Poliomyelitis-like illness after acute asthma (Hopkins syndrome): a histological study of biopsied muscle in a case

Fasciculations in Children

Fasciculations are the most common form of spontaneous muscle contraction. They frequently occur in healthy individuals. However, there are a minority of situations that fasciculations are observed in association with specific neurologic disorders. Publications concerning the evaluation of pediatric patients experiencing fasciculations are limited. These children may undergo invasive or expensive diagnostic investigations that are unnecessary. Moreover, without careful consideration of differential diagnoses, rare neuromuscular disorders that present with fasciculations in the pediatric age group can be under-recognized by pediatric neurologists. This review examines the most important pediatric disorders presenting with fasciculations and other spontaneous muscle contractions to guide pediatric neurologists in evaluating these children.

Hopkins Syndrome: Post Flaccid Paralysis After an Asthma Exacerbation

We report a rare case of a 22-month-old who developed flaccid paralysis of her right arm shortly after she was hospitalized for an asthma exacerbation. There are many etiologies of acute flaccid paralysis; however, because of the uncommon presentation of a focalized finding, establishing the diagnosis of this patient was difficult in the emergency department setting. Associated with asthma exacerbations, Hopkins syndrome is a paralytic illness that resembles poliomyelitis. This case highlights the challenges of evaluating a child with monoparesis and establishing an association with asthma amyotrophy.

Hopkins syndrome following the first episode of bronchial asthma associated with enterovirus D68: a case report

Background

Hopkins syndrome (HS) is a rare disorder presenting with acute flaccid paralysis of the limbs following an asthma attack. Neurologists encounter a diagnostic challenge if patients without a history of bronchial asthma develop neurologic features mimicking HS following acute respiratory distress. We report a case of HS occurring after a first episode of bronchial asthma associated with enterovirus D68 infection.

Case presentation

A 5-year-old girl developed acute respiratory distress. On the fourth hospital day, both her legs became paralyzed except for slight muscle contraction in the right lower limb. Tendon reflexes in the lower limbs were diminished and there was a positive Babinski sign on the right. Sensation was normal in all modalities, and there was no uro-rectal disturbance. Spinal magnetic resonance imaging identified T2-hyperintense lesions with spinal cord edema, mainly involving the bilateral T11 to L1 anterior horns, with left side dominance extending to the left posterior horn. The neurological and neuro-radiological findings of our case were suggestive of HS; however, she had no history of bronchial asthma. An acetylcholine inhalation challenge eventually proved the presence of reversible airway hyper-responsiveness, allowing us to diagnose HS. We identified enterovirus D68 in the patient’s intratracheal aspirates using a sensitive polymerase chain reaction assay. Intravenous immunoglobulin administrations at 2 g/kg² for 5 consecutive days were repeated every month up to four times. After these treatments, the muscle strength of her right lower limb slightly improved while her left lower leg remained completely paralyzed.

Conclusion

This case emphasizes the importance of provocation tests to reveal the presence of airway hyper-responsiveness when a child shows neurological signs mimicking HS following acute respiratory distress. Furthermore, the present case suggests a possible link between HS and acute flaccid paralysis following lower respiratory tract infection by enterovirus D68.

Flaccid paralysis of the limbs after an asthmatic attack

Acute exacerbations of asthma are common in children, but limb weakness after such exacerbations is very unusual. Hopkins' syndrome, a poliomyelitis-like illness associated with asthma, is seldom reported in the literature. We describe a child with weakness of the lower limbs after an asthmatic attack. The clinical profile, possible pathogenesis, and treatment of Hopkins' syndrome are discussed.

Th2 shift in juvenile muscular atrophy of distal upper extremity: a combined allergological and flow cytometric analysis

Juvenile muscular atrophy of the distal upper extremity (JMADUE) is considered to be a type of flexion myelopathy; however, we recently reported cases of JMADUE associated with airway allergy successfully treated by plasma exchange. To further characterize the allergo-immunological features of JMADUE, 11 consecutive JMADUE patients in the neurology clinic at Kyushu University Hospital were studied. Past and present together with family histories of common allergic disorders were investigated. Total serum IgE was measured by an enzyme linked immunosorbent assay (ELISA) and allergen-specific IgE by a liquid phase enzyme immunoassay. Intracellular interferon (IFN) gamma-, interleukin (IL)-4-, IL-5- and IL-13-producing T cells in peripheral blood were analyzed by flow cytometry. Data from 42 healthy subjects were used as controls for allergological studies. Flow cytometric data from 21 healthy subjects were also used for comparison. The patients exhibited significantly higher frequencies of coexisting airway allergies such as allergic rhinitis (p=0.0057) and pollinosis (p=0.0064), family histories of allergic disorders (p=0.0075), and mite antigen specific IgE (p=0.0361) compared with the healthy subjects. Patients with JMADUE had a significantly higher percentage of IFNgamma-IL-4+CD4+T cells (p=0.0017), but not IL-5- or IL-13-producing CD4+T cells, and a reduced intracellular IFNgamma/IL-4 ratio in CD4+T cells (p=0.002) compared to the controls. These findings suggest that JMADUE has a significant T helper 2 (Th2) shift, which may in part contribute to the development of spinal cord damage.

Juvenile muscular atrophy of distal upper extremity associated with airway allergy: two cases successfully treated by plasma exchange

Juvenile muscular atrophy of the distal upper extremity (JMADUE) is postulated to be a type of flexion myelopathy. However, patients with typical clinical features of JMADUE but without evidence of flexion myelopathy have been reported. We recently reported a significant association of JMADUE with airway allergy. Here we report the successful treatment by plasma exchange (PE) of two patients with both airway allergy and JMADUE without evidence of flexion myelopathy. Patient 1 had a 5-year history of allergic rhinitis and high titers of mite antigen-specific IgE, and patient 2 had an 8-year history of pollinosis and high titers of cedar pollen-specific IgE. Both patients noted progressive distal muscle atrophy and weakness of the upper extremities: patient 1 for 3 months and patient 2 for 3 years. Neurologically, both showed asymmetric intrinsic hand muscle atrophy, oblique atrophy of the forearm muscles, and weakness and contraction fasciculation (minipolymyoclonus) of these muscles without any sensory impairment. Neither had any evidence of flexion myelopathy on magnetic resonance imaging (MRI) in a flexed position. Both were subjected to PE three times. Soon after the PEs, both showed improvement of distal muscle weakness of the upper extremities and marked reduction of contraction fasciculation of the forearm muscles. Patient 1 showed marked reduction in ongoing denervation potentials in the distal muscles on needle electromyography, while patient 2 showed marked improvement of F wave persistence of bilateral median and ulnar nerves. Serum total and allergen-specific IgE decreased after PEs in both patients. PE was thus considered to be effective in these two patients having JMADUE without evidence of flexion myelopathy. These observations may suggest the involvement of an immune-mediated process in the neural damage of JMADUE without evidence of flexion myelopathy, especially in patients with atopic diathesis, and may support the notion that JMADUE is etiologically heterogeneous.

A part of the ulnar nerve as an alternative donor nerve for functioning free muscle transfer: a case report

A patient with no active elbow flexion because of poliomyelitis-like syndrome underwent functioning free muscle transfer for elbow flexion reconstruction in which a part of the ulnar nerve was used as a donor motor nerve. Fourteen months after surgery the patient had achieved 120 degrees of active elbow flexion against gravity without functional deficit of the donor ulnar nerve. A part of the ulnar nerve can be used as an alternative donor motor nerve for reconstruction of chronic C5-C6 (or C5-7) brachial plexus injury.

Poliomyelitis-like syndrome following asthmatic attack (Hopkins' syndrome)--recovery associated with i.v. gamma globulin treatment

A report on a 15-year-old male with a diagnosis of poliomyelitis-like syndrome (Hopkins' syndrome) following an asthmatic attack is presented. The prognosis of Hopkins' syndrome is usually poor and the patients remain with permanent paralysis of the affected limb. The outcome correlates with severity of the initial injury to the anterior horn cell as reflected by abnormal electrophysiologic studies. This is the first case report of treatment with i.v. gamma globulin in Hopkins' syndrome which resulted in a nearly complete recovery.