-SHUCHI JOSHI ARIP :30-2:30
Muscular Dystrophy (MD) is a group of inherited diseases in which the voluntary muscles progressively weaken overtime. Heart and other organs can also be affected. MD affects more than 50,000 Americans. 9 major types: Duchenne, Myotonic, Becker, Limb-girdle, Facioscapulohumeral, Congenital, Oculopharyngeal, Distal, and Emery-Dreifuss
Can occur at any age Most common in young males. Type is based on what age the individual is when muscular dystrophy appears
Defects in certain genes The type of MD is determined by which gene is defective In 1987, the muscle protein associated with DMD was given the name dystrophin When the gene fails to produce dystrophin, Duchenne MD occurs Causes
Duchenne muscular dystrophy
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1 in 3500 male births X- linked recessive disease Early onset often before school age Begins with proximal muscle weakness around age 4 Progresses to distal muscles, making walking more difficult Around age 10, most children are in wheelchairs Some experience cognitive problems ]
Asymptomatic at birth - Early gross motor skills ( rolling over, sitting, standing) may be normal or mildly delayed Poor head control in infancy may be the first sign of weakness Walking achieved at the normal age - but hip girdle weakness may be seen as early as the 2nd year - waddling gait Clinical features
Weakness starts in pelvic girdle- Extensor muscles of back affected – Toddlers may assume a lordotic posture when standing to compensate for gluteal weakness. Cannot bend forward without falling Clinical features
Presents – 2- 4 yrs Frequently falls, has difficulty getting up, climbing stairs or getting in and out of a car An early Gower’s sign is often evident by age 3 yr and is fully expressed by age 5 or 6 yr
Gets up climbing up his legs- Gower’s sign
Enlargement of the calves (pseudohypertrop hy) and wasting of thigh muscles is a classic feature. Next most common site of muscular hypertrophy - tongue, forearm.
Pseudohypertrophy also seen - triceps, quadriceps Pseuhypertrophy of muscle fibers - i nfiltration of muscle by fat, and proliferation of collagen. Fasciculations of the tongue do not occur.
Pseudohypertrophy seen in supra, infraspinatus, deltoids – Valley sign 15
Hypertrophy of calf muscles with tightening of tendo achillis- Toe walking By 8 yrs –walking becomes difficult Knee jerks disappear early but ankle jerk may be preserved Positive valley sign Clinical features
Clinical features cont. By 12 yrs – wheel chair bound – Loss of lordosis - lose stabilization of spine ↓ Tendency to tilt to one side ↓ Develop– Scoliosis ↓ Bunching of ribs leads to Esophageal reflux with acute esophagitis, hematemesis, aspiration pneumonitis 18
Clinical features cont. Intellectual impairment in all % - IQ < 70 Contractures most often involve the ankles, knees, hips, and elbows. Cardiac muscle may be affected – Cardiomyopathy Die by 18 yrs – respiratory failure, pneumonia, aspiration, heart failure 19
The function of distal muscles is usually well preserved - child can continue using eating utensils, a pencil, and a computer keyboard. Respiratory muscle involvement - weak and ineffective cough, frequent pulmonary infections Pharyngeal weakness - episodes of aspiration, nasal regurgitation of liquids, and an airy or nasal voice quality Extraocular muscles - well preserved
Death occurs usually at about 18 yr of age. The causes of death are respiratory failure in sleep, intractable heart failure, pneumonia, or occasionally aspiration and airway obstruction
Laboratory findings Serum creatinine phosphokinase (CPK) even in presymptomatic stages, including at birth > 10,000 units ( range 15,000 – 35,000 IU/L) Normal level < 160 IU/L Other lysosomal enzymes of muscles: Aldolase, Aspartate aminotransferase – increased (less specific) 23
Electromyography (EMG) shows characteristic myopathic features : amplitude and duration of MUAP decreased, polyphasic potentials Nerve conduction velocity- normal, No evidence of denervation EMG
Diagnostic (Vastus lateralis/ Gastrocnemius) Myopathic changes – endomysial connective tissue proliferation Scattered degenerating and regenerating myofibers Muscle biopsy –
Muscle biopsy 26
Others Cardiac evaluation CXR ECG ECHO 27
Molecular genetic diagnosis - demonstrating deficient or defective dystrophin by immunohistochemical staining of sections of muscle biopsy
Management No medical cure or a method of slowing its progression. Multidisciplinary approach: Exercise – physical exercise, physiotherapy Dietary – prevent obesity Orthopedic Psychological Education Genetic counselling 29
Corticosteroids can slow muscle damage in patients with Duchenne muscular dystrophy. Phenytoin, procainamide, or quinine may treat delayed muscle relaxation for those with Myotonic MD. Medications can also be prescribed to treat heart problems in some forms of muscular dystrophy. Medications
Preservation of a good nutritional state Adequate calcium intake - to minimize osteoporosis sedentary children burn fewer calories than active children and depression is an additional factor – these children tend to eat excessively and gain weight – Obesity makes a patient with myopathy even less functional
Primary focus is on gaining muscular strength and endurance Aerobic exercise is important in preventing excess body fat, as well as decreasing cardiovascular risk factors Stretching increases ROM and prevents contractures For children, exercise activities should be as game- like as possible Benefits of Exercise
Some approaches Experimental approach – Myoblast transfer therapy Unproven approach – I/M injection of recombinant dystrophin gene " minigenes, " which carry instructions for a slightly smaller version of dystrophin 33
Pulmonary infections should be promptly treated. O 2 therapy Ventilator Scoliosis surgery Tracheotomy To improve breathing:
Prenatal diagnosis for women having risk pregnancies - with a family history of muscular dystrophy. Identification of dystrophin gene axon deletions in a male fetus - Couples may elect to terminate the pregnancy if the fetus is affected. GENETIC COUNSELLING
This disease was first described by Becker and Klener in 1955 X-linked recessive Late onset – ambulatory till late adolescence Calf pseudohypertrophy, cardiomyopathy, increased CPK are similar to DMD Learning disabilities are less Becker muscular dystrophy
Initially experience difficulties between 5-15 years Becker patients ambulate beyond 15 years Majority of patients survive into 4 th or 5 th decade
X-linked disorder characterized by : contracture at elbow, ankle and neck, Cardiomyopathy Conduction disturbances Progressive weakness Proximal U.L. Weakness (scapulohumeral)>Distal L.L. (peroneal) CPK levels moderately elevated EMERY DREIFFUS MUSCULAR DYSTROPHY
Weakness in limb girdle distribution with sparing of facial, extra ocular and pharyngeal muscles. Spared mentation Calf hypertrophy uncommon Cardiomyopathy less predictabe LIMB GIRDLE MUSCULAR DYSTROPHY
Facial, shoulder girdle, proximal arm muscles involved Patient can’t close eyes forcefully, whistle or hold air in oral cavity Scapular winging Foot drop- weak anterior tibial muscles No hypertrophy Less pelvic girdle involvement Sensorineural hearing loss Cardiac ms, mentation –spared CPK levels- mildly elevated EMG- neurogenic picture FASCIOSCAPULOHUMERAL DYSTROPHY
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