Motor Neuron Disease - www.prsharma.com.np
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Transcript Motor Neuron Disease - www.prsharma.com.np
Approach to a child with
weakness
Dr. Pushpa Raj Sharma
Professor of Child Health
Institute of Medicine
Weakness/paresis/paralysis
Upper Motor Neuron.
Lower Motor Neuron
Myopathic
Pattern of weakness
Sign
UMN
LMN
Atrophy
-
+++
+
Fasciculations
-
+++
-
Tone
+++
Myopathic
-
+/-
Distribution
Regional
Segmental
Proximal
Tendon reflexes
+++
-/--
+/-
Babinski’s sign
+
-
-
Important fact:
When there is a discrepancy between the
history and physical findings, it is usually
because the patient complains of
weakness, whereas symptoms are
actually due to other causes.
Child Abuse may be the cause.
Motor Neuron Disease
Asymmetric
Upper and lower motor neurones
Amyotrophic Lateral Sclerosis (ALS)
Sporadic ALS
Hereditary ALS
Superoxide Dismutase; Chromosome 21; Dominant
Other ALS: Recessive & Dominant
Multi-system disorders
ALS with Ophthalmoplegia & Extrapyramidal
Disorders
Polyglucosan body disease
Motor neuronopathy with cataracts and skeletal
abnormalities
Multiple system atrophy
Motor Neuron Disease
Symmetrical and proximal
SMN: Chromosome 5q; Recessive
Androgen Receptor (Bulbo-spinal Muscular Atrophy):
X-linked; Recessive
Hexosaminidase A (Tay-Sachs): Chromosome 15;
Recessive
Hand weakness
Bulbar involvement
Motor Neuron Disease
Lower motor neurones only
• Distal Lower Motor Neuron (LMN) Syndrome
IgM vs GM1 ganglioside
IgM vs GalNAc-GD1a ganglioside
Also see: Multifocal motor neuropathy
• Proximal Lower Motor Neuron Syndromes
Brachial amyotrophic diplegia
? Associated with IgM vs asialo-GM1
Rare: Upper > Lower limbs with anti-Hu antibodies
Motor Neuron Disease
Lower Motor Neuron Syndrome without antibodies
(PMA)
ALS variants
• Hereditary
• Sporadic
Focal motor neuron disease
• Monomelic Amyotrophy
• Paraspinous muscle amyotrophy
• Cervical amyotrophy
Motor Neuron Disease
Paraneoplastic motor neuro(no)pathy
• Mild weakness: With lymphoma
• Severe weakness: With breast cancer
Hopkins' syndrome: Acute post-asthmatic
amyotrophy
Polio & Post-polio syndrome
SMN2 (SMNC) deletions
Neurofibromatosis, Type 25
Motor Neuron Disease
Symmetric & Proximal: Hereditary Spinal
Muscular Atrophy
SMN: Chromosome 5q; Recessive
Androgen Receptor (Bulbo-spinal Muscular
Atrophy): X-linked; Recessive
Hexosaminidase A (Tay-Sachs): Chromosome
15; Recessive
Motor Neuron Disease
Rapid onset
Acute Axonal Motor Neuropathy
(with Campylobacter jejuni or serum IgG vs
GM1)
Poliomyelitis
Porphyria
4 types cause neurologic attacks
•
•
•
•
Acute intermittent
Variegate Porphyria
Coproporphyria
δ-amino-levulinic acid dehydratase deficiency
Urine: All types produce increased δ-amino-levulinic acid
during attacks
Motor Neuron Disease
Painful
Acquired
Others
Motor Neuron Disease
Acquired
Toxic: Lead; Dapsone; Botulism; Tick Paralysis
Infections
Polio
West Nile
Central European encephalitis
Creutzfeld-Jacob
• Amyotrophy
• Polyneuropathy (± Demyelinating)
Weakness/ paresis/ paralysis indicates the lesions in the upper motor
nurone or lower motor neurone or myoneural junction or muscles.
Preservation of sensation/ Increased or absent or diminished jerks/
atrophy or hypertrophy indicates the site of lesions.
The major clinical diagnosis associated
with AFP (n= 517) *
Guillain-Barre syndrome (30.2%),
Central nervous system infection (16.2%),
Transverse myelitis (10.6%)
Non-polio enterovirus infection (6.2%),
Hypokalaemic paralysis (5.2%).
* Hussain IH, Ali S, Sinniah M, Kurup D, Khoo TB, Thomas TG,
Apandi M, Taha AM J Paediatr Child Health. 2004 Mar;40(3):12730
Age distribution of Guillain-Barré syndrome.
AIDP=acute inflammatory demyelinating polyradiculoneuropathy; FS=Fisher syndrome
Lyu, R.-K. et al. J Neurol Neurosurg Psychiatry 1997;63:494-500
Seasonal distribution of Guillain-Barré syndrome
Lyu, R.-K. et al. J Neurol Neurosurg Psychiatry 1997;63:494-500
Recurrent Guillain Barre' Syndrome
Of the 220 patients of acute idiopathic
demyelinating polyneuritis (AIDP/GBS)
seen over a seven year period, 15 patients
(M:F:11:4) had a relapsing course (6.8%).
They had 36 episodes at a variable
interval of 3 months to 25 yrs.
Taly AB, Gupta SK, Anisya V, Shankar SK, Rao S, Das KB, Nagaraja D,
Swamy HS. J Assoc Physicians India. 1995 Apr;43(4):249-52.
Follow-up of AGBS
At a follow-up of 1 year or more, 20
patients recovered and 3 had residua.
Hung PL, Chang WN, Huang LT, Huang SC, Chang YC, Chang CJ, Chang CS, Wang KW, Cheng BC, Chang HW, Lu
CH. Pediatr Neurol. 2004 Feb;30(2):86-91.
permanent neurological defects in children
under 15 years of age was 1.4/10 million
annually
Rantala H, Uhari M, Niemela M. Arch Dis Child. 1991 Jun;66(6):706-8; discussion 708-9.
Subacute Inflammatory Demyelinating
Polyneuropathy.
progressive motor and/or sensory
dysfunction consistent with neuropathy in
more than one limb with time to nadir
between 4 and 8 weeks,
electrophysiologic evidence of
demyelination in at least two nerves,
no other etiology of neuropathy, and
no relapse on adequate follow-up.
Complete recovery was achieved in 69%
of cases and partial recovery in others.
Oh SJ, Kurokawa K, de Almeida DF, Ryan HF Jr, Claussen GC.
Neurology. 2003 Dec 9;61(11):1507-12.
Chronic Inflammatory Demyelinating
Polyradiculoneuropathy
A low frequency of antecedent events.
Weakness accompanied by sensory loss
and diminished tendon reflexes
Pain and cranial neuropathies are
uncommon
Progressive weakness for two months.
Sladky JT; Ashwal S: Peripheral neuropathies in childre. Pediatric Neurology Principles and
Practice. Ed. Swaiman KS; Ashwal S. 3rd ed.1999. Publisher: Mosby
Causes Inflammatory
Polyradiculoneuropathy
GB Syndrome
58%
Chronic inflammatory demyelinating
polyneuropathy
31%
Associated with collagen
vascular disease
7%
Other immune/infectous
disorders
4%
HOPKINS' SYNDROME: Acute postasthmatic amyotrophy
Onset
After acute asthmatic attack: Latency 1 to 18
days
Mild pain: Limb, neck or meningismus
Rapid onset weakness
HOPKINS' SYNDROME: Acute postasthmatic amyotrophy
Weakness
Single limb; Asymmetric; May be Proximal >
Distal
Severity: Mild to severe
Arm or leg
Sensory: Normal
HOPKINS' SYNDROME: Acute postasthmatic amyotrophy
CSF
Pleocytosis
Protein: ± Increased
MRI: May show signal (T2) in spinal cord
Prognosis: Permanent paralysis
Flaccid or hyper tonicity