Marked Facial Weakness, Ptosis, and Hanging Jaw: A Case with RYR1 -Related Congenital Centronuclear Myopathy

Congenital myopathies are an expanding spectrum of neuromuscular disorders with early infantile or childhood onset hypotonia and slowly or nonprogressive skeletal muscle weakness. RYR1 -related myopathies are the most common and frequently diagnosed class of congenital myopathies. Malignant hyperthermia susceptibility and central core disease are autosomal dominant or de novo RYR1 disorder, whereas multiminicore, congenital fiber type disproportion and centronuclear myopathy are autosomal recessive RYR1 disorders. The presence of ptosis, ophthalmoparesis, facial, and proximal muscles weakness, with the presence of dusty cores and multiple internal nuclei on muscle biopsy are clues to the diagnosis. We describe an 18-year-old male, who presented with early infantile onset ptosis, ophthalmoplegia, myopathic facies, hanging lower jaw, and proximal muscle weakness confirmed as an RYR1 -related congenital centronuclear myopathy on genetic analysis and muscle biopsy.

A Randomized, Controlled, Noninferiority Trial Comparing Vitamin B12 Monotherapy Versus Combination Multinutrient Therapy with Vitamin B12 for Efficacy in Treatment of Infantile Tremor Syndrome

OBJECTIVES

To compare the mean Likert (caregiver impression of change) and CAPUTE scores in children with ITS treated with daily injectable vitamin B12 alone versus injectable vitamin B12 with other multinutrients at 1 wk and 1 mo of therapy.

METHODS

This was an open-label, active-controlled, assessor-blinded, noninferiority, randomized clinical trial. The participants included children aged 3 mo to 2 y with infantile tremor syndrome. Children were randomized to receive either 1 mg of daily injectable vitamin B12 or 1 mg of daily injectable vitamin B12 with other multinutrients (B12 + MV). Primary outcome measure was the mean Likert score in the two arms at 1 wk. Secondary outcome measures were mean change in CAPUTE scores at 1 wk of therapy; and mean change in CAPUTE and Vineland Social Maturity Scale (VSMS) scores after 1 mo of treatment.

RESULTS

Seventy-two (N = 72) of the 160 screened were enrolled and randomized. The mean (SD) Likert score in the B12 group (n = 38) was 16.1 (3.7) and in the B12 + MV group (n = 34) was 14.9 (3.7); p = 0.237. Mean (SD) change in CAPUTE (CAT/CLAMS) at 1 mo in the groups was not statistically different. The mean (SD) change in social quotient in the B12 monotherapy group, 35.0 (20.7) was significantly higher than the B12 + multinutrient group 23.5 (15.4); p=0.01.

CONCLUSION

Injectable vitamin B12 monotherapy in ITS resulted in an improvement that was noninferior to combination multinutrient therapy, strongly supporting vitamin B12 deficiency as the cause of infantile tremor syndrome.

TRIAL REGISTRATION

The trial was registered at CTRI.org (CTRI/2018/05/013841).

Peripheral Neuropathy in Children With Chronic Kidney Disease: Are We Looking Enough?

Background:

Peripheral neuropathy in chronic kidney disease (CKD) is the most common neurological complication. We aimed to look at the prevalence and patterns of neuropathy in children with CKD.

Methods:

This cross-sectional study was conducted over 1 year in children with CKD, stage III and above. Nerve conduction studies (NCS) were performed as per standard protocols using surface electrodes on the muscles and by supramaximal stimulation of the corresponding nerves. Presence of electrophysiological abnormalities in the absence of clinical symptoms or signs was considered as subclinical neuropathy.

Results:

Nearly 45 children were evaluated. The majority were males (n = 39, 86.7%). The mean age was 7.9 ± 3 years (range 2–14). The mean estimated glomerular filtration rate (GFR) at enrolment was 23.3 ± 14.6 mL/min/1.73 m² (range 5–67). The majority of children were in stage III (n = 19, 42%), followed by stages V (n = 15, 33%) and IV (n = 11, 25%). There was no evidence of clinical neuropathy; 13 children (29%) showed subclinical neuropathy. All the nerves had an axonal pattern of involvement. Motor polyneuropathy was most common type of peripheral neuropathy. The commonest nerves involved were tibial and common peroneal nerves. There were no biochemical or clinical predictors of neuropathy in our cohort.

Conclusion:

The prevalence of subclinical neuropathy is high in children with CKD, stage III and above. Axonal motor polyneuropathy is the predominant pattern. Electrophysiological assessment of nerve function should be routinely done in children with advanced stages of CKD to prevent chronic complications.

POS1262 A COHORT STUDY OF COVID-19 RELATED MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN AND ADOLESCENTS FROM MULTIPLE TERTIARY CARE CENTRES IN SOUTH INDIA

Background:

After the peak of COVID 19 pandemic, a surge of cases with multi-system involvement and hyperinflammatory state was reported in children, at multiple tertiary care centers across the world. (1) This COVID-19 associated multisystem inflammatory syndrome in children and adolescents is also known as multisystem inflammatory syndrome in children (MIS-C). There is a paucity of literature of clinical profile of MIS-C patients from India.

Objectives:

To study the clinical manifestations and treatment outcomes of COVID-19 related multisystem inflammatory syndrome in children (MIS-C) and adolescents.

Methods:

It was a cohort study including cases defnied as per the case definitions of MIS-C by World Health Organisation (WHO) or Centre for Disease Control and Prevention(CDC).(2)The clinical parameters, laboratory parameters (including inflammatory markers, D dimer and NT ProBNP), electrocardiogram, 2D echocardiogram, course in hospital, and immediate outcomes were noted.

Results:

Twenty five patients (male-14) with a mean age of 6.22 ±4.25 years and a mean body mass index of 16.21 ±3.36 kg/m2 were enrolled on the study. Average length of hospital stay was 8.12±5.76 days. Associated comorbidities were present in 4 of our patients (16%). Figure 1 shows the frequency of clinical features in our study patients. Table 1 shows the clinical, laboratory, imaging findings, disease course and outcomes.

Figure 1.

Frequency of clinical features in our MIS-C cohort patients

Table 1.

Clinical characteristics of MIS-C patients (n)=25

Clinical Phenotypes:Incomplete/ Atypical Kawasaki Disease (KD)18 (72%)Macrophage activation syndrome (MAS)11 (44%)Unexplained Shock13 (52%)Fever with gastrointestinal symptoms17 (68%)Fever with neurological symptoms9 (36%)Fever with respiratory symptoms5 (20%)COVID chronology:MISC with acute COVID 19 with MAS1 (4%)MISC with acute COVID 19 with incomplete/atypical KD1 (4%)COVID 19 tests:COVID 19 RTPCR positive2 (8%)COVID 19 RTPCR negative23 (92%)COVID 19 IgG positive20 (80%)COVID 19 IgM positive6 (24%)COVID 19 IgG and IgM both positive2 (8%)COVID 19 IgG and IgM not done4 (16%)Other laboratory investigations(Peak/ trough values):Anaemia20 (80%)Leukopenia2 (8%)Thrombocytopenia6 (24%)Pancytopenia2 (8%)Positive CRP23 (92%)High Procalcitonin9 (36%)High ferritin10 (40%)High D- dimer17 (68%)High NT ProBNP23 (92%)Hypoalbuminemia14 (56%)Sterile pyuria7 (28%)Proteinuria4 (16%)Cardiac assessment:Abnormal Electrocardiogram (ECG)5 (20%)Abnormal Echocardiography15 (60%)Coronary dilation/prominence/non-tapering9 (36%)Coronary aneurysm1 (4%)LAD Z score (Mean±SD)2.12 ± 1.11Decreased Ejection fraction (EF)5 (20%)Systolic Dysfunction5 (20%)Pericardial effusion9 (36%)Global/septal hypokinesia4 (16%)Mitral Valve regurgitation3 (12%)Complete heart block1 (4%)

Twenty patients (80%) had severe illness requiring intensive care. Fourteen patients (56%) required inotropic support, 8 patients (32%) required supplemental oxygen, 5 patients (20%) required mechanical ventilation and 2 patients (8%) expired. A total of 23 patients (92%) received pulse steroids followed by oral/iv steroids, 22 patients (88%) received IVIG (2g/kg) and 3 patients (12%) required anticoagulation.

Conclusion:

Our MIS-C cohort had varied clinical manifestations ranging from the mild cutaneous and gastrointestinal symptoms to fatal multiorgan dysfunctions. In contrast to western cohorts, our study cohort had higher number of patients from younger age group and lower BMI.

References:

[1]Ahmed M, Advani S, Moreira A, Zoretic S, Martinez J, Chorath K et al. Multisystem inflammatory syndrome in children: A systematic review. EClinicalMedicine. 2020;26:100527.

[2]Jiang L, Tang K, Levin M, Irfan O, Morris S, Wilson K et al. COVID-19 and multisystem inflammatory syndrome in children and adolescents. The Lancet Infectious Diseases. 2020;20(11):e276-e288.

Disclosure of Interests:

None declared

The expanding spectrum of dystrophinopathies: HyperCKemia to manifest female carriers

Background:

X-linked dystrophinopathies have a wide spectrum of manifestation. The most common forms are severe Duchenne muscular dystrophy (DMD) and Becker’s muscular dystrophy (BMD). However, less common manifestations are isolated cardiomyopathy, myalgia, cramps, rhabdomyolysis, hyperCKemia, and manifest female carriers.

Materials and Methods:

This case series is a part of an ongoing long-term prospective cohort of children with DMD and BMD from the year 2013. The clinical details are maintained in the clinic files and standard management protocols are followed. For this case series, clinical details were collected from the clinic files and recorded on a case record proforma. Details of cardiology, radiology, and genetic investigations were collected.

Results:

We report cases of classical DMD, BMD, manifest female carrier with proximal pelvic girdle weakness, a female carrier with isolated dilated cardiomyopathy, and infantile-onset asymptomatic hyperCKemia. We also report less common but notable clinical presentations of DMD, autism, intellectual disability, epilepsy, and asymptomatic transaminitis.

Conclusions:

It is important for clinicians to be aware of these less common clinical presentations for prompt diagnosis, and to avoid unnecessary investigations. Here, we report the clinical spectrum of dystrophinopathies seen in pediatric neuromuscular clinic and emphasize the variability and expanding knowledge about different manifestations of dystrophinopathies.

Familial hypercholesterolaemia IIA with bicuspid aortic valve

A young male presented with multiple xanthomas and xanthelesmas, progressive breathlessness and angina on exertion. Investigations confirmed diagnosis of familial hypercholesterolaemia, bicuspid aortic valve with severe aortic stenosis and significant obstructive coronary artery disease.

The coming of age of a joint elderly medicine-psychiatric ward: 18 years' experience

INTRODUCTION

There is a large population of elderly medical inpatients with co-existent medical and mental health disorders who pose a significant management challenge for medical, nursing and allied staff. Our hospital has a joint elderly medicine-psychiatry unit to cater for this patient group; this article reviews how this unit was set up and presents a representative sample of inpatients.

RESULTS

The mean age was 81 years with a female preponderance. The mean length of stay was 44 days. The commonest medical conditions were cerebrovascular disease, urinary tract infections, chest infections and falls. The commonest mental health diagnoses were cognitive impairment, delirium and depression. The mortality rate was 21%; of the remainder, 55% were discharged to long-term care, 40% returned home and 5% were transferred to the local psychiatric hospital.

DISCUSSION

This cohort of elderly patients has complex medical, nursing and therapy needs in addition to complex discharge planning needs. Our unit has a shared care approach, with joint responsibility shared by a consultant in Medicine for the Elderly and a Consultant in Old Age Psychiatry. This, in combination with a multidisciplinary team approach, provides an effective means of delivering care to this patient group.

CONCLUSION

A joint elderly medicine-old age psychiatry ward provides a high standard of care for elderly patients with co-existent physical and mental health needs. We hope that the information presented in this article will be of use to those hoping to set up a similar unit in their own hospitals.

A survey of physiotherapy and occupational therapy provision in UK nursing homes

BACKGROUND

Nursing homes in the UK are increasingly regarded as potential rehabilitation facilities for disabled older people.

OBJECTIVE

To determine the current physiotherapy and occupational therapy provision to UK nursing homes.

SAMPLE

Four hundred private nursing homes in England, Scotland and Wales were selected by stratified proportional random sampling and surveyed by postal questionnaire.

RESULTS

The response rate for the effective sample was 346/355 (97%). Only 10% of residents were in current receipt of physiotherapy, mostly through private physiotherapists employed by the nursing homes. Occupational therapy was being provided to only 3.3% of residents.

CONCLUSION

Older people in nursing homes in the UK currently receive little physiotherapy and occupational therapy input and are particularly isolated from National Health Service (NHS) services.

Tumor cell toxicity of hypericin and related analogs

A series of hypericin analogs were found to differ in their cytotoxic activity induced by ambient light levels. These analogs vary in their ability to partition into cells, to generate singlet oxygen as well as in other photophysical properties. The data suggest that the biological activity of hypericin is due to a combination of factors whose roles may vary under different circumstances.

Identification of a vibrational frequency corresponding to H-atom translocation in hypericin

Using time-resolved infrared spectroscopy, ab initio quantum mechanical calculations and synthetic organic chemistry a region in the infrared spectrum of triplet hypericin has been found between 1400 and 1500 cm-1 corresponding to the translocation of the hydrogen atom between the enol and the keto oxygens, O...H...O. This result is discussed in the context of the photophysics of hypericin and of eventual measurements to observe directly the excited-state H-atom transfer.

An unusual tumour metastasis to the cervix

INTRODUCTION

The vast majority of tumours in the cervix are either primary carcinomas or direct extension of primary tumours from nearby sites such as the endometrium, myometrium, rectum and bladder. Patients usually present with abnormal bleeding, pain and dyspareunia. A smaller number of patients are asymptomatic and their tumours can be diagnosed early by PAP smears.

CLINICAL PICTURE

We present an unusual case of an elderly lady with breast cancer that had metastasized to the cervix 4 years after primary treatment of the breast malignancy. Although the appearance of the cervix was "normal looking", it was firm and indurated on palpation.

PATHOLOGY

A definite diagnosis of metastatic infiltration could only be made by colposcopic biopsy. Early PAP smears had shown some abnormal cells suggestive of metastatic lobular carcinoma but were not conclusive of metastasis from breast carcinoma. Subsequent bone scans and CT scans of the abdomen revealed metastatic lesions in the skull, spine, left femoral shaft and liver.

Meningioma with rhabdoid transformation

A 29-year-old man was operated on for an intracranial tumour with the gross features of a meningioma. Histology showed features of a rhabdoid tumour. The tumour recurred in 1997, 17 months after the first operation, and was re-excised and showed identical histology. Meningiomas with rhabdoid change are very rare. The clinicopathologic features are presented and the differential diagnoses discussed.

The effects of lipid extraction on the immunomodulatory activity of Malassezia species in vitro

Malassezia spp. are believed to be the causative agents of pityriasis versicolor and are strongly implicated in seborrhoeic dermatitis. The yeast also forms part of the normal human cutaneous microflora. We have previously shown that when Malassezia yeast cells are incubated with human peripheral blood mononuclear cells (PBMCs), they are capable of reducing the levels of pro-inflammatory cytokines produced. In order to test the hypothesis that this immunoevasive phenomenon may be related to the unusually high level of lipid in the Malassezia yeast cell wall, we have compared the immunomodulatory capacity of normal and lipid-depleted yeast cells. Stationary phase yeast cells of Malassezia sympodialis, M. globosa and M. restricta were treated with chloroform/methanol to extract the surface lipids. The lipid-depleted and non-depleted yeast cells were then co-cultured with human PBMCs from three different human donors at a ratio of 20 yeasts per leukocyte for 24 h. The levels of interleukin (IL)-1beta, IL-6 and tumour necrosis factor (TNF)-alpha were then determined by enzyme-linked immunosorbent assay (ELISA). The results demonstrated that extraction of lipid reversed the yeast cell capacity to reduce the levels of pro-inflammatory cytokines. The levels of IL-1beta, IL-6 and TNF-alpha produced in response to lipid-extracted Malassezia of all three species were either no different from or significantly greater (P < 0.05; ANOVA) than the constitutive control levels. These results suggest that the lipid microfibrillar layer of Malassezia may prevent the yeast cells from inducing inflammation and provide an explanation for the normal commensal status of the organism on human skin. The hypothesis that the lipid layer is absent or altered in seborrhoeic dermatitis may provide an explanation for the inflammatory nature of this dermatosis.

Serotonin syndrome with fluoxetine plus tramadol

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Now wash your hands? A survey of hospital handwashing facilities

We studied the adequacy of handwashing facilities on elderly-care wards in seven UK hospitals. We found 10.9% of sinks were inaccessible, 12% of sinks did not have any cleansing agent, 93.2% of ward sinks and 79% of treatment room sinks had no antiseptic agent. We conclude that in our survey, handwashing facilities were inadequate and have suggested a standard checklist for hospital sinks.

The effects of Malassezia on pro-inflammatory cytokine production by human peripheral blood mononuclear cells in vitro

Malassezia spp., the causative agents of pityriasis versicolor, are members of the normal human cutaneous microflora. Utilizing a combination of both enzyme-linked immunosorbent assay (ELISA) and bioassay, we have investigated the ability of both formalin-preserved and viable Malassezia (serovars A, B and C) to modulate pro-inflammatory cytokine (IL-6, IL-1beta and TNF-alpha) release by human peripheral blood mononuclear cells (PBMNC) in vitro, over a 48-h co-incubation period. The results demonstrated that formalin-preserved Malassezia (serovars A, B and C) at mid-exponential phase were generally able to induce a pro-inflammatory cytokine response at a yeast cell to PBMNC ratio of 1:1. In addition, the results consistently demonstrated that at a yeast cell to PBMNC ratio of 20:1, formalin-preserved Malassezia, irrespective of serovar, growth phase or PBMNC donor, were capable of significantly (P<0.05) decreasing the release of both immunochemical IL-6 and IL-1beta plus bioactive IL-1beta and TNF-alpha below that of unstimulated culture medium control values. This was apparent following 24- and 48-h co-incubation times, where maximal cytokine production was detected after 24 h. Similar results were obtained for the effect of viable Malassezia on pro-inflammatory cytokine release by PBMNC. Our results suggest that a possible inhibitory component, present perhaps within the cell wall of Malassezia, was responsible for this depressive effect on pro-inflammatory cytokine production.