for detecting weaknes of psychiatric origin. The method involves the interpolation of a single indirect stimulus to a muscle during the course of a supposedly maximal voluntary contraction. Incomplete motor activation is revealed by the presence of a twitch superimposed on the recording of voluntary torque.

The Eaton-Lambert syndrome

The Eaton-Lambert syndrome is a non-metastatic manifestation of oat-cell carcinoma of the bronchus, although it has been reported in patients with carcinoma at other sites. The clinical picture is usually one of subacute muscular fatiguability with weakness and wasting affecting the proximal parts of the limbs and trunk, but occasionally the external ocular and bulbar muscles are involved. The weakness is often myasthenic, but it has been observed that muscle power may in fact increase after brief exercise. The pathogenesis, diagnosis, electrophysiological features and some aspects of therapy are reviewed.

Fetal muscle characteristics in nemaline myopathy

In addition to the intracytoplasmic rods in approximately 1/4 muscle fibers, there were a large number of fibers with fetal muscle characteristics in a female infant who had severe muscle weakness and hypotonia, and failure to thrive since birth. A histochemical examination disclosed abnormal distribution in muscle fiber types including remarkable type 1 fiber predominance and increased number of type 2 C fibers (11.4%). Scattered throughout were fibers consisting of multiple myocytes enclosed in a single basement membrane, and small-calibered fibers containing abundant intermediate (skeleton) filaments and dispersed microtubules. Both were histologically identical to premature fibers found in the fetal muscle. The existence of an increased number of satellite cells as compared with age-matched controls was also suggestive of delayed or arrested muscle fiber maturation. A certain impaired neural influence upon the developing muscle is probably responsible for producing abnormal fiber type distribution and immature small-calibered fibers which account for small muscle bulk and muscle weakness in nemaline myopathy.

The diagnostic value of electromyography in infantile hypotonia

There is controversy over the usefulness of electromyography (EMG) in the examination of hypotonic infants with suspected neuromuscular disease. We compared the initial EMG findings of 51 such children under 1 year of age with their final clinical diagnoses determined by independent means. The EMG predicted the final diagnosis in 82% of infants less than 4 months of age and 85% of those over 4 months of age. Botulism was correctly identified by EMG in nine of 11 cases. The EMG diagnosis was identical to that obtained by muscle biopsy in 64% of cases in which biopsy was done, and diagnosis obtained by the two methods were inconsistent in only 14%. Electromyography is a sensitive and noninvasive diagnostic tool for the diagnosis of neuromuscular disease in infantile hypotonia.

Ultrasound imaging in the diagnosis of muscle disease

A comparative study has been done of the static B-scan ultrasound appearance of the quadriceps muscle of the thigh in 60 new patients attending our muscle clinic and in 60 control children. In the control subjects there was good visualization of bone and fascia, which stood out clearly against the background of echo-free muscle tissue. Striking change was found in children with neuromuscular disease. Muscular dystrophies were associated with an increase in the intensity of echo reflected from the muscle substance, with corresponding loss of bone echo. Spinal muscular atrophies and neuropathies also showed an increase in muscle echo along with atrophy of the muscle and increase in depth of subcutaneous tissue. Various congenital myopathies also showed changes. Infants with hypotonia from nonneuromuscular causes had normal scans. Severity of change on the scan did not relate to functional disability, and some children had good function yet strikingly abnormal scans. Three degree of change on the scan correlated with the degree of disruption of muscle architecture on biopsy. Ultrasound imaging has proved to be a useful, noninvasive screening tool in the investigation of children with neuromuscular disease.

[Biocybernetic tests on the identification and mathematical modelling of the motor regulation system and its disorders]

By means of the biocybernetically conceived step and impulse loads on the forearm the motor postural regulation of healthy test persons and neurological patients with rigor, spasticity and flaccid pareses of slight degree, respectively, were examined. The analysis of the forms of the transient processes rendered possible a significant differentiation of the groups of test persons and patients. With the help of the mathematical mode the response curves of healthy test persons as well as of patients could be simulated with sufficient exactness. Apart from the step and impulse loads psendorandom binary series of test signals are particularly suitable for the analysis of the motor postural regulation.

Hypotonia in infants and children

Many diseases in the pediatric population present with hypotonia and/or weakness. In order to ensure proper diagnosis and facilitate appropriate treatment, the nurse must be familial with those diseases which produce motor unit dysfunction in infants and children; among these conditions are infantile botulism and Guillain-Barré Syndrome. An understanding of the particular features which distinguish central from peripheral hypotonia is essential for the nurse. It is also important to obtain detailed histories and to ensure thorough physical examination. The nurse should also be aware of those laboratory studies that evaluate hypotonia and weakness, including the EMG, PNCT, muscle biopsy, and lumbar puncture.

Guidelines for neurological consultation

Referral to specialists for care which requires expert knowledge is a common occurrence in primary care. The role of the nurse practitioners is often to make judgments about the need for such referrals, seek appropriate specialists, prepare records and the patient for the referral and maintain contact with patient once expert advice and diagnosis is complete. This article specifically addresses the referral of patients with neurologic problems. Emphasis is placed upon general rules relating to how to refer and how to determine the need for referral. Some common complaints of ambulatory proteins which may need referral such as headache, dizziness the difference between those complaints which need referral and those that do not.

Mental retardation, hypotonia, obesity, ocular, facial, dental, and limb abnormalities (Cohen syndrome). Report of three patients

Three patients with features of the Cohen Syndrome are reported. Main facial features are prominent nasal bridge, short philtrum, prominent upper central incisors, and retrogenia. There is microcephaly and short stature. Truncal obesity appears in mid childhood. Mental retardation seems to be severe. There is marked variability among the as yet reported cases. The best diagnostic criteria seem to be the typical face and mental retardation. As yet 3 affected sibs, offspring of healthy, non consanguineous parents are reported, as well as 8 sporadic cases. The condition seems inherited as auto-somal recessive. The variability of this condition is discussed.

[Head and brain injury in a patient with familial paroxysmal hypokalaemic paralysis (author's transl)]

The case of severe skull and brain injury is reported in a patient with known familial paroxysmal hypokalaemic paralysis. Multiple cerebral contusions were seen in the brain trauma. The central nervous function could not be clearly determined since the patient had a hypokalaemic state at the time of admission to the hospital. Only electroencephalographic follow-up studies could reveal the central nervous function at that time.

Electromyographic assessment of neonatal muscle tone

A new psychiatric research method for measuring infant muscle tone using quantified electromyography is described. Muscle tone was assessed electromyographically from the arms and legs of 44 neonates; 18 offspring of drug abusing women, 26 control infants. Infants from the drug group had higher muscle tone than control infants. There was also a tendency for smaller infants and females to have higher muscle tone. Electromyographic assessments of tone were correlated with examiners' clinical assessments, but tended to be more sensitive to tone in specific muscle groups.

Premenstrual periodic paralysis

A 17-year-old girl suffered from episodes of flaccid paralysis during each menstrual cycle. No relevant changes were found in potassium concentrations in serum or erythrocytes, nor in the values of pituitary, ovarian, adrenal or thyroid hormones. Acetazolamide administration prevented the attacks.

Flaccidity after head injury: diagnosis, management, and outcome

Upon admission, 17 of 223 (8%) consecutive patients with severe head injury exhibited a flaccid, wholly unresponsive motor examination. In this study alcoholic intoxication neither caused depressed motor responsiveness in head-injured patients with high serum ethanol levels nor accounted for the motor examination in those exhibiting the flaccid state. Flaccidity was attributed principally to impaired ventilation in 4 patients, a major intracranial mass in 12, and a spinal cord injury in 1. Compared to the larger group of head-injured patients, the flaccid patients had a significantly greater incidence of hypercapnia (P less than 0.001), acidosis (P less than 0.01), and both elevated and uncontrollable intracranial pressure (ICP) (P less than 0.001). These findings and the high mortality rate (76%) in this study suggest that the magnitude of respiratory complications and the severity of mechanical brain injury are greater in flaccid patients. The flaccid patients undergoing surgical decompression for major intracranial mass lesions (11 cases) have all died and, although still small in number, this group may represent an important subset with a poor prognosis. Nonetheless, a protocol that encourages rapid radiological and electrophysiological assessment and vigorous surgical and ICP management until the probable cause of flaccidity is identified and treated has benefit. The flaccid state was reversed and a good recovery was attained after the restoration of blood pressure and/or ventilation in 2 patients who appeared to have sustained a very grave head injury. In another patient, absent somatosensory evoked potentials greatly facilitated the diagnosis of a spinal subdural hematoma. This program of prompt diagnosis and intense therapy did not result in a protracted course or undue numbers of severely brain-damaged survivors.

Ponto-bulbar palsy with deafness (Brown-Vialetto-Van Laere syndrome)

The authors describe the clinical and electrophysiological features in 2 cases of ponto-bulbar palsy with deafness, and the clinical course and post-mortem findings in a sibling of one of these, who died in infancy, and who appears to have suffered from the same disease. The cases are compared with 17 previously published cases, and the disease is discussed in relation to other progressive neurological diseases of childhood.

[Male idiopathic bladder atonia--origin of occasional failures of bladder neck operations]

The rare idiopathic atony of the urinary bladder in man becomes important when it determines the failure of an operation of the neck of the vesicle. Among 200 patients with vesical retention after all 5 cases of primary weakness of the detrusor were found. The compulsory cystomanometry is often not possible during the normal consulting hours or the clinical work on account of the more and more increasing number of patients with diseases of the neck of the vesicle. The measuring of the maximum miction pressure during the endoscopic examination is recommended as screening without greater expenditure.

The group of hypotonic schizophrenics

The physical and psychological characteristics of hypotonic schizophrenic children are described. It is hypothesized that hypotonic schizophrenia constitutes a homogeneous subgroup within the schizophrenic spectrum. The criteria for diagnosing hypotonic schizophrenia are stated. By selecting a homogeneous subgroup of schizophrenic patients, investigators may improve the probability of identifying a common biochemical etiology within this subgroup.

[Clinical aspects and therapy of Landry's paralysis]

On the basis of an analysis of 56 acute cases of polyneuritis of the Landry type treated in a period of 15 years at a neuropsychiatric intensive care unit, an attempt is made to establish relations between spinal fluid findings, kind of the course of the disease, rate of development of paralyses and the prognosis. According to the results of the examinations, the spinal-fluid findings cannot be attributed a prognostic significance. It appears, however, remarkable that the group of patients with a high rate of spreading of the pareses showed both the highest mortality and full remission rates. On the basis of own experiences and compilation of intensive medical literature, the most frequent complications of the disease and its therapy problems are dealt with.