Metabolic myopathies. A diagnostic evaluation.

This article briefly reviews the initial approach to the patient suspected of having metabolic myopathy. Diagnostic highlights include relevant points of history, physical examination, blood work-up, forearm ischemic exercise test, electrophysiologic testings and muscle biopsy. The diagnostic evaluation is discussed in detail in separate articles.

Endocrine myopathies.

This article provides a review of some of the muscular disorders that can arise from some of the commonly seen endocrinologic disturbances. Thyroid, parathyroid, and adrenal dysfunctions as they relate to neuromuscular symptoms are discussed. Common clinical presentations of the endocrine myopathies are highlighted, along with diagnostic evaluation and treatments.

Stretch of mammalian nerve in vitro: effect on compound action potentials.

Stretch of nerve has been reported to decrease the amplitude of the compound action potential (CAP) with a complete block appearing in approximately 30 minutes. But for the most part, those experiments were carried out in vivo, and it is generally accepted that the failure of responses was due to a closure of vessels supplying the nerve with a resulting ischemia and anoxia. These studies were undertaken to determine if stretch of nerve has effects that are independent of interference with its vascular supply. In the studies, lengths of rat sciatic and dog peroneal nerves were removed and placed in a chamber supplied with oxygen in which their CAPs were continuously elicited and recorded. This in vitro preparation obviated interference with the nerve's metabolism on stretching. We have previously shown that the form change termed 'beading,' appearing within 10 seconds and reversing as quickly on relaxation, can be elicited with tensions of only several grams. We wished to determine if stretch adequate to produce beading could alter CAPs with the same rapidity. Tensions below 2 g had little effect. On applying tensions of 10-100 g, levels well above those needed to bead the fibers, both increases and decreases of CAP amplitude were seen. The changes occurred within 10 seconds of stretch application, the time at which beading arises with stretch. Although the decreases of CAP amplitudes could be accounted for by beading, the degree of CAP change did not correspond to the amount of tension applied. We hypothesize that the constrictions in the beaded fibers increase axial resistivity and diminish local currents so as to block conduction. The lack of an increasing degree of decreased CAP amplitude with increases in tension is ascribed to the inhibition of elongation offered by the collagen fibrils present in nerve. Collagenase applied to nerves allowed a further increase in length, producing a 'hyperbeading,' showing much longer lengths of beading constrictions on stretch. This would further increase axial resistance and is taken to account for the greater decreases of CAP amplitudes seen following collagenase treatment. To account for those cases where increases of CAP amplitude were seen on stretch, we hypothesize that stretch can also cause an increase in the excitability of the nodes. The outcome of stretch in any given nerve would be the resultant of two opposing actions; beading of the internodes causes a decrease of local currents leading to block of CAPs, while an increased excitability of the nodes acts to augment the responses.

Long-term tracheostomy ventilation in neuromuscular diseases: patient acceptance and quality of life.

Domiciliary assisted ventilation has been used to prolong life in patients with neuromuscular diseases. Although earlier studies suggest that the majority of patients are satisfied with their lives, the physician's perception of a patient's poor quality of life on assisted ventilation is a major reason for discouraging assisted ventilation. In this study, the quality of life was assessed in 19 patients with neuromuscular diseases on domiciliary tracheal intermittent positive-pressure ventilation for a mean duration of 54 months. An attempt was made to compare the quality of life of Duchenne muscular dystrophy patients with that of amyotrophic lateral sclerosis patients. More than two-thirds of patients were satisfied with their lives. Eighty-four percent thought they had made the right choice. Patients with amyotrophic lateral sclerosis were somewhat more negative or ambiguous toward assisted ventilation and had lower life satisfaction scores as compared with Duchenne muscular dystrophy patients. Financial stresses were significant. Assisted ventilation should be offered as a viable option to patients with neuromuscular diseases. Larger studies may be useful in influencing insurance companies to make expenses associated with assisted ventilation reimbursable.

Diabetic neuropathy.

The most common form of diabetic neuropathy is chronic, distal symmetrical sensorimotor, or predominantly sensory neuropathy; the latter is invariably associated with some degree of autonomic dysfunction. There are, however, other neuropathic patterns in diabetes mellitus that are uncommon but are important to recognize, since they may mimic many other non-neurologic diseases. This article discusses a variety of forms of mononeuropathies and diabetic proximal motor neuropathy, commonly known as diabetic amyotropy.

Toxic myopathies.

Toxic myopathies may occur with a variety of prescribed medications, illicit drug abuse, or other toxins. The article discusses an overview of some of the compounds that may cause myopathy, the clinical and laboratory features, histology, mechanisms of action, and potential risk factors of myopathy. The ability to recognize these syndromes is essential to avoid unnecessary tests and to avoid delay in treatment, especially in critically ill patients or patients with other neuromuscular diseases.

The origin and nature of beading: a reversible transformation of the shape of nerve fibers.

Nerve fibers which appear beaded (varicose, spindle-shaped, etc.) are often considered the result of pathology, or a preparation artifact. However, beading can be promptly elicited in fresh normal nerve by a mild stretch and revealed by fast-freezing and freeze-substitution, or by aldehyde fixating at a temperature near 0 degree C (cold-fixation). The key change in beading are the constrictions, wherein the axon is much reduced in diameter. Axoplasmic fluid and soluble components are shifted from the constrictions into the expansions leaving behind compacted microtubules and neurofilaments. Labeled cytoskeletal proteins carried down by slow axonal transport are seen to move with the soluble components and not to have been incorporated into and remain with, the cytoskeletal organelles on beading the fibers. Lipids and other components of the myelin sheath are also shifted from the constrictions into the expansions, with preservation of its fine structure and thickness. Additionally, myelin intrusions into the axons are produced and a localized bulging into the axon termed "leafing". The beading constrictions do not arise from the myelin sheath: beading occurs in the axons of unmyelinated fibers. It does not depend on the axonal cytoskeleton: exposure of nerves in vitro to beta, beta'-iminodipropionitrile (IDPN) disaggregates the cytoskeletal organelles and even augments beading. The hypothesis advanced was that the beading constrictions are due to the membrane skeleton; the subaxolemmal network comprised of spectrin/fodrin, actin, ankyrin, integrins and other transmembrane proteins. The mechanism can be activated directly by neurotoxins, metabolic changes, and by an interruption of axoplasmic transport producing Wallerian degeneration.

Design and construction of a hybrid immunoglobulin domain with properties of both heavy and light chain variable regions.

The complementarity-determining regions (CDRs) of a human kappa light chain were replaced with CDRs from a murine gamma-1 heavy chain and, by use of molecular modeling, key heavy chain framework residues were identified and thus included to preserve the native conformation of the heavy chain CDRs. Co-expression of this hybrid human kappa chain (V[HB]C[L]) with a human kappa chain counterpart (V[L]C[L], engineered to contain murine light chain CDRs) resulted in the secretion of high levels of a heterodimeric protein (V[HB]C[L]::V[L]C[L]) termed 'kappabody'. This protein also had equivalent affinity for antigen as the Fab' of the parent murine IgG1. High-level secretion was also observed for the hybrid chain as homodimers (V[HB]C[L]::V[HB]C[L]), which is not observed for chimeric chains consisting of a heavy chain variable region and light chain constant region, i.e. V[H]C[L] homodimers or single chains are not secreted. This indicates that regions within the variable domain, required for secretion of light chains, reside outside of the hypervariable regions (CDRs) and that the heavy chain CDRs and supporting residues do not prevent secretion. These results demonstrate the possibility of designing small, single-domain molecules possessing a given binding activity which may be secreted at high levels from mammalian cells.

Myasthenia gravis.

Adult-onset myasthenia gravis is an acquired autoimmune disorder of neuromuscular transmission in which acetylcholine receptor antibodies attack the postsynaptic membrane of the neuromuscular junction. Although the cause of this disease is unknown, the role of immune responses in its pathogenesis is well established. Circulating acetylcholine receptor antibodies are present in 80% to 90% of patients with the generalized form of myasthenia gravis. Most patients have ptosis, diplopia, dysarthria and dysphagia. The weakness and fatigue worsen on exertion and improve with rest. Respiratory muscle and limb weakness are rare at the onset of the disease. For the past two decades, there has been considerable progress in understanding the diagnosis and management of myasthenia gravis. The diagnosis is based on clinical presentation, neurologic examination, and confirmation by means of electrophysiologic testing and immunologic studies. Myasthenia gravis mimics many neuromuscular diseases and even illnesses such as depression and chronic fatigue syndrome. One should always exclude drug-induced myasthenia gravis for all patients. With the introduction of new modalities of treatment, particularly immunosuppressive or immunomodulating drugs, plasma exchange and thymectomy, the morbidity and mortality of myasthenia gravis have decreased dramatically to the point that myasthenia gravis should not be considered as serious a disease as it once was. Although the several therapeutic options are usually effective and have meant independence in daily life to many patients with myasthenia gravis, well-designed, controlled, prospective studies are still lacking.

AAEM case report #31: paraneoplastic sensory neuronopathy.

Sensory neuronopathy (SN) presents with sensory ataxia and no weakness. The site of pathology is in the dorsal root ganglia. Electrodiagnostic studies show absence of sensory nerve action potentials and preservation of motor nerve function. Elderly individuals with sensory ataxia and typical electrodiagnostic findings of SN should be evaluated for underlying carcinoma.

Seizures and epilepsy in older patients: evaluation and management.

Seizures and epilepsy in older patients are commonly caused by a previous stroke or other organic CNS insult. In patients who have "spells", the first step is to determine whether or not the events are epileptic. Rule out other potential causes of transients loss of consciousness with a careful history, physical exam, lab tests, and imaging studies. An EEG and CT or MRI of the brain are essential. Candidates for treatment with an antiepileptic drug include those with recurrent unprovoked seizures, those with onset of epilepsy presenting with status epilepticus, and those with a strong family history of epilepsy. Monotherapy with a drug known to work best for the type of seizure is preferred. Monitor patients closely for side effects and potential drug-drug interactions.

Origin of beading constrictions at the axolemma: presence in unmyelinated axons and after beta,beta'-iminodipropionitrile degradation of the cytoskeleton.

Myelinated nerve fibres become beaded when nerves are subjected to a mild stretch; the beading is seen as varicosities, a series of alternating constrictions and enlargements, when using freeze-substitution or cold-fixation to hold this labile form change in place during fixation. One possibility for how this form change comes about is that the myelin sheath or its Schwann cell initiates beading. We now report, however, that a similar beading is seen in the axons of unmyelinated fibres. In electron micrographs, longitudinal sections of axons show the series of constrictions and expansions typical of beading. In cross-sections, axons with unusually small diameter, corresponding to the constrictions, are seen to contain closely packed microtubules and neurofilaments while neighbouring swollen axons with widely dispersed microtubules correspond to the beading expansions. Another possibility for the form change is that the cytoskeleton is responsible for beading. We discovered that direct exposure of nerves to beta, beta'-iminodipropionitrile in vitro for 1-6 h causes both axonal microtubules and neurofilaments to become degraded and replaced by an amorphous residue. Nevertheless, beta,beta'-iminodipropionitrile-treated nerves show constrictions in myelinated fibres when stretched. An even greater degree of beading with narrower and longer constrictions appears in some fibres, with the expanded regions having oblate ends giving the appearance of a string of sausages. In cross-sections taken through the constrictions, a greater than usual reduction of axonal area was seen, this was due to the loss of cytoskeletal organelles which would act to limit the degree of constriction. With longer exposure to beta, beta'-iminodipropinitrile more fibres show complete degeneration of the cytoskeleton and form ovoids typical of Wallerian degeneration. Unmyelinated axons of beta, beta'-iminodipropionitrile-treated nerves which showed degeneration of their cytoskeleton with its replacement by amorphous material still demonstrated beading. As neither the myelin sheath nor the intact cytoskeleton within the axon is necessary for beading, by exclusion, we consider beading constrictions to be initiated at the level of the axolemma. In our hypothesis the membrane skeleton is responsible; namely, the spectrin, actin and other molecular species lining the inside of the axolemma and binding to transmembrane proteins. The membrane skeleton may be activated by stretch via transmembrane proteins (e.g. beta 1-integrins). The membrane skeleton mechanism may also be directly engaged in the production of Wallerian degeneration or be induced by neurotoxic agents.