DM neuropathy v CIDP

Use rules

1.  With proximal weakness and distal weakness, in absence of genetic disorder, CIDP is overwhelmingly more likely; diabetic is usually not proximal\

2.  Diabetic is sensory, CIDP is motor more

3.  Diabetic is insidious, CIDP is aggressive

4.  Distal/proximal gradient reflex loss is more common in DM

5.  Objective response to immunomodulation is much more common in CIDP

 

(Obvious but still useful)

HNPP pearls

EMG

 

1.  Median >>> ulnar,  2.  Peroneal is involved

3.  Tibial nerve is almost never involved

4.  Pathology is tomaculi

5.  ulnar slowing across elbow is 100 %

6.  peroneal slowing across knee is 85 %

7.  SNAP's are abnormal-- amplitudes always reduced, latencies may be prolonged-- have not only pressure palsies but also an age related neuropathy

 

 

Clinical

Unlike CIDP, in which patients are usually symptomatic, HNPP patients often are asymptomatic with EMG changes

Remote weakenss after botox therapy

Richardson and Beckerly (Muscle and Nerve, 2008) described a patient who received repeated botox A for spasticity post stroke who developed contralateral shoulder weakness with decrement seen on repetitive nerve stimulation, suggestive of neuromuscular blockade.

Spurling's maneuver, in cervical radiculopathy

SM produces Spurling's sign. Method-- rotate head and flex neck towards affected limb then axially compress the head. Production of radicular pain or numbness is called SS, suggests active radiculopathy. Author Wieting et al. modified procedure by extending neck, rotating, then flexing and axially compressing towards affected side in 363 patients. EMG was done immediately after. Modified SM was more sensitive for radiculopathy then traditional SM. Prediction of radiculopathy increased from 17 to 55 % . (Muscle and Nerve 2008).

Alternative to tongue EMG in ALS

Sonoo et al. studied 100 ALS patients. Tongue EMG is sensitive when patients can relax for examination, but only about half or less can. Fibs , positive waves and fasciuclations were seen in 62 % of trapezii, 17 % of sternocleidomastoid muscles, and 8 % of tongue, whereas the number was zero abnormal muscles in cervical spondyslosis patients.

Nerve conductions in POEMS synrdome

Presentation is symmetric peripheral neuropathy resembling CIDP, with areflexia and mixed demyelinating.axonal features. The systemic features include organomegaly, endocrinopathy, monoclonal serum protein ( M protein), and dermatologic abnormalities In a study of 138 patients with POEMS seen over 47 years, Mauermann et al found slowed motor and sensory velocity, prolonged distal latiencues and F waves. However, unlike CIDP there was rarely temporal dispersion or conduction block.

Glycogenosis type II in adults

Bembi et al. Diagnosis of glycogenosis type II. Neurology 2008; 71: S2: S4-S11.
Also known as glycogen storage disease type II, Pompe d or acid maltase deficiency caused by a mutation in the gene encoding acid alpha-glucosidase (GAA) enzyme leading to accumulation of glycogen in lysosomes of several tissues including cardiac skeletal and smooth muscle cells.

In juvenile/adult type, phenotype may vary somewhat and more than 200 mutations of the GAA gene are reported. In adults, skeletal muscle involves the proximal lower limbs, and paraspinal muscles often followed by severe diaphragmatic and accessory muscle failure. Complaints may include exertional pain, cramps and aches, back pain, slow disease progression. Respiratory involvement may occur early and may be presenting symptom in 30 % of cases. Sleep apnea, exertional dyspnea and RTI's are common.

Evaluation should include CPK (high in 95%), ALT, AST, DH, +/- urinary Glc4 . NCS are normal. EMG is nonspecific shows fibs, myotonic and myopathic findings. Classic muscle biopsy may show acid phos positive cytoplasmic vacuoles but may be negative. Biochemical assays for GAA activity are often needed to confirm. Skeletal muscle or skin fibroblasts may be used. Molecular analysis of the gene may also be needed. In adults cardiac muscles is usually not affected, unlike infants and juveniles.

The differential diagnosis includes Becker, limb girdle, scapuloperoneal, rigid spine s, other glycogen related diseases (debrancher deficiency, branching enzyme def, myophosphorylase def, PFK def, Danon disease, mitochondrial disease, polymyositis.

MRI's in adults (n=11) with confirmed disease showed adductor magnus, semimembranosus, semitendinosis involved early on. Later, fatty infltration occurs in long head of biceps femoris, 3 heads of vastus, with SPARING OF SHORT HEAD OF BICEPS, SARTORIUS, RECTUS, GRACILIS AND PERIPHERAL PART OF VASTUS LATERALIS. CALF MUSCLES ARE NORMAL.

PEARL 2 DISTINGUISHING FEATURES FROM OTHER MYOPATHIES IS SPARING OF SHORT HEAD OF BICEPS AND TENSOR FASCIA LATA WITH ATROPHY OF OTHER PELVIC MUSCLES.

Respiratory management: Cough peak expiratory flow (CPEF) is single best test to determine if patient can clear secretions with a threshold value of 160 L/min being adequate. A high negative maximal inspiratory pressure (>80 cm H2O) or high positive maxinal expiratory pressure (>90 cm H2O) excludes relavant inspiratory or expiratory weakness. Sniff expiratory pressure should also be checked.

Sleep disordered breathing refers to central, obstructive or mixed apnea, hypoventilation or both during sleep. SDB occurs in two thirds. Hypoventilation during REM sleep is due to decreased tidal volume especially during REM sleep. OSA may be life threatening. Orthopnea and dyspnea may be late findings. Late tachypnea at rest occurs. On exam look for failure of outward distension of abdomen during breathing (inspiration) accessory recruitment and mucus encumbrance of upper and lower airways.

No outpatient surgery should be done, and anesthesia consulted.

Genetics usually is AR. Risk of being a carrier for a sib of an affected patient is 2/3, and risk of being a carrier for sibs of a parent of an affected patient is 1/2. Risk of an affected child for a sib of an affected patient is > 1/600 and for sibs of a parent, > 1/800.

A clinical trial with a Genzyme drug, alglucosidase alfa resulted in improved walking distance and stabilized pulmonary function over an 18 month period (van der Ploeg et al., A randomized study of alglucosidase alfa in late onset Pompe's disease NEJM 2010; 362: 1396-1406) (ClinicalTrials.gov.number, NCT00158600).  Outcome measures were six minute walk and percentage of predicted FVC. 

Peroneal intraneural ganglia: clinical and electrical findings

Young NP, Sorenson EJ, Spinner RJ, Daube JR. Clinical and electrodiagnostic correlates of peroneal intraneural ganglia. Neurology 2009; 72: 447-452.

Common peroneal neuropathy (CMP) with (n=22) and without (n=11) IG.

Features found with CMP + IG group but not found in -IG group: greater body mass, more pain at knee (52 v . 0 %); more likely fluctuating weakness with weight bearing ( 48 v. 4 %); and palpable mass at fibular head ( 47 v. 0 %). Less presentation of weight loss, immobility or leg crossing. There were no electrophysiologic differences. Tinel's sign and weakness were present in both groups. Higher grade of fibrillations were usually found in tibialis anterior than peroneus longus reflecting cmp. MRI or ultrasound was used to diagnose the entity.

NCS Safety with defbrillators

AANEM report 2006 patients underwent NCS with sensing pacemaker electrodes. The electrical impulses in 15 patients with varous types of defibrillators were never detected by the sensing amplifier of the defibrillator or pacemaker. It did not affect the settings or cause the defibrillator to charge. Monitoring and and pre/post interrogations were normal. Conclusion, NCS are safe in patients with implanted cardiac pacemakers and defibrillators with bipolar sensing configurations.