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Because the latter disease has been reproduced in animals by injecting extracts of thyroid with Freund adjuvants antifungal diet purchase mentax from india, it had long ago been sug gested that the so-called thymitis of myasthenia gravis is the result of a similar autoimmune sensitization but the inciting events for this process are entirely unknown anti fungal mould wash discount mentax 15 gm with mastercard. With regard to thymic tumors fungi queensland order cheapest mentax and mentax, two forms have been described: one composed of histiocytic cells like the reticulum cells in the center of the follicles fungus rx proven mentax 15 gm, and the other predominantly lymphocytic and considered to be lympho sarcomatous. Thymic tumors may be unattended by myasthe nia, though myasthenia has eventually developed in all of the cases under our observation, sometimes 15 to 20 years after the tumor was removed surgically. According to Bril and colleagues, the severity of myasthenic symptoms is no different in patients with thymoma than it is from that in patients without a tumor, but our impression has been that patients with tumors, particularly children, often have a peculiar clinical course. For example, we have observed unexpected sudden remissions and severe relapses, as well as resistance to medications. The brain and spinal cord are normal unless damaged by hypoxia and hypotension from cardiorespiratory failure. Furthermore, the m uscle fibers are generally intact, although in fatal cases with extensive paralysis, isolated fibers of esopha geal, diaphragmatic, and eye muscles may undergo segmental necrosis with variable regeneration (Russell). Scattered aggregates of lymphocytes (lymphorrhages) are also observed, as originally noted by Buzzard, but none of these changes in muscle explains the widespread and severe weakness. Engel and associates (1976, 1977, 1987), consist of a reduction and simplification in the surface area of the postsynaptic membrane (sparse, shallow, abnormally wide, or absent secondary synaptic clefts) and a widening of the synaptic cleft. The observation of regenerating axons near the junction, the many simplified junctions, and the absence of nerve terminals supplying some postsynaptic regions suggested to Engel and coworkers (1976, 1977, 1987) that there was an active process of degeneration and repair of the neuromuscular junction, particularly of the postsynaptic side. Although not directly relevant to myasthenia, it is of interest that a number of curious neurologic disorders occur in association with thymoma. Among our own patients were 2 with "limbic encephalitis" with memory loss and confusion that could not be differentiated from the paraneoplastic variety of encephalitis (see Chap. Such cases appear in the literature, and all are considered to have a humoral immune basis. The terminal axon contains abundant presynaptic vesicles, but the post synaptic folds are wide and there are few secondary folds. Thyrotoxicosis with periodic paralysis (5 percent of myasthenic patients; see further on and Chap. A proportion of young women with myasthenia have moderately elevated titers of antinuclear antibody without the clinical manifestations of systemic lupus. Eti o l og y and Path o g e n es i s the clear demonstration o f a n immunologic mechanism operative at the neuromuscular junction was the most sig nificant development in our understanding of myasthenia gravis. Lennon and colleagues recognized this model as being similar to that of myasthenia gravis. These observations were followed by the creation of an experimental model of the disease and the demonstration that experimen tally induced myasthenia had clinical, pharmacologic, and electrophysiologic properties identical with those of human myasthenia gravis (Engel et al, 19 76). Thus, the accu mulated evidence satisfied the criteria for the diagnosis of an autoantibody-mediated disorder (Drachman, 1990). The present view is that myasthenic weakness and fatigue are a result of the failure of effective neuromus cular transmission on the postsynaptic side. Blocked transmission at many endplates results in a reduction in the contractile power of the mus cle. This deficiency is reflected first in the ocular and cra nial muscles that thymus (according to Schluep et al). Another suggested pathogenesis, yet unconfirmed, is that a virus with a tropism for thymic cells might alter such cells and induce antibody formation. A viral infection might at the same time have a potential for oncogenesis, accounting for thymic tumors, but this is all speculative. Diag nosis In patients who present with a changeable, specifically fatigable, diplopia or ptosis and the typical myasthenic facies-unequally drooping eyelids, relatively immobile mouth turned down at the corners, a smile that looks more like a snarl, a hanging jaw supported by the hand the diagnosis can hardly be overlooked. Ptosis, diplopia, difficulty in speaking or swallowing, or weakness of the limbs is at first mild and inconstant and may be mistaken for a cerebrovascular disease. However, the finding that sustained activity of small cranial mus cles results in weakness. Several special clinical problems and associated conditions are summ arized further on. The presence of receptor antibodies has proved to be a reasonably sensitive and reliable test of the disease, as discussed later. Neuromuscular transmission is therefore impaired in several ways: to the has been shown to induce an increase in the degradation antibodies to cross-link the receptors; folds (Engel and Arahata). Although the evidence that an autoimmune mecha nism is responsible for the functional disorder of muscle in myasthenia gravis is incontrovertible, the source of the autoimmune response has not been established. Because most patients with myasthenia have thymic abnormali ties and a salutary response to thymectomy; it is logical to implicate the lymphoid reaction in this gland in the pathogenesis of the disease. It is not known with certainty that thymic myoid cells are the source of immunologic stimulation in myasthenia gravis. Reversal of this response by neostigmine or edrophonium has been a reliable confirmatory finding in most cases. A deere mental response to stimulation can usually be obtained most often from the proximal limb muscles followed by the facial and, to a lesser extent, the hand muscles, which may or may not be clinically weak. During a pro gressive phase of the disease or during corticosteroid therapy, a slight initial incrementing response may be obtained, not to be confused with the marked increment ing response after voluntary contraction that character izes the Lambert-Eaton syndrome (see further on). This technique demonstrates an inconstancy of the normally invariant interval between the firing of muscle fibers connected to the same motor unit ("jitter"-see "Single-Fiber Electromyography" in Chap.

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What is evident from this listing is that the experience of anxiety is con joined with a polysymptomatic physical syndrome antifungal antibacterial dog shampoo buy mentax cheap. Many patients experience a constant uneasiness that the spells may reoccur fungus juice 15gm mentax with visa, especially in public; hence the patient may be fearful of leaving home lest help not be available should an attack occur (agoraphobia) antifungal soap for ringworm purchase generic mentax pills. Except in minor details garlic antifungal yeast infection buy mentax without prescription, it is notable that the attacks are alike in any one individual. Between attacks, most patients feel relatively well but many complain of the symptoms of anxiety and asthenia in lesser but persistent fashion. Hyperventilation is a special, although not invari able, feature of the anxiety attack. Hyperventilation itself, by reducing the Pco2, will cause giddiness, paresthesias of the fingers, tongue, and lips, and, at times, frank tetany. However, contrary to what is stated in some textbooks, in only a minority of patients does a 3-min period of deep breathing reproduce the symptoms of an anxiety or panic attack. Nonetheless, this maneuver may be used to assist the patient in describing certain aspects of an attack. Attacks in minor form, without the full force of the physical accompaniments may occur at infrequent inter vals or several times a day. In other instances, a trying or upsetting experience induces an attack, which is nonetheless excessive for the condition that provoked it. In some patients, attacks are brought on consistently by confinement to a closed space (claus trophobia)-an elevator, for example-or by crowded surroundings, as in a church, restaurant, or theater. An anxiety state frequently follows an accident and then may, according to Modlin, be a source of ongoing disability, a condition more akin to posttraumatic stress disorder. Similar spells of anxiety are also a prominent feature of the postconcussive and posttraumatic stress syndromes. In one, there is a nearly lifelong history of poor exercise tolerance, little stamina, and inability to do heavy physical work or participate in vig orous sports, tenseness, nervousness, and intolerance of crowds, i. A 20-year followup study by Wheeler and associates showed that symptoms were still present in 88 percent but persisted in being moderately or severely disabling in only 15 percent. Most affected patients were able to work and to enjoy a reasonably normal family and social life. Their only liability to further psychiatric illness was to later anxious depression, whereas so-called psychosomatic ill nesses and other psychiatric illnesses did not occur more frequently than in the general population. Etiology and Pathogenesis Anxiety disorder has been attributed to a genetic abnor mality, to a "constitutional weakness" of the nervous system, to social and psychologic factors, and to physi ologic and biochemical derangements; but none of these factors provides a completely satisfactory explanation of the primary problem. The onset of both acute and chronic anxiety is rare before age 18 years or after 35 to 40 years of age (average age of onset 25 years). The condition in some series is twice as frequent in women as in men and there is clearly a high familial incidence. In one study (Wheeler et al) there was a prevalence of 49 percent among the grown children of patients with anxiety neurosis, compared with 5 per cent in the general population. Slater and Shields found that there was a concordance rate of 40 percent in identi cal twins, compared with 4 percent in dizygotic twins. Among the relatives of index cases, the mothers suffered from anxiety neurosis more often than did the fathers; in the latter, alcoholism was more frequent than in the population at large (Modlin). A clear pattern of inheri tance has not been established, but it approximates that of autosomal dominance with incomplete penetrance. The psychodynamic theories that attempt to provide a unified explanation of these diverse anxiety states were reviewed by Nemiah and we do not dismiss them but cannot com ment authoritatively. The most important difference, however, is that the cause of fear is known to the patient, whereas that of anxiety is not. The most extreme but not inconceivable interpretation of anxiety is the James-Lange theory of emotion, mentioned earlier, which attributes the psychologic experience entirely to the accompanying physical symptoms. On the physiologic and biochemical side, it has been observed that anger provokes an excessive secre tion of norepinephrine, whereas fear is accompanied by increased secretion of epinephrine. Actually, fear acti vates the autonomic nervous system as a whole and the increase in epinephrine is more than counterbalanced by a parasympathetic discharge. Attention has been focused on overactivity of the locus ceruleus and upper brainstem nuclei as the possible anatomic substrates of anxiety Q"udd et al). Evidently, the responsiveness of the autonomic nervous system in these patients remains heightened and a number of stimuli (cold, pain, muscular effort) may pro duce abnormal responses in pulse, respiration, oxygen consumption, and work performance. Another interest ing abnormality (first noted by Cohen et al) is that the blood lactic acid levels in response to exercise are higher than normal. The presence of these changes does not necessarily mean that they are causal; they are as likely secondary to other factors such as poor physical condi tion and apprehension associated with the syndrome. Nevertheless, some investigators have found that infu sions of lactic acid can trigger panic attacks in persons with anxiety neurosis (Liebowitz et al). Studies correlating cerebral function and blood flow indicate that when panic is induced by an intravenous injection of sodium lactate, there is an immediate increase in blood flow to the cortex of both temporal lobes. In states of fear, the tips of the temporal lobes and the amygdaloid nuclei are known to become activated. In the relaxed period between panic attacks, the right limbic system and the parahippocampal gyrus are abnormally active in some studies. As with the aforementioned biochemical models, these seem to be more reflections of brain activ ity in response to the psychic experience than they are explanations. Nevertheless, parts of the limbic system are presumably involved in a germinal way in the production and perpetuation of anxiety and its related states.

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The palatal incision is in the mid line extended laterally at the junction of the hard and soft palate behind the maxillary tuberosity (Figure 4 fungi usually considered poisonous buy 15 gm mentax visa. The nasopalatine bundle is preserved if the bone cut is between the central and lateral incisor teeth quinone antifungal discount 15gm mentax with mastercard. Bone cuts the bone cuts are made with fine saws or a fissure burr and completed with osteotomes antifungal drying powder buy 15 gm mentax amex. The mucoperiosteum of the floor/lateral wall of the nose is elevated and the bone cuts made (1) between the central and lateral incisor teeth fungus ease buy generic mentax line, continued paramedially through the length of hard palate into the nasal floor; (2) laterally from the piriform fossa, below the inferior turbinate (preserving the nasolacrimal duct) through the anterior maxilla inferior to the infraorbital nerve through the zygomatic buttress back to the pterygoid plates. The infraorbital nerve is sectioned at the infraorbital foramen as it prevents lateral retraction of the maxilla. The bone cut posterior to the zygomatic buttress is angled downwards and may be made either with a fine osteotome or reciprocating saw, to reduce soft tissue stripping. The maxilla is prelocalized with bone plates (1) above the incisor teeth anteriorly; (2) at the frontal process of the maxilla; (3) on the zygomatic buttress. The maxilla and pterygoid plates are separated with a curved pterygoid chisel placed through a small vertical buccal incision (Figure 4. The maxilla can be secured to the soft tissues with 0-silk sutures over a gauze swab (Figure 4. Following nerve division, wide lateral retraction of the maxilla exposes the soft palate, nasophar ynx and infratemporal fossa (Figure 4. The buccal pad of fat is within the operative field and immediately available for reconstruction as a pedicled flap. The coronoid process and the attached temporalis tendon may impede access to the infratemporal fossa. A coronoidectomy will improve access and has the added benefit of reducing post-operative trismus. The palatal soft tissues are covered with an acrylic cover plate wired to the standing teeth. Greater palatine foramen Soft tissue incision Osteotomy bone cuts Alternative (favoured) palatal incision. A damp tonsillar swab is placed in the opposite nostril and the cartilaginous nasal septum divided vertically in line with the osteotomy bone cuts. The nasal bones and the nasal soft tissues are retracted to the opposite side (Figure 4. The nasal swing links readily with a frontal craniotomy for resection of pathology that also involves the central compartment of the anterior cranial fossa. The transfacial approaches may also be combined with either a Le Fort I osteotomy or mandibular osteotomies for further access. On the side opposite the skin incision, subperiosteal dissection is achieved by tunnelling. For combined access to the oral cavity and infratemporal fossa, an extended mandibular swing is appropriate; a lip split is necessary. Mandibular swing the technique provides excellent access to the floor of the mouth, mid and posterior third of tongue, tonsillar fossa, soft palate, oropharynx including the posterior pharyngeal wall, supraglottic larynx and medial aspect of the mandibular ramus. Extended posteriorly, it provides equally good access to the infratemporal fossa, and the parapharyngeal space with vascular control. There are three separate elements: 1 Division of the lower lip and chin 2 Division of the mandible in the incisor region 3 Elevation of the soft tissues off the lingual aspect of the mandible. Surgical technique A full thickness vertical incision is made through the midline of the lower lip; a V-shaped notch is incorporated in the midline lip incision and the vermilion incision for precise closure and to mask scarring. The incision curves around the chin with the concavity of the incision towards the side of the lesion, reducing the risk of chin necrosis. Intraorally, the incision through the labial mucosa and the attached gingiva is stepped so as not to lie directly over the subsequent osteotomy bone cut. Periosteal elevation and mentalis muscle stripping should be sufficient only for the application of bone plates and screws. The mucoperiosteal flaps are pedicled on the side opposite to the lesion as a precaution against ischaemic necrosis of the flap edges (Figure 4. A full thickness lingual mucoperiosteal flap is subsequently elevated off the lingual aspect of the mandible when the mandible is retracted laterally. The incision through the oral tissues is Stepped soft tissue incision and bone cuts. The osteotomy is always performed in the incisor region for tumours involving the oral cavity. Osteotomy in the premolar region anterior to the mental foramen is only employed by the authors to access tumours in the infratemporal fossa/parapharyngeal space when avoiding a lip split incision (see below under Angle osteotomy and double mandibular osteotomy avoiding lip split). The mandible is divided with a fine saw blade between the roots of the incisor teeth. Occasionally, an incisor tooth is removed if there is insufficient room between the dental roots for the bone cut. Prior to division, the mandible is Transmandibular approaches 287 prelocalized with bone plates acrosss the osteotomy bone cut. The osteotomy bone cut is a simple straight line in all cases as opposed to the stepped cut demonstrated in Figure 4. Following division, the mandible is gently retracted laterally and the lingual soft tissues, including the mylohyoid muscle, are stripped off the mandible (Figures 4. For smaller tumours, very limited access is provided by simply elevating the mandibular angle or by detaching the stylomandibular ligament at the angle of the mandible and dislocating the mandibular condyle anteriorly (Figure 4.

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Before the pedicle is divided antifungal used to treat thrush buy mentax with american express, adequate perfusion of the muscle segment is checked fungus gnats basil buy generic mentax canada. After complete separation fungus gnats killing my plants cheap mentax 15gm with mastercard, the function of the obturator nerve segment included in the graft should also be checked with the nerve tester after placing the graft on a moist adductor longus muscle pulled upward ligated branches to the adductor longus muscle Dissection of the muscle to identify individual muscular units antifungal nail tablets discount mentax 15gm on-line. The graft is then stored in moist surgical towels until definite graft fixation and microvascular anastomosis are performed. Post-operative complications Wound closure and post-operative care Meticulous control of bleeding from the transectioned muscle tissue is performed by electrocautery. The anterior margin of the remaining parts of the gracilis muscle is attached to the fascia of the adductor longus muscle to stabilize the gracilis muscle and restore easy function of the adductor muscles. A 10 gauge suction drainage is placed on the reconstructed fascia and the wound is closed in layers. The leg is bandaged with decreasing pressure from distal to proximal or a pressure stocking is applied to avoid postoperative thrombosis. Routine post-operative prevention of thrombosis is applied by administration of fractionated heparin. The operated leg should be positioned in a slightly elevated position for a couple of days until complete mobilization of the patient is achieved. Post-operative mobilization with the help of a physical therapist can be performed from the first post-operative day on as the muscle function of the adductor group remains grossly unaffected by the removal of the small gracilis segment and its nerve supply. If no substantial bleeding occurs, the suction drainage can be removed on the second postoperative day. Post-operative bleeding is unlikely to occur as the site of harvest does not contain high volume flow vessels and the dissection is carried out only along intermuscular septa without dividing or cutting vessels with relevant blood flow that could be violated inadvertently and overlooked during wound closure. Nevertheless, improperly seated ligation clips after separation of the pedicle from the profunda femoris vessels can become detached and cause substantial haemorrhage. Thus, great care is required during this part of the dissection to make sure that ligations of the adductor vessels are reliable. Secondary bleeding from the transected muscle may occur if haemostasis has been inadequate. The careful use of electrocautery after identification of individual intramuscular branches under the microscope before wound closure minimizes this risk. Thrombosis is also unlikely to occur if routine heparin prophylaxis is administered and early mobilization is accomplished. The saphenous vein that drains the superficial venous system is located above the site of harvest. This vein is commonly not encountered during dissection and thus can be easily preserved. Deep venous thrombosis may occur if ligation clips or sutures compromise the blood flow in the profunda femoris veins, which can be avoided by observing an adequate distance to the vein during ligation as described above. The dissection of the flap is very straightforward, with little chance for it to go grossly wrong. During flap dissection, the division of the branches that go off into the adductor longus is a crucial point. As the pedicle is rather short, use as much length as you can get, however, keep in mind to preserve a 5 mm cuff for ligation to avoid thrombosis of the profunda femoris vein. Careful nerve testing and definition of functional muscle units will improve the result in terms of cosmetics, as unsightly bulging of the grafted muscle during contraction is avoided. Trimming of the muscle after transfer is always more difficult and carries the risk of removing the wrong muscle units. Intraoperative complications Damage to the pedicle may occur during release of the branches to the adductor longus and adductor magnus muscle. The use of the microscope during dissection and the use of clips rather than electrocautry during ligation are helpful in avoiding this problem. Damage to the profunda femoris vessels may occur during separation and ligation of the pedicle. In particular, the profunda femoris veins are prone to compromised blood flow and subsequent thrombosis. This can be avoided by observing an adequate distance of 5 mm pedicle length during ligation and separation of the pedicle from the profunda femoris vessels and by using clips rather than sutures for ligation. Nerve damage is unlikely to occur as the dissected segment of the obturator nerve is only short and interference with other nerves is not encountered. Hari K, Ohmori K, Torii S, Free gracilis muscle transplantation with micorvascular anastomosis for the treatment of facial paralysis. There is usually little morbidity at the donor site, and it is highly reliable with a 95 per cent success rate (when used, the skin paddle component is reported to be less reliable). Bone height is the main potential disadvantage, especially when reconstructing the dentate mandible. Distraction osteogenesis, followed by implant placement, can also give a very good result (Figure 3. It is usual to leave the flap for several months before distraction to allow bony union with the recipient bed and enable the fixation plates to be removed. As the flap was increasingly used, modifications were made, such as including large parts of the soleus muscle, and skin paddles.

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It is interesting that most mutations behave as dominant traits fungus gnats bonsai generic 15 gm mentax amex, whereas others have either a dominant or recessive pattern of inheritance (see Table 50-1) fungus gnats organic order genuine mentax. The physiologic mechanism whereby these mutations alter ion fluxes across the muscle mem brane and cause myotonia is described further on fungus gnats organic control 15 gm mentax with amex. H i sto ry the disorder was first brought to the attention of the medical profession in 1876 by Julius Thomsen fungus killing snakes trusted mentax 15gm, a Danish physician who himself suffered from the disease, as did 20 members of his family over 4 generations. His designa tion of ataxia muscularis was not correct, but his descrip tion left no doubt as to the nature of the condition in that it featured "tonic cramps in voluntary muscles associated with an inherited psychical indisposition. Erb provided the first description of its pathology and called attention to two additional unique features: muscular hyperexcitability and hypertrophy. Repeated contractions "wear it out," so to speak, and the later movements in a series become more swift and effective. Rarely, the converse is observed-where only the later movements of a series induce myotonia (myotonia paradoxica); usually this is a feature of another condition, cold-induced paramyotonia congenita (see further on). Unlike cramp, the myotonic spasm is painless but after prolonged activity, nocturnal myalgia (a pinching-aching sensation in the overactive muscles) may develop and prove distressing. Close observation reveals a softness of the muscles during rest and the initial contraction appears not to be significantly slowed. The disease as mentioned above is usually inherited as a dominant trait so that most often, other members of the family have been affected. In other cases, the myotonia becomes evident only later in the first or second decade. The muscles are generously proportioned and may become hypertrophied but seldom to the degree observed in the recessive form of the disease described further on. Despite their muscular appearance, these patients are inept in athletic pursuits as a result of the myotonia. When severe, myotonia affects all skeletal muscles but is especially prominent in the lower limbs. Attempts to walk and run are impeded to the extent that the patient stumbles and falls. Other limb and trunk muscles are also thrown into spasm, as are those of the face and upper limbs. One of the characteristic features is grip myotonia in which the patient is unable to release a handshake and must slowly open the fingers one at a time. Occasionally a sudden noise or fright may cause generalized stiffness and falling. Small, gentle movements such as blinking or elicitation of a tendon reflex do not initiate myotonia, whereas strong closure of the eyelids, as in a sneeze, sets up a spasm that may prevent complete opening of the eyes for many seconds. If the patient has not spoken for a time, there is sometimes a striking dysarthria. Arising at night, the patient cannot walk without first moving the legs for a few minutes. After a period of rest, the patient may have difficulty in arising from a chair or climbing stairs. Loosening of one set of muscles after a succession of contractions does not prevent the appearance of myotonia in another area, nor in the same ones if used in another pattern of movement. Lacking also are the narrow face, frontal balding, cataracts, and endocrine changes typical of myo tonic dystrophy that is discussed in Chap. Myotonia that is evident in infancy is far more likely to represent myotonia congenita than myotonic dystrophy, in which myotonia rarely has its onset in the first few years of life. Myotonia can also be induced in most cases by tap ping a muscle belly with a percussion hammer (percus sion myotonia). Unlike the lump or ridge produced in hypothyroid or cachectic muscle (myoedema), the myo tonic contraction involves an entire fasciculus or an entire muscle and, unlike the phenomenon of idiomuscular irritability (contraction of a fascicle in response to striking the muscle), it persists for several seconds. An electrical stimulus delivered to the motor point in a muscle induces a pro longed contraction (Erb myotonic reaction). In Thomsen disease, as in virtually all forms of myotonia, the stiffness is somewhat exaggerated in cold. On a cold day, affected individuals may have a prolonged grimace with closed eyes after a sneeze. We encountered two brothers with this disorder who described diving into a cool swim ming pool on a hot s ummer day and having to lie nearly motionless at the bottom of the pool for several seconds until the muscle stiffness abated enough to allow them to swim to the top. However, as mentioned, prominent cold-induced myotonia, is more characteristic of para myotonia congenita (see later). Biopsy reveals no abnormality other than enlarge ment of muscle fibers, and this change occurs only in hypertrophied muscles. As often happens in fibers of increased volume, central nucleation is somewhat more frequent than it is in normal muscle. In well-fixed biopsy material examined under the electron microscope, Schroeder and Adams discerned no significant morphologic changes. Myotonia levior was the name applied by DeJong to a dominantly inherited form of myotonia congenita in which the symptoms are milder and of later onset than those of Thomsen disease. Diag nosis In patients who complain o f spasms, cramping, and stiff ness, myotonia must be distinguished from several of the disorders of persistent muscle activity described in Chap. The only possible exceptions are the Schwartz-Jampel syndrome of hereditary stiffness combined with short stature and muscle hypertrophy, and stiff-man syndrome which are discussed in Chap. Uncertainty in diagnosis arises in patients who have only myotonia in early life and later prove to have classic (type 1) myotonic dystrophy or who notice myotonia in adulthood with mild proximal weakness and are found to have type 2 myotonic dystrophy (see later). The most troublesome aspect of the disease is the transient weakness that fol lows initial muscle contraction after a period of inactivity. Progression of the disease continues to about 30 years of age, and according to Sun and Streib, the course of the illness thereafter remains unchanged. In paramyotonia congenita there is also In contrast myotonia of early onset, but, again, it tends to be mild, involving mainly the orbicularis oculi, levator palpebrae, and tongue; the diagnosis of paramyotonia is seldom in doubt because of the worsening with continued activity and prominent cold-induced episodes of myotonia and paralysis.

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