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PHYSICIANS MEETPHYSICIANS MEET
Prof T.V.K’S UNIT
Dr.D.Premkumar
HISTORYHISTORY
A 85yrs old lady admitted with complaints of spontaneous movements of left upper and left lower limb- one weeks
Involuntary movements- one week,sudden in onset,involving left upper and left lower limb,fast flinging movement, increased during emotions, decreased during rest.
No H/O--- Loss of consciousness, headache, vomiting, visual disturbance, weakness, seizures,cranial nerve,sensory involvement, bladder bowel disturbance,speech disturbance.
No H/O--- Fever, joint pain, skin lesions No H/O---Chest pain,palpitation, syncope,
dyspnoea No H/O---Vomiting, loose stools, abdominal pain,
abdominal distension
No H/O trauma, TIA,RIND. PAST HISTORY: History of previous similar
episodes present- one month back. No H/O chronic fever, Rheumatic fever, dog
bite,vaccination, chronic drug intake. Not-DM,SHT, CAD, BA, PT. PERSONAL HISTORY: Not a smoker,
alcoholic, tobacco chewing, No similar episodes in the family.
EXAMINATIONEXAMINATION
GENERAL EXAMINATION : Patient conscious,co-operative afebrile moderately built& nourished no pallor, not icteric no-cyanosis, clubbing no-pedal edema, lymphadenopathy No Neurocutaneous Markers
VITALS
pulse rate-84/min
Blood pressure-130/80
respiratory rate-24/min
SYSTEMIC EXAMINATIONSYSTEMIC EXAMINATION
CENTRAL NERVOUS SYSTEMHigher motor function: NormalCranial nerves examination:NormalMotor system: bulk-normal tone- slightly reduced power-4+/5 reflexes- normal, Plantar- b/l flexor co-ordination-normal
Involuntary movements- non-rhythmic,rapid,flinging type of movement is present in the left upper and lower limb,which is aggravated during activity& emotion and decreased or absent during rest and sleep.
Sensory system- intact
Cerebellum- intact
Autonomic nervous system-no bladder bowel disturbance
Fundus – normal
Other systems- CVS, RS, ABDOMEN- Normal
investigationsinvestigations
Hb %-9.7gm% Total count-8200 DC:P68,L30,E2 ESR-5/10 Platelet count-2.5lakhs MCV-88.1 MCH-29.0 MCHC-32.9 PCV-29.2
RBS-122mg% Urea-38 Creatinine-1.1 S.Electrolytes:Na-144,K+-4.5,HCO3-22, CI-98 Urine Examination:alb-nil, sugar-nil, deposits-2-3
pus cells HPF ECG-NSR CXR-NAD
CT BRAIN- normalMRI BRAIN- Degenerative changes
in the CAUDATE NUCLEUS and PUTAMEN.
MRI BRAINMRI BRAIN
MRI BRAINMRI BRAIN
MRI BRAINMRI BRAIN
OPINIONSOPINIONS
Neurologist opinion: HEMICHOREA
Cardiologist opinion:mild AV sclerosis, no
RWMA, normal LV function
DIAGNOSISDIAGNOSIS
This is a case of involuntary movement affecting the left side of the body without signs of cerebrovascular disease, rheumatic fever- HEMICHOREA (Senile Chorea)
Treatment : Haloperidol 1mg BD Trihexyphenidyl
HYPERKINETIC MOVEMENT HYPERKINETIC MOVEMENT DISORDERSDISORDERS
CHOREA/HEMICHOREAHEMIBALLISMUSATHETOSISCHOREO-ATHETOSISDYSTONIASMYOCLONUSFASCICULATIONS
CHOREACHOREA
Semi-purposive, flowing,irregular, non-repatitive and brief,jerky movement arising in the proximal joints and apper to flit from one part of the body to another randomly.
Absent during sleep and increased on attempting voluntary movement.
Due to lesion in CAUDATE NUCLEUS.
Causes of choreaCauses of chorea
Hereditary: 1.Huntington’s disease 2.Neuroacanthocytosis 3.Benign hereditary/senile chorea 4.Wilson’s disease 5.Hallervorden-Spatz syndrome
Post-infectious/autoimmune: 1.syndenham’s chorea
2.SLE 3.AIDS
Endocrinology
1.hyperthyroidism
2.chorea gravidarum
Drug induced Chorea
1.OCP
2.Levodopa
3. Anticonvulsants
4.neuroleptics
5.Antidepreesants
Vascular
1.Strokes
2.Polycythemia vera
Others
Neoplastic/metabolic
Signs elicitale in choreaSigns elicitale in chorea
‘Jack in the box’tongueRespiratory irregularityMilk maid signHung up reflexPronator sign
studystudy
Piccolo et al studied 51 cases of sporadic chorea. On follow up only 20 cases had chorea at the end of six months.
Analysis revealed1.vascular related-21 cases
2.vasculitis-2 cases3.hypoxia-2 cases4.drug induced- 7 cases
5.AIDS-related-5 cases
6.Borreliosis-1 case7.Syndenham’s Chorea-1 case
8.Hyperglycemia-2 cases9.Hyponatremia-2
cases 10.Huntington’s chorea-5 cases11.Neuroacanthocytosis-1 case
12.No causes found-3 cases
Areas involvedAreas involved
Chorea- caudate nucleusAthetosis-putamenHemiballismus-subthalamic nucleusDystonias-putamen
HemiballismusHemiballismus
Usually affects proximal joint of one arm resulting in wild,rapid,flinging movement of wide radius,occuring constantly, interspersed with short period of freedom.
Absent during sleepIncreased tone,reflexesSub thalamic nucleus
AthetosisAthetosis
Slow writhing movement,best seen at wrist, fingers and ankle.
Lesion in putamenAbsent during sleep
DystoniasDystonias
Idiopathic/primary torsion dystonias is a disorder charecterised by involuntary sustained muscle contractions frequently causing twisting and repetitive movements or abnormal posture
Types-generalized, segmental,focal
Common causes of secondary dystonias1.drugs-phenothiazine
2.Wilsons disease3.Degenerative
ataxias 4.kernicterus5.sickle
cell disease6.stroke,tumor,trauma
MyoclonusMyoclonus
Consists ofrapid,brief shock like muscle jerks which are often repetitive, sometimes rhythmical
Normal phenomenon or may be a manifestation of major seizures
FasciculationsFasciculations
Irregular non-rhythmical contraction of muscle fascicles.
Best seen in large muscles(deltoid/calf muscle) Present at rest and may be increased after
voluntary movement Sign of LMN lesion Precipitated – contracting the musce,
hyperventilation, cooling the muscle
Causes of fasciculation1.MND
2.Syringomyelia3.Cervical
spondylosis 4.PMA 5.Thyrotoxic myopathy 6.carcinomatous myopathy 7.OPC poisoning
Presence of fasciculation excludes myopathy except thyrotoxic and carcinomatous myopathies
TREATMENTTREATMENT
CHOREAHuntington’s- no specific, phenothiazines or
haloperidol, reserpineSyndenham’s chorea- Dopamine receptor blockers
and anti-convulsants(valproic acid,carbamezapine)
Wilson’s disease- D-Penicillamine & trientin&zinc
HEMIBALLISMUS: haloperdol,clonazepam,baclofen
Dystonias :anticholinergics,BDZ,Baclofenbotulinum toxin
Myoclonus : valproic acid, clonazepam, oxitriptan
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