Metronidazole-Induced Acute Cerebellitis in a Young Patient: Unusual Onset, Delayed Remission, and Characteristic Imaging Features

Metronidazole-induced acute cerebellitis is an exceptionally rare condition resulting from severe adverse reactions to metronidazole, a medication generally employed in the management of infections caused by anaerobic microbes. Although neuropathy has been linked to metronidazole use, reports of acute cerebellitis are infrequent. The neurological effects associated with metronidazole can include weakness, dysarthria, postural instability, seizures, giddiness, vertigo, ataxia, confusion, encephalopathy, headaches, and tremors. The onset of cerebellitis can vary, occurring as early as one day or after several weeks of metronidazole treatment. This article presents a case of a young girl who presented to us with weakness in both upper and lower limbs, dysarthria, and postural instability after exposure to 12 grams of metronidazole (suicidal, 30 tablets of 400 mg). With the above-mentioned complaints, the patient was advised of magnetic resonance imaging of the brain, which showed the features of cerebellitis.

Interpreting a Delayed Workup of Idiopathic Inflammatory Myopathy

Idiopathic inflammatory myopathies are a widely heterogeneous group of muscle diseases and encompass multiple clinicopathologic entities. Our case presentation describes a 70-year-old male who presented with progressively worsening dyspnea, along with worsening proximal muscle weakness in the bilateral lower extremities. Extensive clinical evaluation revealed a creatine kinase level of 105 IU/L, severe and chronic widespread myopathy seen on electromyography (EMG), and asymmetric but widespread muscle atrophy with fibro-fatty replacement seen on ultrasonography. Muscle biopsy specimen from the left deltoid was suboptimal but demonstrated characteristics that could be consistent with several clinicopathologic diagnoses, including sporadic inclusion body myositis (sIBM), immune-mediated necrotizing myositis (IMNM), antisynthetase syndrome (AS), and direct toxin-induced myopathy. Electron microscopy revealed tubulofilamentous inclusion associated with autophagic debris, finally rendering an accurate diagnosis. This case summary highlights the testing workflow required to diagnose a patient with an inflammatory myopathy and outlines the difficulty in establishing a diagnosis when the workup for an inflammatory myopathy is delayed and the muscle biopsy is suboptimal.

Functional electrical stimulation cycling-based muscular evaluation method in mechanically ventilated patients

BACKGROUND

Intensive care acquired muscle weakness is a common feature in critically ill patients. Beyond the therapeutic uses, FES-cycling could represent a promising nonvolitional evaluation method for detecting acquired muscle weakness.

OBJECTIVES

To assess whether FES-cycling is able to identify muscle dysfunctions, and to evaluate the survival rate in patients with detected muscle dysfunction.

METHODS

A prospective observational study was carried out, with 29 critically ill patients and 20 healthy subjects. Maximum torque and power achieved were recorded, in addition to the stimulation cost, and patients were followed up for six months.

RESULTS

Torque (2.64 [1.53 to 4.81] vs 6.03 [4.56 to 6.73] Nm) and power (3.31 [2.33 to 6.37] vs 6.35 [5.22 to 10.70] watts) were lower and stimulation cost (22 915 [5069 to 37 750] vs 3411 [2080 to 4024] μC/W) was higher in patients compared to healthy people (p < 0.05). Surviving patients showed a nonsignificant difference in power and torque in relation to nonsurvivors (p > 0.05), but they had a lower stimulation cost (4462 [3598 to 11 788] vs 23 538 [10 164 to 39 836] μC/W) (p < 0.05). In total, 34% of all patients survived during the six months of follow-up. Furthermore, 62% of patients with a stimulation cost below 15 371 μC/W and 7% of patients with a stimulation cost above 15 371 μC/W survived.

CONCLUSIONS

FES-cycling has good sensitivity and specificity for detecting muscle disorders. Critical patients have low torque and power and a high stimulation cost. Stimulation cost is related to survival. A low stimulation cost was related to a 3 times greater chance of survival.

Hypokalemic Periodic Paralysis: A Rare Case of a Descending Flaccid Paralysis

Hypokalemic periodic paralysis (HPP) is an uncommon condition resulting from channelopathy, impacting skeletal muscles. It is distinguished by episodes of sudden and temporary muscle weakness alongside low potassium levels. The normalization of potassium resolves the associated paralysis. Most of these cases are hereditary. Few cases are acquired and are associated with an etiology related to endocrine disorders (e.g., thyrotoxicosis, hyperaldosteronism, and hypercortisolism). It is characterized by acute flaccid paralysis, usually of the ascending type, affecting the proximal region more than the distal region. Herein, we report the case of a 29-year-old male who instead of the ascending type presented with descending-type acute flaccid paralysis. Potassium level at presentation was 1.7 mEq/L. The patient was managed with parenteral and oral potassium supplementation, after which the weakness was completely resolved.

Safety and feasibility of a functional electrical stimulation cycling-based muscular dysfunction diagnostic method in mechanically ventilated patients

BACKGROUND

A nonvolitional diagnostic method based on FES-Cycling technology has recently been demonstrated for mechanically ventilated patients. This method presents good sensitivity and specificity for detecting muscle dysfunction and survival prognosis, even in unconscious patients. As the clinical relevance of this method has already been reported, we aimed to evaluate its safety and feasibility.

METHODS

An observational prospective study was carried out with 20 critically ill, mechanically ventilated patients. The FES-cycling equipment was set in a specific diagnostic mode. For safety determination, hemodynamic parameters and peripheral oxygen saturation were measured before and immediately after the diagnostic protocol, as well as venous oxygen saturation and blood lactate. The creatine phosphokinase level (CPK) was measured before and 24, 48, and 72 h after the test. The time taken to carry out the entire diagnostic protocol and the number of patients with visible muscle contraction (capacity of perceptive muscular recruitment) were recorded to assess feasibility.

RESULTS

Heart rate [91 ± 23 vs. 94 ± 23 bpm (p = 0.0837)], systolic [122 ± 19 vs. 124 ± 19 mm Hg (p = 0.4261)] and diastolic blood pressure [68 ± 13 vs. 70 ± 15 mm Hg (p = 0.3462)], and peripheral [98 (96-99) vs. 98 (95-99) % (p = 0.6353)] and venous oxygen saturation [71 ± 14 vs. 69 ± 14% (p = 0.1317)] did not change after the diagnostic protocol. Moreover, blood lactate [1.48 ± 0.65 vs. 1.53 ± 0.71 mmol/L (p = 0.2320)] did not change. CPK did not change up to 72 h after the test [99 (59-422) vs. 125 (66-674) (p = 0.2799) vs. 161 (66-352) (p > 0.999) vs. 100 (33-409) (p = 0.5901)]. The time taken to perform the diagnostic assessment was 11.3 ± 1.1 min. In addition, 75% of the patients presented very visible muscle contractions, and 25% of them presented barely visible muscle contractions.

CONCLUSIONS

The FES cycling-based muscular dysfunction diagnostic method is safe and feasible. Hemodynamic parameters, peripheral oxygen saturation, venous oxygen saturation, and blood lactate did not change after the diagnostic protocol. The muscle damage marker (CPK) did not increase up to 72 h after the diagnostic protocol.

When Hearts and Minds Collide: A Case Report of Left Ventricle Noncompaction Syndrome as a Precursor to Acute Ischemic Stroke in a 15-Year-Old Along With a Literature Review

Pediatric stroke, though uncommon, is often underdiagnosed due to subtle symptoms and delayed recognition. Cardiac diseases, accounting for up to 33% of pediatric ischemic strokes, play a significant role. This case report explores the rare occurrence of ischemic stroke in a 15-year-old boy with left ventricular non-compaction syndrome (LVNC). It underscores the complexity of managing pediatric ischemic stroke, particularly in the context of LVNC, emphasizing the challenges in timely diagnosis and management.

Longitudinally extensive transverse myelitis, a disabling disorder with a good prognosis: a case series from Nepal

Introduction

Longitudinally extensive transverse myelitis (LETM) is a rare spinal cord disorder with variable etiologies and presentations. It can present solely or as an association with other neurological disorders.

Methodology

It was a series of cases of LETM in a tertiary care hospital.

Clinical presentation and outcomes

The initial three cases presented with bilateral lower extremity weakness and were diagnosed as transverse myelitis while, the fourth case, already diagnosed as LETM presented with seizure followed by loss of consciousness. All four cases had a good prognosis to date with continued physiotherapy.

Conclusion

The early diagnosis of the disease helps to guide the optimal management and decide the potential need for physiotherapy.

Targeting Weakness With a Combination of Isotonic Exercises in Dermatomyositis With Polyneuropathy: A Case Report

Dermatomyositis, an autoimmune inflammatory myositis commonly linked to polymyositis, is marked by inflammatory and degenerative transformations impacting muscles, skin, limb girdles, the neck, and the pharynx. These changes result in symmetrical weakness and diverse levels of muscle atrophy. Uncommonly, the condition may impact the esophagus, lungs, and heart. While dermatomyositis is believed to involve genetic, immunological, and environmental factors, its precise etiology remains elusive. Typically, the classical presentation involves a symmetrical proximal myopathy alongside dermatological manifestations such as a purplish-red rash affecting the face, arms, hands, legs, and other areas. Additional symptoms may include dysphagia, myalgia, fever, and weight loss. The primary objectives of managing dermatomyositis are to address muscular weakness, skin manifestations, and any underlying health concerns. Integral to this management is the utilization of physical therapy and rehabilitation interventions. This study introduces a 23-year-old female patient with a noteworthy medical history covering a duration of two months. The patient reported a chief complaint of persistent thigh pain and a concurrent complaint concerning bilateral weakness in upper and lower extremities. Furthermore, the patient faced the additional challenge of difficulty swallowing. Intriguingly, the patient's clinical presentation was marked not only by the aforementioned symptoms but also by the development of a distinctive facial rash. This facial rash was accompanied by symptoms of stiffness in both small and large joints and a reduction in the range of affected joints. The physiotherapeutic assessment revealed quadriparesis of bilateral upper and lower limbs. The rehabilitation programme for the patient was planned by targeting proprioceptors to increase dynamic trunk balance in patients with DM. The Proprioceptive Neuromuscular Facilitation (PNF) technique employs diagonal movement patterns, thereby proving instrumental in enhancing the patient's daily activities. This methodology serves to optimize the individual's capacity to execute routine daily tasks, promoting independence in their daily life. An investigation like the Nerve Conduction Velocity (NCV) report shows the absence of motor excitation, suggesting motor axonal neuropathy. This approach, comprising isometric, concentric, and eccentric contraction exercises, demonstrated efficacy in mitigating muscular weakness, enhancing motor function, and alleviating the diverse symptoms associated with this condition.

The Role of Exercise in Cancer-Related Sarcopenia and Sarcopenic Obesity

One of the most common adverse effects of cancer and its therapeutic strategies is sarcopenia, a condition which is characterised by excess muscle wasting and muscle strength loss due to the disrupted muscle homeostasis. Moreover, cancer-related sarcopenia may be combined with the increased deposition of fat mass, a syndrome called cancer-associated sarcopenic obesity. Both clinical conditions have significant clinical importance and can predict disease progression and survival. A growing body of evidence supports the claim that physical exercise is a safe and effective complementary therapy for oncology patients which can limit the cancer- and its treatment-related muscle catabolism and promote the maintenance of muscle mass. Moreover, even after the onset of sarcopenia, exercise interventions can counterbalance the muscle mass loss and improve the clinical appearance and quality of life of cancer patients. The aim of this narrative review was to describe the various pathophysiological mechanisms, such as protein synthesis, mitochondrial function, inflammatory response, and the hypothalamic-pituitary-adrenal axis, which are regulated by exercise and contribute to the management of sarcopenia and sarcopenic obesity. Moreover, myokines, factors produced by and released from exercising muscles, are being discussed as they appear to play an important role in mediating the beneficial effects of exercise against sarcopenia.

Myopathy in systemic sclerosis

PURPOSE OF REVIEW

Systemic sclerosis associated myopathy (SSc-AM) is a complex, heterogenous disease that is associated with poor outcomes. SSc-AM lacks a clear definition, and continues to be poorly recognized. The purpose of this review is to provide a contemporary overview of the clinical, serological and pathophysiologic findings in SSc-AM to guide optimal recognition and management of this challenging disease manifestation.

RECENT FINDINGS

There have been several advances in diagnostic techniques to facilitate characterization of SSc-AM, including muscle MRI, in which findings were correlated to distinct histopathologic categories of muscle involvement in SSc, histopathologic findings of prominent fibrosis or inflammation on biopsy, and the identification of novel autoantibodies associated with SSc-AM, which may be associated with distinct clinical phenotypes. In one of the largest studies to date, 17% of a well phenotyped SSc cohort were found to have myopathy, which was an independent risk of death, even after adjusting for potential confounders, further highlighting the importance of timely recognistion and management of SSc-AM.

SUMMARY

There is increasing recognition of the importance of SSc-AM. Novel diagnostic tools provide the opportunity for more detailed insights into pathophysiologic mechanisms, which may facilitate the development of a rigorous consensus definition of SSc-AM.

Associations of handgrip weakness and asymmetry with new-onset stroke in Chinese middle-aged and older adults: a cohort study

Background

Weak handgrip strength (HGS) has been linked to adverse health outcomes including stroke. However, the joint associations of HGS weakness and asymmetry between limbs with stroke incidence remain underexplored.

Methods

This cohort study analyzed data of participants aged ≥45 years from three waves (2011, 2013, and 2015) of the China Health and Retirement Longitudinal Study. Weak HGS was defined according to the recommendation of European Working Group on Sarcopenia in Older People. Asymmetric HGS was defined if the HGS ratio of both hands was over 1.1 or below 0.9. New-onset stroke was confirmed through self-report of physician's diagnosis.

Results

A total of 10,966 participants without stroke at baseline were included in the analysis. During the 4 years follow-up, there were 262 (2.39%) new-onset stroke cases. Compared to individuals with non-weak and symmetric HGS, those with HGS asymmetry alone and weakness alone were associated with hazards of 1.09 (95% confidence interval [CI]: 0.80-1.48) and 1.27 (95%CI: 0.86-1.88) for new-onset stroke, respectively, while co-occurrence of both HGS asymmetry and weakness was associated with 1.80 (95%CI: 1.24-2.60) greater hazard for new-onset stroke after controlling for confounders. Such associations were consistent in older adults aged ≥60 years, but not in those aged<60 years.

Conclusion

Individuals with both weak and asymmetric HGS tended to have greater risk of new-onset stroke, compared to those with normal HGS, or with either weak or asymmetric HGS alone. Our finding suggested that examining HGS asymmetry alongside weakness may help to improve the risk-stratification and target prevention of stroke, particularly in the older population.

Segmental Zoster Paresis Accompanied by Horner's Syndrome

We herein report a 90-year-old immunocompromised woman who developed right upper limb weakness and right ptosis with a miotic pupil 1 week after oral therapy for zoster on the right T2 dermatome. The right pupil was dilated with instillation of 1% apraclonidine, indicating Horner's syndrome. The patient was treated with intravenous acyclovir and methylprednisolone. Focal weakness related to zoster, generally known as segmental zoster paresis, improved over five months, but Horner's syndrome remained. We suggest that aggressive intravenous treatment should be considered for rare cases of zoster that occur with a combination of these two neurological conditions.

An Unusual First Presentation of Stroke and Seizure in a 32-Year-Old Patient With Brugada Syndrome Type 2 Electrocardiogram Pattern

We report a case of a 32-year-old lady who was admitted to the hospital with right-sided weakness that preceded an episode of seizure. On the day of admission, she woke up early in the morning with mild right-sided weakness and numbness. She had difficulty walking and later had a seizure, which was witnessed by her son. She had no signs of infection prior to this. She had no fever, chest or abdominal pain, or urinary symptoms. In the emergency department, she complained of left-sided chest tightness and heaviness, which lasted for a few minutes with associated tachycardia, electrocardiogram (ECG) was consistent with Brugada syndrome type 2. A magnetic resonant imaging (MRI) scan of her head shows a left hemispheric infarct involving the frontoparietal cortex. She was treated for an ischaemic stroke and seizure. She made a good recovery and was discharged home on secondary stroke prevention medication with community physiotherapy. She was followed up in the cardiology, genetics, and stroke outpatient clinics. The occurrence of ECG changes consistent with Brugada syndrome, stroke, and seizure in a young patient with no other risk factors for stroke is rare.

Longitudinal assessment of strength and body composition in a mouse model of chronic alcohol-related myopathy

BACKGROUND

Excessive, chronic alcohol consumption can result in muscle atrophy and weakness (i.e., alcoholic myopathy) that impairs the quality of life. However, the precise mechanisms responsible for ethanol's detrimental impact on skeletal muscle have not been fully elucidated, in part due because the time course of disease development and progression are not well established. Therefore, we examined muscle strength and body composition longitudinally using an established preclinical mouse model of chronic alcoholic myopathy.

METHODS

To establish a time course of chronic alcoholic myopathy, we fed High Drinking in the Dark (HDID) female mice (n = 7) 20% ethanol for ~32 weeks (following a 2-week ethanol ramping period). We assessed in vivo isometric contractility of the left ankle dorsiflexor and lean mass via NMR every 4 weeks. Outcomes were compared with age-matched control HDID mice that did not consume ethanol (n = 8).

RESULTS

At study completion, mice who consumed ethanol were 12% weaker than control mice (p = 0.015). Compared to baseline, consuming ethanol resulted in an acute transient reduction in dorsiflexion torque at Week 4 (p = 0.032) that was followed by a second, more sustained reduction at Week 20 (p < 0.001). Changes in lean mass paralleled those of dorsiflexor torque, with ~40% of the variance in dorsiflexor torque being explained by the variance in lean mass of the ethanol group (p < 0.001). Dorsiflexor torque normalized to lean mass (mN·m/g lean mass) did not differ between the ethanol and control groups from Weeks 4 to 32 (p ≥ 0.498).

CONCLUSIONS

These results indicate that reductions in muscle mass and strength due to chronic, excessive ethanol intake are dynamic, not necessarily linear, processes. Moreover, the findings confirm that ethanol-induced weakness is primarily driven by muscle atrophy (i.e., loss of muscle quantity). Future studies should consider how chronic alcoholic myopathy develops and progresses rather than identifying changes after it has been diagnosed.

A questionnaire-based investigation of the swimming puppy syndrome: 115 dogs

Swimming Puppy Syndrome (SPS) is a benign reversible condition of unknown etiology in multiple dog breeds. Affected dogs show laterally abducted limbs and are unable to stand and walk on their own. The current knowledge of this condition derives from few case reports or small case series. Therefore, the aim of this study was to collect data on the clinical course from a large cohort of dogs with SPS with an online questionnaire supported by video footage. Potential risk factors were compared between 110 litters with SPS and 103 unaffected litters. SPS was reported in 115 dogs from 48 different breeds comprising a wide range of small, middle, and large breeds. Litters with SPS were significantly smaller than unaffected litters. Cesarean sections were reported more frequently in affected litters, but the overall rate of reported birth complications did not differ significantly from unaffected litters. Most puppies were able to stand and walk at a median age of 4.5 weeks (up to 12 weeks) and clinical signs resolved at a median age of six weeks (up to 12 weeks). Puppies from large breeds showed faster recovery than puppies from medium and small breeds. Occasionally, residual deficits were reported and only three dogs failed to recover. A clustering of SPS occurred in closely related litters in four kennels of four different dog breeds (Greater Swiss Mountain Dog, Golden Retriever, Miniature Bull Terrier, Norwich Terrier). The study shows the benign clinical course of SPS in a large cohort of puppies from multiple dog breeds. Potential risk factors including reports on birth complications, size and muscle mass compared to littermates and diet of the dam during pregnany were evaluated and no influence on the occurrence of SPS was identified.

A Case Report of Nitrous Oxide-induced Myelopathy: An Unusual Cause of Weakness in an Emergency Department

INTRODUCTION

Weakness is a common symptom that within itself does not indicate a specific diagnosis. Recreational inhalant use such as nitrous oxide (NO) may not often be disclosed. Additionally, professional or occupational history, such as being a dentist or dental assistant, should be determined because of higher reported rates of NO misuse. Nitrous oxide can cause vitamin B12 deficiency and resulting neuropathy. Nitrous oxide toxicity can have a wide variation of presentations with or without laboratory abnormalities or remarkable imaging findings, which can further complicate a diagnosis of weakness secondary to NO use.

CASE REPORT

A 33-year-old female presented to the emergency department with progressive bilateral leg numbness and objective weakness after repeated recreational NO use. After an extensive workup, she was found to have vitamin B12 deficiency and an electromyography study consistent with myeloneuropathy, despite normal imaging. She was prescribed high-dose vitamin B12 therapy and stopped using NO. One year after diagnosis, our patient maintained NO sobriety and had near-complete resolution of prior neurologic deficits.

CONCLUSION

The use of recreational inhalant and the patient's occupation should be considered when a patient presents with weakness. Obtaining vitamin B12 and methylmalonic acid levels should be considered for diagnosis. However, NO-induced neuropathy can be seen in patients with normal vitamin B12 and methylmalonic levels and patients do not always have abnormal imaging findings. The healthcare team should consider the varied presentations and findings of substance-induced conditions such as NO toxicity.

Head computerized tomography in emergency department evaluation of the geriatric patient with generalized weakness

Objective

Weakness in older emergency department (ED) patients presents a broad differential. Evaluation of these patients can be challenging, and the efficacy of head computed tomography (CT) imaging is unclear. This study assesses the usefulness of head CT as a diagnostic study of acute generalized weakness in older ED patients.

Methods

This retrospective review of patients aged 65 years and older presenting to 2 community EDs included patients with a chief complaint of generalized weakness who received a head CT. Patients presenting with a focal neurologic complaint, altered mental status, or trauma were excluded. Variables evaluated included additional triage chief complaints, dementia diagnosis, and deficits on physical examination. Primary outcome was acute intracranial finding on head CT. Secondary outcomes included neurology consultation, neurosurgical consultation, and neurosurgical intervention.

Results

Of 247 patients, 3.2% had an acute intracranial abnormality on head CT. Emergent consultations for neurology and neurosurgery occurred for 1.6% and 2.4% of patients, respectively. None required neurosurgical intervention. Patients with objective weakness or focal neurologic deficits on physical examination were more likely to have acute findings on head CT (8.5% vs. 2.0%, odds ratio 4.56, confidence interval 1.10-18.95). Additional characteristics did not predict acute intracranial abnormality or need for emergent consultation.

Conclusion

Few patients with generalized weakness evaluated with head CT had acutely abnormal intracranial findings. Patients with objective weakness or neurologic deficits were more likely to have acute abnormalities. Although head CT is frequently used to evaluate geriatric weakness, its utility is low, especially in patients with normal physical examinations.

Diagnostic dilemma in acute neurological presentation of spinal arachnoid cysts: A case report

Background

Spinal arachnoid cysts are relatively uncommon, cerebrospinal fluid-filled sacs formed by arachnoid membranes that can be either idiopathic or acquired. The neurological presentation of these cysts is varied. Advances in imaging techniques have allowed an improved characterization of these entities and excluded other possible causes of clinical manifestation. Their presentation remains varied, ranging from pain to progressive neurological deficits. Here, we present two cases of patients with thoracic arachnoid cysts that posed a diagnostic dilemma at initial presentation because of their acute neurological deficit, and their eventual recovery after surgical intervention.

Case description

The first case is of a patient with end-stage renal failure, which prevented the administration of contrast during the workup. The differential diagnosis ranged from intradural abscess to arachnoid cyst. The second patient presented with non-remitting back pain that progressed to an acute neurological deficit. Both patients recovered well after decompression of the cyst.

Conclusion

The decision to intervene is still patient-dependent and based on the extent of neurological deterioration at the time of presentation due to the relatively benign nature and lack of understanding of the temporal presentation of neurological symptoms, which are rapidly and almost completely reversed after surgery. However, further studies need to be done to understand the acute presentation of these cysts, which are apparently long-standing.

Spontaneous Development of Immune-Mediated Necrotizing Myopathy (IMNM) After Chronic Use of Statins: A Case Report

Statin medications, in addition to lifestyle modifications, have been the regimen of choice for addressing dyslipidemia in the general population. Its widespread use has been justified by increasing evidence that hyperlipidemia is a strong risk factor for the development of atherosclerotic disease resulting in myocardial infarction and other cardiovascular events. Unfortunately, this medication is not tolerated by some patients as it causes uncomfortable side effects such as myalgias, arthralgias, and headaches to name a few.  On rare occasions, some patients may develop immunity against the medication itself resulting in a condition known as immune-mediated necrotizing myopathy (IMNM). In such instances, patients carry antibodies against 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) or signal recognition particle (SRP). A small subset of patients may develop IMNM even in the absence of these two antibodies and they are termed seronegative. In this care report, we review the case of a 55-year-old Hispanic male with a history of Hashimoto's thyroiditis and hyperlipidemia who presented to an outpatient rheumatology office for severe proximal muscle weakness after being asymptomatic on rosuvastatin for over 20 years. The patient was stabilized with high-dose steroids and was subsequently given a regimen of mycophenolate and intravenous immunoglobulin (IVIG). He was able to regain approximately 75%-80% of his baseline muscle strength.

COVID-19 infection in myasthenia gravis: Clinical course and outcomes

INTRODUCTION/AIMS

Myasthenia gravis (MG) patients have been predicted to have high rates of coronavirus disease-2019 (COVID-19) complications due to frequent involvement of respiratory muscles in MG and frequent use of immunosuppressive therapies. We investigated outcomes of MG patients infected with SARS-CoV-2 to identify risk factors for exacerbation and severe disease.

METHODS

This was a retrospective analysis of 39 MG patients with SARS-CoV-2 infection from January March 1, 2020 to October 25, 2021 at Emory University. Patients' records were queried for demographic data, MG history, and COVID-19 treatments and hospitalizations.

RESULTS

At the time of infection, 8 of 39 were vaccinated, 30 of 39 unvaccinated, and 1 unknown. Average age was 52.6 years. Twenty-seven patients were receiving immunomodulatory treatments at the time of infection. Thirty-five of 39 were symptomatic, 21 were hospitalized, and 7 required ventilations. MG exacerbations occurred in 5 and were treated with therapeutic plasma exchange (n = 1), intravenous immunoglobulin (IVIg) (n = 1), and prednisone taper (n = 5). Four hospitalized patients died from COVID-related lung injuries. No deaths were attributed to MG exacerbation; however, one patient receiving IVIg for MG exacerbation had a pulmonary embolism. There were no deaths in fully vaccinated patients, and only one vaccinated patient was admitted to the intensive care unit.

DISCUSSION

High rates of COVID-19 complications and death were observed in this cohort of MG patients. Some patients with MG and COVID-19 also had an exacerbation during infection. Further studies are needed to determine whether MG patients are at higher risk for complications than the rest of the population.

Generation of percentile curves for strength and functional abilities for boys with Duchenne muscular dystrophy

INTRODUCTION/AIMS

Considering the heterogeneity of the clinical manifestations of Duchenne muscular dystrophy (DMD), it is important to describe their various clinical profiles. Thus, in this study we aimed to develop percentile curves for DMD using a battery of measures to define the patterns of functional abilities, timed tests, muscle strength, and range of motion (ROM).

METHODS

This retrospective data analysis was based on the records of patients with DMD using the Motor Function Measure (MFM) scale, isometric muscle strength (IS), dorsiflexion ROM, 10-meter walk test (10 MWT), and 6-minute walk test (6 MWT). Percentile curves (25th, 50th, and 75th percentiles) with MFM, IS, ROM, 10 MWT, and 6 MWT on the y axis and patient age on the x axis were constructed using the generalized additive model for location, scale, and shape, with Box-Cox power exponential distribution.

RESULTS

There were records of 329 assessments of patients between 4 and 18 years of age. The MFM percentiles showed a gradual reduction in all dimensions. Muscle strength and ROM percentiles showed that the knee extensors were the most affected from 4 years of age, and dorsiflexion ROM negative values were noted from the age of 8 years. The 10 MWT showed a gradual increase in performance time with age. For the 6 MWT, the distance curve remained stable until 8 years, with a subsequent progressive decline.

DISCUSSION

In this study we generated percentile curves that can help health professionals and caregivers follow the trajectory of disease progression in DMD patients.

Clinical Diagnosis of Rhabdomyolysis without Myoglobinuria or Electromyographic Abnormalities in a Dog

A 2-year-old female neutered Old German Shepherd was presented for acute non-ambulatory tetraparesis. Upon presentation to the emergency department, hematology and biochemical blood tests revealed no abnormalities aside from mildly elevated C-reactive protein levels (22.5 mg/L, reference range 0.0-10.0) and immeasurable creatine kinase (CK) activity. Neurological evaluation the next day revealed ambulatory tetraparesis, general proprioceptive deficits, mild ataxia and dubious diffuse myalgia. Withdrawal reflexes were weak on both thoracic and pelvic limbs. The CK was determined to be significantly elevated at that point (32.856 U/L, ref. range 10.0-200.0). Urinalysis revealed no abnormalities. An electromyographic (EMG) study of thoracic limb, paraspinal and pelvic limb muscles revealed no abnormalities. A magnetic resonance imaging (MRI) study of the cervicothoracic spinal cord was performed and revealed no abnormalities. A presumptive clinical diagnosis of rhabdomyolysis without myoglobinuria or EMG abnormalities was formed. Muscular biopsies were declined due to the rapid clinical improvement of the dog. A follow-up showed the progressive decline of CK activity to normal values and clinical remission of signs. A diagnosis of rhabdomyolysis was concluded based on clinical signs, consistent CK activity elevations and the response to supportive treatment for rhabdomyolysis, despite the absence of myoglobinuria and EMG abnormalities. Rhabdomyolysis should not be excluded based on the lack of EMG abnormalities or myoglobinuria in dogs.

The Influence of Knee Extensor and Ankle Plantar Flexor Strength on Single-Leg Standing Balance in Older Women

Impaired balance is a significant risk factor for falls among older adults. The precise impact of lower-extremity muscles, including the proportion of muscle strength, on the performance of single-leg standing balance tests in older individuals is very interesting. The aim of this study is to examine the correlation between the knee extensor (KE), ankle plantar flexor (AP) muscle strength, and performance in single-leg standing balance tests in older females. Additionally, it aims to evaluate the combined proportion of KE and AP muscle strength in maintaining balance during single-leg standing. A total of 90 older females (mean age 67.83 ± 8.00 years) were recruited. All participants underwent maximum voluntary isometric contraction (MVIC) testing of the KE and AP muscles, as well as single-leg standing balance tests with eyes open (SSEO) and eyes closed (SSEC). To examine the influence of KE and AP muscle strength on balance performance, multiple regression analysis was conducted. Low correlations were found between SSEO and MVIC of KE and AP muscles, but moderate correlations were found with percentage of MVIC to body weight ratio (%MVIC/BW). The best model for SSEO included 0.99 times of the %MVIC/BW of AP and 0.66 times that of KE muscles as independent predictor variables (r = 0.682). In conclusion, AP muscle strength was found to have a greater impact on single-leg standing balance compared with KE muscle strength.

Immune-mediated polyneuropathy in cats: Clinical description, electrodiagnostic assessment, and treatment

BACKGROUND

Suspected immune-mediated polyneuropathy has been increasingly reported in cats, especially in the last decade, but the condition remains poorly understood.

OBJECTIVES

Refine the clinical description and review the classification of this condition based on electrodiagnostic investigation and evaluate the benefit of corticosteroid treatment and L-carnitine supplementation.

ANIMALS

Fifty-five cats presented with signs of muscular weakness and electrodiagnostic findings consistent with polyneuropathy of unknown origin.

METHODS

Retrospective, multicenter study. Data from the medical records were reviewed. The owners were contacted by phone for follow-up at the time of the study.

RESULTS

The male-to-female ratio was 2.2. The median age of onset was 10 months, with 91% of affected cats being <3 years of age. Fourteen breeds were represented in the study. The electrodiagnostic findings supported purely motor axonal polyneuropathy. Histological findings from nerve biopsies were consistent with immune-mediated neuropathy in 87% of the tested cats. The overall prognosis for recovery was good to excellent, as all but 1 cat achieved clinical recovery, with 12% having mild sequelae and 28% having multiple episodes during their lifetime. The outcome was similar in cats with no treatment when compared with cats receiving corticosteroids or L-carnitine supplementation.

CONCLUSIONS AND CLINICAL IMPORTANCE

Immune-mediated motor axonal polyneuropathy should be considered in young cats with muscle weakness. This condition may be similar to acute motor axonal neuropathy in Guillain-Barré syndrome patients. Based on our results, diagnostic criteria have been proposed.

Spinal Dural Arteriovenous Fistula: Insights Into Operative Management

Spinal Dural Arteriovenous Fistula (SDAVF) is a rare and complex vascular condition with significant neurological consequences if left untreated. We present a case of SDAVF in a 46-year-old male who presented with progressive myelopathy. The patient presented with a three-month history of progressive lower extremity weakness, numbness, urinary retention, constipation, and gait disturbance. The spine's magnetic resonance imaging (MRI) showed diffuse T2 hyperintensity and contrast enhancement from T11 to L1, raising the suspicion of an intradural spinal cord lesion. Further evaluation with spinal angiography revealed an SDAVF at the level of T11-T12. The patient underwent surgical resection of the fistula, His lower extremity weakness and numbness improved significantly after surgery, and he was discharged with a plan for close follow-up. Early diagnosis and appropriate treatment prevent neurological deficits and improve patient outcomes. Surgical resection of the fistula can significantly improve neurological symptoms and should be considered a treatment option for SDAVF.

FDG-PET shows weak correlation between focal motor weakness and brain metabolic alterations in ALS

Objective: Amyotrophic lateral sclerosis (ALS) is a clinically heterogenous disease, typically presenting with focal motor weakness that eventually generalizes. Weather there is a correlation between focal motor weakness and metabolic alterations in specific areas of the brain has not been thoroughly explored. This study aims to systematically investigate this by using fluorodeoxyglucose-positron emission tomography (FDG-PET), including longitudinal imaging. Methods: This observational imaging study included 131 ALS patients diagnosed and examined with FDG-PET at the ALS Clinical Research Center at the Karolinska University Hospital in Stockholm, Sweden. Thirteen ALS patients had a second scan and were analyzed longitudinally. The findings were compared to 39 healthy controls examined at the University Medical Center of Gröningen, the Netherlands. Results: There was a general pattern of brain metabolic alterations consistent with previously reported findings in ALS, namely hypometabolism in frontal regions and hypermetabolism in posterior regions. A higher symptom burden was associated with increased hypometabolism and decreased hypermetabolism. However, there was no clear correlation between focal motor weakness and specific metabolic alterations, neither when analyzing focal motor weakness with concomitant upper motor neuron signs or when including all focal motor weakness. Longitudinal FDG-PET imaging showed inconsistent results with little correlation between progression of motor weakness and metabolic alterations. Conclusion: Our results support the disease model of ALS as a diffuse process since no clear correlation was seen between focal motor weakness and specific metabolic alterations. However, there is need for further research on a larger number of patients, particularly including longitudinal imaging.

Associations of Country-Specific and Sociodemographic Factors With Self-Reported COVID-19-Related Symptoms: Multivariable Analysis of Data From the CoronaCheck Mobile Health Platform

BACKGROUND

The COVID-19 symptom-monitoring apps provide direct feedback to users about the suspected risk of infection with SARS-CoV-2 and advice on how to proceed to prevent the spread of the virus. We have developed the CoronaCheck mobile health (mHealth) platform, the first free app that provides easy access to valid information about the risk of infection with SARS-CoV-2 in English and German. Previous studies have suggested that the clinical characteristics of individuals infected with SARS-CoV-2 vary by age, gender, and viral variant; however, potential differences between countries have not been adequately studied.

OBJECTIVE

The aim of this study is to describe the characteristics of the users of the CoronaCheck mHealth platform and to determine country-specific and sociodemographic associations of COVID-19-related symptoms and previous contacts with individuals infected with COVID-19.

METHODS

Between April 8, 2020, and February 3, 2022, data on sociodemographic characteristics, symptoms, and reports of previous close contacts with individuals infected with COVID-19 were collected from CoronaCheck users in different countries. Multivariable logistic regression analyses were performed to examine whether self-reports of COVID-19-related symptoms and recent contact with a person infected with COVID-19 differed between countries (Germany, India, South Africa), gender identities, age groups, education, and calendar year.

RESULTS

Most app users (N=23,179) were from Germany (n=8116, 35.0%), India (n=6622, 28.6%), and South Africa (n=3705, 16.0%). Most data were collected in 2020 (n=19,723, 85.1%). In addition, 64% (n=14,842) of the users were male, 52.1% (n=12,077) were ≥30 years old, and 38.6% (n=8953) had an education level of more than 11 years of schooling. Headache, muscle pain, fever, loss of smell, loss of taste, and previous contacts with individuals infected with COVID-19 were reported more frequently by users in India (adjusted odds ratios [aORs] 1.3-8.3, 95% CI 1.2-9.2) and South Africa (aORs 1.1-2.6, 95% CI 1.0-3.0) than those in Germany. Cough, general weakness, sore throat, and shortness of breath were more frequently reported in India (aORs 1.3-2.6, 95% CI 1.2-2.9) compared to Germany. Gender-diverse users reported symptoms and contacts with confirmed COVID-19 cases more often compared to male users.

CONCLUSIONS

Patterns of self-reported COVID-19-related symptoms and awareness of a previous contact with individuals infected with COVID-19 seemed to differ between India, South Africa, and Germany, as well as by gender identity in these countries. Viral symptom-collecting apps, such as the CoronaCheck mHealth platform, may be promising tools for pandemics to support appropriate assessments. Future mHealth research on country-specific differences during a pandemic should aim to recruit representative samples.

Identification and Characterization of Genomic Predictors of Sarcopenia and Sarcopenic Obesity Using UK Biobank Data

The substantial decline in skeletal muscle mass, strength, and gait speed is a sign of severe sarcopenia, which may partly depend on genetic risk factors. So far, hundreds of genome-wide significant single nucleotide polymorphisms (SNPs) associated with handgrip strength, lean mass and walking pace have been identified in the UK Biobank cohort; however, their pleiotropic effects on all three phenotypes have not been investigated. By combining summary statistics of genome-wide association studies (GWAS) of handgrip strength, lean mass and walking pace, we have identified 78 independent SNPs (from 73 loci) associated with all three traits with consistent effect directions. Of the 78 SNPs, 55 polymorphisms were also associated with body fat percentage and 25 polymorphisms with type 2 diabetes (T2D), indicating that sarcopenia, obesity and T2D share many common risk alleles. Follow-up bioinformatic analysis revealed that sarcopenia risk alleles were associated with tiredness, falls in the last year, neuroticism, alcohol intake frequency, smoking, time spent watching television, higher salt, white bread, and processed meat intake; whereas protective alleles were positively associated with bone mineral density, serum testosterone, IGF1, and 25-hydroxyvitamin D levels, height, intelligence, cognitive performance, educational attainment, income, physical activity, ground coffee drinking and healthier diet (muesli, cereal, wholemeal or wholegrain bread, potassium, magnesium, cheese, oily fish, protein, water, fruit, and vegetable intake). Furthermore, the literature data suggest that single-bout resistance exercise may induce significant changes in the expression of 26 of the 73 implicated genes in m. vastus lateralis, which may partly explain beneficial effects of strength training in the prevention and treatment of sarcopenia. In conclusion, we have identified and characterized 78 SNPs associated with sarcopenia and 55 SNPs with sarcopenic obesity in European-ancestry individuals from the UK Biobank.

Neuromuscular and Neuromuscular Junction Manifestations of the PURA-NDD: A Systematic Review of the Reported Symptoms and Potential Treatment Options

PURA-related neurodevelopmental disorders (PURA-NDDs) are a rare genetic disease caused by pathogenic autosomal dominant variants in the PURA gene or a deletion encompassing the PURA gene. PURA-NDD is clinically characterized by neurodevelopmental delay, learning disability, neonatal hypotonia, feeding difficulties, abnormal movements, and epilepsy. It is generally considered to be central nervous system disorders, with generalized weakness, associated hypotonia, cognitive and development deficits in early development, and seizures in late stages. Although it is classified predominantly as a central nervous syndrome disorder, some phenotypic features, such as myopathic facies, respiratory insufficiency of muscle origin, and myopathic features on muscle biopsy and electrodiagnostic evaluation, point to a peripheral (neuromuscular) source of weakness. Patients with PURA-NDD have been increasingly identified in exome-sequenced cohorts of patients with neuromuscular- and congenital myasthenic syndrome-like phenotypes. Recently, fluctuating weakness noted in a PURA-NDD patient, accompanied by repetitive nerve stimulation abnormalities, suggested the disease to be a channelopathy and, more specifically, a neuromuscular junction disorder. Treatment with pyridostigmine or salbutamol led to clinical improvement of neuromuscular function in two reported cases. The goal of this systematic retrospective review is to highlight the motor symptoms of PURA-NDD, to further describe the neuromuscular phenotype, and to emphasize the role of potential treatment opportunities of the neuromuscular phenotype in the setting of the potential role of PURA protein in the neuromuscular junction and the muscles.

Neuromuscular Weakness and Paralysis Produced by Snakebite Envenoming: Mechanisms and Proposed Standards for Clinical Assessment

Respiratory and airway-protective muscle weakness caused by the blockade of neuromuscular transmission is a major cause of early mortality from snakebite envenoming (SBE). Once weakness is manifest, antivenom appears to be of limited effectiveness in improving neuromuscular function. Herein, we review the topic of venom-induced neuromuscular blockade and consider the utility of adopting clinical management methods originally developed for the safe use of neuromuscular blocking agents by anesthesiologists in operating rooms and critical care units. Failure to quantify neuromuscular weakness in SBE is predicted to cause the same significant morbidity that is associated with failure to do so in the context of using a clinical neuromuscular block in surgery and critical care. The quantitative monitoring of a neuromuscular block, and an understanding of its neurophysiological characteristics, enables an objective measurement of weakness that may otherwise be overlooked by traditional clinical examination at the bedside. This is important for the initial assessment and the monitoring of recovery from neurotoxic envenoming. Adopting these methods will also be critical to the conduct of future clinical trials of toxin-inhibiting drugs and antivenoms being tested for the reversal of venom-induced neuromuscular block.

Erratum: Case Report: Uncommon cause of limp in the 21st century

[This corrects the article DOI: 10.3389/fendo.2022.968015.].

Risk factors differ for viable and low viable crushed piglets in free farrowing pens

Newborn piglets have a high risk of being crushed by the sow, and this risk implies welfare and economic consequences. The aim of this study was to investigate the importance of differentiating between low viable (secondary crushing losses) and viable crushed (primary crushing losses) piglets for the evaluation of risk factors for crushing related to characteristics of the sow, the litter, and the environment. Eleven Swiss farmers recorded sows' production data (parity class, gestation length, numbers of live-born and stillborn piglets), data (age, sex, weight, cause of death, and signs of weakness) for every live-born piglet that died in the first week after birth (piglet loss), and ambient temperature. Piglet losses were assigned to five categorical events: piglet loss, subdivided into not crushed and crushed, the latter being further subdivided into low viable crushed and viable crushed. Piglets recorded by the farmer as crushed were assigned to the events low viable crushed and viable crushed based on the piglet's body weight and signs of weakness (diseases, malformations). Data of 9,543 live-born piglets from 740 litters were eventually used to statistically model the hazard of dying at any given time in the first week after birth due to one of these events (mixed-effects Cox model). Five potential risk factors were analyzed as co-variates: parity class, gestation length, number of live-born piglets, number of stillborn piglets, and daily number of hours with ambient temperature >30°C. We identified two risk factors for dying from the event viable crushed that were not identified as risk factors for low viable crushed, namely shorter gestation length and higher daily number of hours with ambient temperature  > 30°C. Vice-versa, we identified additional live-born piglets in the litter as risk factor for low viable crushed, but not for viable crushed. Our results show the importance of differentiating between low viable and viable crushed piglets for the interpretation of risk factors for crushing losses. Therefore, we suggest that for breeding purposes and in research, this differentiation should be made.

Spinal Gunshot Wound With an Air Rifle: A Case Report

Spinal gunshot injuries are one of the most serious injuries that can cause morbidity and mortality. We report a case of a nine-year-old boy, referred to our emergency department from another hospital, with lower limb weakness after being shot by an air gun in his back. After extensive investigation, it appeared that a foreign body representing the bullet was found in his spinal canal; the patient was taken to the operating room for surgical decompression and removal of foreign bodies. After that, the patient started to show partial improvement in his neurological deficits and is to be continued on physiotherapy.

Objective and self-perceived lower limb weakness in Parkinson's disease

BACKGROUND

Lower limb weakness is a long-recognized symptom in patients with Parkinson's disease (PD), described by James Parkinson in his seminal report on 'paralysis agitans'. However, little is known on the frequency, clinical correlations, and association with objective decrease in muscle strength in such patients.

OBJECTIVE

The objective of this study was to assess the frequency of objective and perceived lower limb weakness in patients with PD.

METHODS

We studied 90 consecutive patients with PD and 52 age-matched controls. We recorded clinical and demographic variables, as well as perceived weakness and allied abnormal lower limb sensations, including 'heavy legs', 'fatigued legs', and 'pain'. Symptoms consistent with restless legs syndrome were not considered. Lower limb strength was determined in both legs by means of the Medical Research Council scale, dynamometric (leg flexion) and weighting machine (leg pressure) measures.

RESULTS

Weakness and allied abnormal lower limb sensations were reported in 69% of patients with PD and 21% of healthy controls. Patients with PD had decreased leg pressure compared with healthy controls (p = 0.002). Among patients with PD, an association between perceived leg weakness (and allied sensations) and gait freezing (p = 0.001) was observed in the multivariate regression analysis; however, these variables only explained 30.4% of the variance. Moreover, PD patients with and without abnormal lower limb sensations had similar muscle strength by objective measurements.

CONCLUSION

Perceived lower limb weakness and allied abnormal sensations are common in patients with PD. However, there is a dissociation between perceived weakness and objective muscle strength in the lower limbs. These abnormal sensations were mostly related to gait freezing but a causal association is questionable.

Hypogonadism in Males With Genetic Neurodevelopmental Syndromes

Genetic syndromes that affect the nervous system may also disrupt testicular function, and the mechanisms for these effects may be interrelated. Most often neurological signs and symptoms predominate and hypogonadism remains undetected and untreated, while in other cases, a thorough evaluation of a hypogonadal male reveals previously unrecognized ataxia, movement disorder, muscle weakness, tremor, or seizures, leading to a syndromic diagnosis. Androgen deficiency in patients with neurological diseases may aggravate muscle weakness and fatigue and predispose patients to osteoporosis and obesity. The purpose of this mini review is to provide a current understanding of the clinical, biochemical, histologic, and genetic features of syndromes in which male hypogonadism and neurological dysfunction may coexist and may be encountered by the clinical endocrinologist.

Effects of total knee arthroplasty on skeletal muscle structure and function at the cellular, organellar, and molecular levels

Total knee arthroplasty (TKA) is an important treatment option for knee osteoarthritis (OA) that improves self-reported pain and physical function, but objectively measured physical function typically remains reduced for years after surgery due, in part, to precipitous reductions in lower extremity neuromuscular function early after surgery. The present study examined intrinsic skeletal muscle adaptations during the first 5 weeks post-TKA to identify skeletal muscle attributes that may contribute to functional disability. Patients with advanced stage knee OA were evaluated prior to TKA and 5 weeks after surgery. Biopsies of the vastus lateralis were performed to assess muscle fiber size, contractility, and mitochondrial content, along with assessments of whole muscle size and function. TKA was accompanied by marked reductions in whole muscle size and strength. At the fiber (i.e., cellular) level, TKA caused profound muscle atrophy that was approximately twofold higher than that observed at the whole muscle level. TKA markedly reduced muscle fiber force production, contractile velocity, and power production, with force deficits persisting in myosin heavy chain (MHC) II fibers after expression relative to fiber size. Molecular level assessments suggest reduced strongly bound myosin-actin cross bridges and myofilament lattice stiffness as a mechanism underlying reduced force per unit fiber size. Finally, marked reductions in mitochondrial content were apparent and more prominent in the subsarcolemmal compartment. Our study represents the most comprehensive evaluation of skeletal muscle cellular adaptations to TKA and uncovers novel effects of TKA on muscle fiber size and intrinsic contractility early after surgery that may contribute to functional disability.NEW & NOTEWORTHY We report the first evaluation of the effects of total knee arthroplasty (TKA) on skeletal muscle at the cellular and subcellular levels. We found marked effects of TKA to cause skeletal muscle fiber atrophy and contractile dysfunction in older adults, as well as molecular mechanisms underlying impaired contractility. Our results reveal profound effects of TKA on muscle fiber size and intrinsic contractility early after surgery that may contribute to functional disability.

Disseminated Zoster Involving the Whole Body in an Immunocompetent Patient Complaining of Left Leg Radiating Pain and Weakness: A Case Report and Literature Review

Introduction

Disseminated herpes zoster is defined as at least 20 skin lesions in multiple dermatomes. In particular, it has been reported mainly in patients with immunological defects. To our knowledge, there is no reported case of disseminated zoster in a non-immunocompromised patient with leg radiating pain and weakness.

Case presentation

A 74-year-old man visited our hospital with left leg radiating pain and left hip pain. He had no underlying disease other than hypertension. Neurologic examination revealed radiating pain on the L4 dermatome of the left leg. The muscle power was grade 3 for the hip flexor and knee extensor, and grade 4 for the ankle dorsiflexor and big toe dorsiflexor of the left leg. There were no sensory changes or skin lesions on his left leg. Herniation of the nucleus pulposus of the lumbar spine was suspected and lumbar magnetic resonance imaging (MRI) was performed. However, no pathologic lesions were seen on lumbar MRI. On the third day of hospitalization, erythematous patches and vesicles were observed on the head, face, ear, neck, trunk, back, and both lower extremities. Herpes zoster infection was confirmed by polymerase chain reaction analysis. Treatment was performed with 250 mg of intravenous acyclovir every 8 hours for 6 days and 62.5 mg of intravenous methylprednisolone for 4 days. On the 13th day of hospitalization, the skin lesions and left leg radiating pain and weakness improved.

Conclusion

We report the first case of disseminated herpes zoster involving the whole body in a non-immunocompromised patient complaining of left leg radiating pain and weakness. After treatment, both the patient's radiating pain and weakness improved.

Muscle Weakness and Walking Slowness for the Identification of Sarcopenia in the Older Adults from Northern Brazil: A Cross-Sectional Study

Background: This study aimed to analyze the prevalence of sarcopenia in elderly people from Northern Brazil according to muscle weakness or walking slowness. Methods: The sample consisted of 312 elderly people (72.6 ± 7.8 years). For walking slowness, a gait speed ≤ 0.8 m/s was used as a cut-off value, and for muscle weakness the following handgrip strength criteria were used for men and women, respectively: CI: <27.0/16.0 kg; CII: <35.5/20.0 kg; CIII: grip strength corrected for body mass index (BMI) < 1.05/0.79; CIV: grip strength corrected for total fat mass: <1.66/0.65; CV: grip strength corrected for body mass: <0.45/0.34. Results: Walking speed was reduced in 27.0% of women and 15.2% of men (p < 0.05). According to grip strength criteria, 28.5% of women and 30.4% of men (CI), 58.0% of women and 75.0% of men (CII), 66.0% of women and 39.3% of men (CIII), 28.8% of women and 19.6% of men (CIV), and 56.5% of women and 50.0% of men (CV) were identified as having sarcopenia. Conclusions: Walking slowness is more prevalent in women and muscle weakness is more prevalent in men in Northern Brazil. Walking slowness proved to be more concordant with muscle weakness in both sexes when the CI for handgrip strength was adopted.

Perceived utility of electrodiagnostic testing in critical illness myopathy and polyneuropathy: A survey of intensive care unit providers

INTRODUCTION/AIMS

Critical illness myopathy (CIM) and critical illness polyneuropathy (CIP) are common disorders associated with substantial morbidity. Electrodiagnostic studies (EDx) are effective in diagnosing CIM/CIP and identifying mimicking conditions. We surveyed intensive care unit (ICU) providers to better understand their approach to ICU-acquired weakness (ICU-AW) and the perceived utility of EDx.

METHODS

This was a single health system, Web-based survey of ICU providers.

RESULTS

Survey responses were received from 52 providers with a response rate of 22.1%. Most providers were somewhat familiar with CIM/CIP and median perceived prevalence was 30-49%. The majority (92.3%) of providers had no standard evaluation approach for ICU-AW. Electrodiagnostic testing was commonly considered, but many providers obtained it infrequently in presumed CIM/CIP cases. Electrodiagnostic studies were used to rule out other causes of weakness or to confirm the diagnosis of CIM/CIP. Many providers ordered EDx within 1 wk of identifying weakness. Finally, EDx were overshadowed by personal experience as the most helpful management tool for ICU-AW.

DISCUSSION

Overall, ICU providers perceive that CIM/CIP are commonly encountered, but they may not have a standard approach to evaluation. Clinical experience increased familiarity of ICU-AW and is central to management. EDx results are usually thought to be helpful, albeit not often ordered, and more study is needed to determine when implementation is of most assistance. Increasing education and developing institutional standards may lead to increased awareness and improved evaluation of CIM/CIP, but more study is needed to determine if algorithmic approaches would change patient outcomes.

Associations of Handgrip Asymmetry With Impaired Health-Related Quality of Life Among Older Adults in South Korea: A Cross-Sectional Study Using National Survey Data

This study aimed to examine the associations of handgrip strength (HGS) and asymmetry with health-related quality of life among South Korean older adults. We enrolled 7395 older adults from the Korea National Health and Nutrition Examination Survey. Health-related quality of life was measured using the EuroQol-5 Dimension. Weakness was defined as a HGS of <26 kg for men and <18 kg for women. Handgrip strength symmetry was defined as an HGS ratio of 0.9:1.1, and HGS asymmetry was defined as a ratio outside that range. Data were analyzed using the Rao-Scott χ², F test, and multivariate logistic regression. Compared with those in the "symmetric HGS and not weak" group, those in the "asymmetric HGS and weak" group had impaired health-related quality of life for all variables among men (odds ratios [ORs] = 1.67-3.75, 95% confidence interval [CI] [1.14, 6.27]). A greater risk of impaired self-care (SC; odds ratio [OR] = 2.33, 95% CI [1.67, 3.25]) and anxiety/depression (AD; OR = 1.40, 95% CI [1.04, 1.88]) was observed among women in the "asymmetric HGS and weak" group. Handgrip weakness and asymmetry are associated with impaired health-related quality of life. Handgrip asymmetry can be a clinical marker of health-related quality of life in older adults and must be measured alongside HGS.

Recurring Weakness in Rhabdomyolysis Following Pfizer-BioNTech Coronavirus Disease 2019 mRNA Vaccination

Rhabdomyolysis is a well-known clinical syndrome of muscle injury. Rhabdomyolysis following coronavirus disease 2019 (COVID-19) vaccination has recently been reported. The patients’ weakness gradually subsided and did not recur. Rhabdomyolysis associated with COVID-19 vaccination has not been assessed by repeated magnetic resonance imaging (MRI) within a short time. We report a rare case of an older woman who developed recurring weakness with rhabdomyolysis after COVID-19 vaccination. A 76-year-old woman presented with myalgia 2 days after receiving a third dose of the COVID-19 vaccine. A physical examination showed weakness of the bilateral iliopsoas muscles. Her creatine kinase concentration was 9816 U/L. MRI showed hyperintensity of multiple limb muscles. She was treated with intravenous normal saline. Her symptoms disappeared within 3 days. However, MRI on day 4 of hospitalization showed exacerbation of the hyperintensity in the left upper limb muscles. On day 5 of hospitalization, weakness of the left supraspinatus and deltoid muscles appeared. MRI on day 8 of hospitalization showed attenuation of the hyperintensity in all muscles. Her weakness and elevated creatine kinase concentration disappeared by day 10. Repeated MRI over a short time may be useful to predict potential weakness and monitor the course of COVID-19 vaccine-induced rhabdomyolysis.

Causal Effects of Motor Control on Gait Kinematics After Orthopedic Surgery in Cerebral Palsy: A Machine-Learning Approach

Background

Altered motor control is common in cerebral palsy (CP). Understanding how altered motor control affects movement and treatment outcomes is important but challenging due to complex interactions with other neuromuscular impairments. While regression can be used to examine associations between impairments and movement, causal modeling provides a mathematical framework to specify assumed causal relationships, identify covariates that may introduce bias, and test model plausibility. The goal of this research was to quantify the causal effects of altered motor control and other impairments on gait, before and after single-event multi-level orthopedic surgery (SEMLS).

Methods

We evaluated the impact of SEMLS on change in Gait Deviation Index (ΔGDI) between gait analyses. We constructed our causal model with a Directed Acyclic Graph that included the assumed causal relationships between SEMLS, ΔGDI, baseline GDI (GDIpre), baseline neurologic and orthopedic impairments (Imppre), age, and surgical history. We identified the adjustment set to evaluate the causal effect of SEMLS on ΔGDI and the impact of Imppre on ΔGDI and GDIpre. We used Bayesian Additive Regression Trees (BART) and accumulated local effects to assess relative effects.

Results

We prospectively recruited a cohort of children with bilateral CP undergoing SEMLS (N = 55, 35 males, age: 10.5 ± 3.1 years) and identified a control cohort with bilateral CP who did not undergo SEMLS (N = 55, 30 males, age: 10.0 ± 3.4 years). There was a small positive causal effect of SEMLS on ΔGDI (1.70 GDI points). Altered motor control (i.e., dynamic and static motor control) and strength had strong effects on GDIpre, but minimal effects on ΔGDI. Spasticity and orthopedic impairments had minimal effects on GDIpre or ΔGDI.

Conclusion

Altered motor control did have a strong effect on GDIpre, indicating that these impairments do have a causal effect on a child's gait pattern, but minimal effect on expected changes in GDI after SEMLS. Heterogeneity in outcomes suggests there are other factors contributing to changes in gait. Identifying these factors and employing causal methods to examine the complex relationships between impairments and movement will be required to advance our understanding and care of children with CP.

Hip Adduction and Abduction Strength Profiles Among Bantam, High School, Juniors, and Collegiate American Ice Hockey Players

Background

Adductor strains are the most common non-contact musculoskeletal injury sustained in ice hockey. Systematic reviews have determined higher level of play and lower hip adduction to abduction strength ratios to be associated with an increased risk of adductor strain across multiple sports. Limited research exists regarding hip adduction and abduction strength profiles across various levels of ice hockey players.

Purpose

To compare isometric hip adduction and abduction strength profiles among bantam, high school, tier one juniors, and NCAA Division I collegiate ice hockey players. A secondary purpose was to identify whether differences in strength profiles between dominant and non-dominant limbs exist.

Study Design

Cross-sectional cohort study.

Methods

A questionnaire of demographic data, hockey, and injury specific information was completed by all subjects. The mean of three reps of maximal hip isometric adduction and abduction strengths were quantified using a handheld dynamometer with external belt-fixation. Ratios of hip adduction-to-abduction strength were calculated and normalized for body weight.

Results

A total of 87 uninjured skaters were included in this study with a mean age of 17 years. Mean hip adductor-to-abductor ratios for Bantam hockey players were 121% followed by collegiate (115%), Juniors (111%), and high school (109%) hockey players. No statistically significant differences were found between peak hip adduction and abduction isometric strength and playing level. In addition, there was no difference between unilateral hip strength ratios and shooting hand or leg dominance. While 34.5% of subjects reported a history of adductor injury, no significant differences existed regarding strength ratios during bilateral comparison or when compared to their team norms. Three subjects were found to have unilateral ratios of less than 80%, while two subjects demonstrated bilateral ratios of less than 80%.

Conclusions

Symmetry is illustrated between dominant and non-dominant legs in ice hockey players with and without a history of adductor injury. Results align well with previously established cross-sectional data from Australian football, with ratios of 103% in high school players, 107% in semi-professional players, and 113% in collegiate players.

Level of Evidence

Level 3.

Investigation of neural and biomechanical impairments leading to pathological toe and heel gaits using neuromusculoskeletal modelling

KEY POINTS

Pathological toe and heel gaits are commonly present in various conditions such as spinal cord injury, stroke or cerebral palsy. These conditions present various neural and biomechanical impairments and the cause-effect relationships between these impairments and pathological gaits are hard to establish clinically. Based on neuromechanical simulation, this study focuses on the plantarflexor muscles and builds a new reflex circuit controller to model and evaluate the potential effect of both neural and biomechanical impairments on gait. Our results suggest an important contribution of active reflex mechanisms in pathological toe gait. This "what if" based on neuromechanical modelling is thus deemed of great interest to target potential pathological gait causes.

ABSTRACT

This study investigates the pathological toe and heel gaits in human locomotion using neuromusculoskeletal modelling and simulation. In particular, it aims at investigating potential cause-effect relationships between biomechanical or neural impairments and pathological gaits. Toe and heel gaits are commonly present in spinal cord injury, stroke or cerebral palsy. Toe walking is mainly attributed to spasticity and contracture at plantarflexor muscles, whereas heel walking can be attributed to muscle weakness from biomechanical or neural origin. To investigate the effect of these impairments on gait, this study focuses on the soleus and gastrocnemius muscles as they contribute to ankle plantarflexion. We built a reflex circuit model on top of Geyer and Herr's work (2010) with additional pathways affecting the plantarflexor muscles. The SCONE software, which provides optimisation tools for 2D neuromechanical simulation of human locomotion, is used to optimise the corresponding reflex parameters and simulate healthy gait. We then modelled various bilateral plantarflexors biomechanical and neural impairments, and individually introduced them in the healthy model. We characterised the resulting simulated gaits as pathological or not by comparing ankle kinematics and ankle moment with the healthy optimised gait based on metrics used in clinical studies. Our simulations suggest that toe walking can be generated by hyperreflexia, whereas muscle and neural weaknesses induce partially heel gait. Thus, this "what if" approach is deemed of great interest as it allows the investigation of the effect of various impairments on gait and suggests an important contribution of active reflex mechanisms in pathological toe gait. Abstract figure legend Various biomechanical and neural impairments are individually modelled at the level of the plantarflexor muscles in a musculoskeletal model and a complex reflex circuit-based gait controller. For instance, as shown on the left, the plantarflexors spindle reflex gain (KS) is increased to mimic hyperreflexia. The gait controller is then optimised for each of the impaired condition and the resulting gaits are characterised as pathological gait based on ankle kinematics and ankle moment metrics used in clinical studies. Thus, this "what if" approach allows the investigation of the effect of various impairments on gait presented in the table on the right. This article is protected by copyright. All rights reserved.

Breakfast Protein Quality and Muscle Strength in Japanese Older Adults: A Community-Based Longitudinal Study

OBJECTIVES

The amount of breakfast protein intake is important for maintaining muscle strength. However, the effect of breakfast protein quality (ie, bioavailability) remains unclear. We investigated the association between breakfast protein quality and the incidence of muscle weakness.

DESIGN

Longitudinal study.

SETTING AND PARTICIPANTS

Healthy older adults age 60-83 years without stroke, arthritis, Parkinson disease, or muscle weakness at baseline (maximum follow-up period and participations were 9.2 years and 5 times, respectively).

METHODS

Weakness was defined by the Asian Working Group for Sarcopenia 2019 criteria, using grip strength. Breakfast protein quality was evaluated using the protein digestibility-corrected amino acid score (PDCAAS), where higher scores represent higher quality, calculated from 3-day dietary records. Participants were classified according to sex-stratified tertiles of breakfast PDCAAS (ie, low to high groups). The association between PDCAAS and incident weakness was analyzed using the generalized estimating equation, after adjusting for sex, age, follow-up time, grip strength, body mass index, physical activity, cognition, education, smoking, economics, medical history, lunch and dinner PDCAASs, and energy and protein intake during 3 regular meals at baseline.

RESULTS

Overall, 14.4% of the initial sample was excluded owing to a diagnosis of weakness-related diseases, and 58.3% (n = 701) had at least 1 follow-up measurement for inclusion in the analysis. The mean ± SD follow-up period was 6.9 ± 2.1 years; the cumulative number of participants was 3019, and 282 developed weakness. Using the low PDCAAS group as the reference, the adjusted odds ratios (95% CIs) for incident weakness in the middle and high PDCAAS groups were 0.71 (0.43-1.18) and 0.50 (0.29-0.86), respectively.

CONCLUSIONS AND IMPLICATIONS

Higher breakfast protein quality was associated with a reduction in incident weakness in older adults, independent of protein intake. These findings may highlight the role of protein quality for muscle health in older adults.

Approach to the child with fatigue: A focus for the general pediatrician

BACKGROUND

Fatigue is a common, nonspecific complaint commonly used to describe various conditions, ranging from a vague, subjective sense of weariness to muscular weakness, fatigability, exercise intolerance or excessive daytime somnolence. Despite its high frequency in the general population, literature addressing the approach to the child with fatigue from a general pediatrician perspective is poor. We herein propose a review of the available evidence on the topic, providing a practical framework to assist physicians in dealing with the issue.

METHODS

Data were identified by searches of MEDLINE, UpToDate, Google Scholar and references from relevant articles. Articles published between 1990 and 2021 were considered, prioritizing systematic reviews and meta-analyses. Then, an empirically-based model of approaching the tired child was proposed according to our center experience.

RESULTS

To correctly characterize the meaning of fatigue reporting, specific clues from history and physical examination should be emphasized. Duration, severity, and the age at onset are to be considered. Then, specific queries about everyday activities, sleep hygiene and social domain could be useful in reaching a specific diagnosis and offering an appropriate treatment.

CONCLUSIONS

We suggest a pragmatic approach to fatigue in children based on age assessment, targeted questions, physical examination clues, and some laboratory first-level tests. This could provide pediatricians with a useful tool to discriminate the broad etiology of such a complaint, disentangling between psychological and organic causes. Further studies are needed to investigate the predictive value, specificity and sensitivity of this diagnostic workflow in managing the child with fatigue.

Case Report: Uncommon cause of limp in the 21st century

Scurvy results from a deficiency of ascorbic acid. This disease first appeared in children during the 19th century with the emergence of new dietary habits; in particular, heating milk that leads to a loss of ascorbic acid. Even though scurvy has become a rare condition in western countries, many cases are still reported in pediatric patients, especially in those who lack proper nutrition due to neurological or psychiatric illnesses. Symptoms include bleeding and swollen gums, loosening of teeth, bone abnormalities, arthralgia, delayed wound healing, anemia, petechiae, and purpura. Bone lesions are mainly irregularities of long bones metaphyses. We report the case of a five-year-old boy who presented with arthralgia and limb deformation (genu valgum). The patient was investigated for vitamin deficiencies to exclude rickets. The radiologic investigations revealed metaphyseal signs compatible with scurvy. During the hospitalization, the patient was observed to have abnormal eating patterns and the scurvy was attributed to malnutrition. Although the occurrence of scurvy is rare, it remains essential to detect this disease in children at risk of developing vitamin deficiencies. Without targeted treatment, the complications of scurvy can be serious and potentially fatal.

Electromyographic Analysis of Hip and Trunk Muscle Activity During Side Bridge Exercises in Subjects With Gluteus Medius Weakness

CONTEXT

Side bridge exercises strengthen the hip, trunk, and abdominal muscles and challenge the trunk muscles without the high lumbar compression associated with trunk extension or curls. Previous research using electromyography (EMG) reports that performance of the side bridge exercise highly activates the gluteus medius (Gmed). However, to the best of our knowledge, no previous research has investigated EMG amplitude in the hip and trunk muscles during side bridge exercise in subjects with Gmed weakness.

OBJECTIVE

The purpose of this study was to examine the EMG activity of the hip and trunk muscles during 3 variations of the side bridge exercise (side bridge, side bridge with knee flexion, and side bridge with knee flexion and hip abduction of the top leg) in subjects with Gmed weakness.

DESIGN

Repeated-measures experimental design.

SETTING

Research laboratory.

PATIENTS

Thirty subjects (15 females and 15 males) with Gmed weakness participated in this study.

INTERVENTION

Each subject performed 3 variations of the side bridge exercise in random order.

MAIN OUTCOME MEASURES

Surface EMG was used to measure the muscle activities of the rectus abdominis, external oblique, longissimus thoracis, multifidus, Gmed, gluteus maximus, and tensor fasciae latae (TFL), and Gmed/TFL muscle activity ratio during 3 variations of the side bridge exercise.

RESULTS

There were significant differences in Gmed (F2,56 = 110.054, P < .001), gluteus maximus (F2,56 = 36.416, P < .001), and TFL (F2,56 = 108.342, P < .001) muscles among the 3 side bridge exercises. There were significant differences in the Gmed/TFL muscle ratio (F2,56 = 20.738, P < .001).

CONCLUSION

Among 3 side bridge exercises, the side bridge with knee flexion may be effective for the individuals with Gmed weakness among 3 side bridge exercises to strengthen the gluteal muscles, considering the difficulty of the exercise and relative contribution of Gmed and TFL.