Arjun G. Shah Profile picture
Mar 28 9 tweets 3 min read Twitter logo Read on Twitter
An illustration of the importance of pattern recognition in Neurology. At the outset, let me reveal this is a Myopathy. Try to note how this particular one is different from others. 10 years history

As with most myopathies, limb girdle weakness is present
But wait! Foot drop and prominent distal muscle weakness in a muscle disease??
And look at how strong the Quadriceps are! weak proximal and weakness with selective sparing of the quadriceps!
So this is a 10 year story. Muscle disease with distal weakness(foot drop). Sparing the quadriceps. CPK isn't all that high. This is GNE Myopathy (Nonaka Myopathy)

#NeuroTwitter #Neurology #MedEd #MedTwitter
Not all myopathies are purely proximal. There is a distinct set of Distal Myopathies, GNE being one of the commoner ones seen in India

It classically spares the quadriceps muscle, mostly affects Tibialis Anterior. Inheritance is Autosomal Recessive, usually in 3rd decade of life
The weakness may be asymmetric as well
Muscle biopsy shows rimmed vacuoles, and the CPK may not be excessively elevated.
If you think of it. A distal myopathy, asymmetric, modest CPK elevation, rimmed vacuoles. Sounds familiar?
It's similar to Inclusion Body Myositis!
In fact, GNE was initially known as hIBM-2
Again, pattern recognition!
GNE gene encoded proteins involved in the formation of sialic acid.
There is yet another striking clinical feature of GNE/Nonaka Myopathy. I have alluded to it in an earlier post. Can you remember it?

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More from @neurogenicpoet

Mar 17
Distraught parents bring their son to you. They tell you that he has been having weakness of his left hand since 1 year. With wasting. No sensory symptoms. They have been told, Motor Neurone Disease . You look at his hand and smile reassuringly. Why?
First things first, the demographics don't fit ALS. He's a young boy. Secondly, The disease seems quite restricted. Third, no signs of upper motor neuron disease. Finally, this OBLIQUE AMYOTRPOHY is classical and clinches a diagnosis of HIRAYAMA DISEASE

#MedTwitter #NeuroTwitter
Hirayama Disease typically affects young Asian males in their twenties. I have seen dozens of patients with Hirayama, never a girl (although case reports exist)
These boys tend to be lean and have long necks!
It is much more benign compared to ALS!
Read 13 tweets
Mar 15
Some Tips to select a Residency Programme

1. Make sure you get to take INDEPENDENT DECISIONS

2. Department is supportive, not toxic. A toxic department even in the most reputed institutes may hamper your growth

#NEETPG2023RESULTS
3. Look for colleges with super speciality rotations

4. Patient load should not be the only driving factor, as long has there are enough cases to learn, it’s just a number

5. Academics is good to have, but a motivated student can compensate for a lack of it IMO
6. There is nothing like the perfect residency, decide what you’re ready to compromise one

7. Don’t let your rank dictate your choice! Take up the subject you find engaging! Eventually however hectic it may seem, you will be glad you didn’t settle!

(Views are personal!)
Read 4 tweets
Mar 14
You are again asked to see a patient with GBS. A young man in his 30's, does not seem perturbed by his acute onset of weakness of lower limbs. He says he has been through it on many occasions before. This particular bout was triggered after a hearty meal at a wedding. Thoughts?
An important differential to GBS are the Channelopathies. This gentleman had low levels of Potassium, and correction of the same completely reversed his symptoms! On evaluation, he was diagnosed with a Channelopathy
Simplified Approach

#Neurology
Hypokalaemia is notorious to cause neurological weakness often mimicking GBS. However clinical pointers for it are
- Recurrent Attacks
- Triggered by Alcohol/Carbs
- No Bulbar/ Facial Involvement
-Preserved reflexes (Can have areflexia!)
-Rapid (to come and go)
-Normal CSF
Read 16 tweets
Mar 9
Young boy w/ acute onset quadriparesis with areflexia, admitted to ICU with "GBS". You happen to glance at Urine Bag. something is off! The old urine is darker!? The patient is squealing with abdominal pain. Relatives tell you- seizures in the past
Thoughts?

#MedTwitter
This surely doesn't feel like a routine GBS. Young boy with seizures and abdominal pain, think of the Porphyrias!

Our patient probably has one of the acute Porphyrias. Confirmation of the type eluded us unfortunately since genetic analysis is expensive. Probably AIP
Neuro Porphyrias include
1. Acute Intermittent Porphyria (AD)
2. Hereditary Coproporphyria (AD)
3. Variegate Porphyria (AD)
4. ALA Dehydrates Porphyria
Read 11 tweets
Mar 6
2 brothers in their 30’s presented to us with progressive Cerebellar ataxia. On examination, there is slightly restricted vertical gaze.

Thoughts ?

#MedTwiter #NeuroTwitter #Neurology
One of the typical features of Niemann-Pick C disease is SUPRANUCLEAR VERTICAL GAZE PALSY

Ataxia, Dystonia Psychomotor Regression are common

GELASTIC CATAPLEXY is another common feature
The disease follows an Autosomal Recessive inheritance and unlike A/B, C can present in older ages with neurological features, without hepatosplenomegaly
Read 9 tweets
Dec 29, 2022
Resources to study #Neurology

Adams and Victor’s. By far my favourite textbook.
The book is more clinically oriented, coloured with anecdotes and mental models. Reading it feels like seeing a pt in the ward/OPD

#MedTwitter #neurotwitter
It has elements of philosophy, history and is written eloquently.
Whimsical, yet profound, it’s teachings stay with me. Added bonus, my Guru in Neurology finds mention in the text 🙃 I’d recommend this for #mbbs #md and #dm students
Bradley is the standard #textbook in #neurology. A great book, it’s more like #Harrison. Great for information, latest research and management. Essential for the DM #neurology candidate, but also useful for MD #internalmedicine
Read 11 tweets

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