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MARIE-TOOTH
DISEASE
Sakunrat Sarikit, M.D.
REFERENCES
SCOPE
01. Overview
02. Clinical Manifestation
03. Electrophysiology and electrodiagnosis
04. Genetic pathogenesis
05. Treatment
CHARCOT-MARIE-TOOTH DISEASE
Inheritedneuronal
neuropathies
Axonal form ,AD
Hypertrophicneuropathy
Early onset with severe form
Demyelinating form, AR
Hypertrophicneuropathy
with Phytanic acid excess
Demyelinating form, AR
MAJOR TYPE OF CMT
● Clinical phenotype
● Identification of inheritance pattern
● Electrophysiological examination
● Molecular analyses
● Nerve biopsy
INVESTIGATION
Exuberantcallous
Pes cavus: formation
high arched foot
Intrinsic hand atrophy
Neuromuscular scoliosis
Hypertrophic nerves
Palpation of this nerve reveals a
rather firm substance
CMT 1 > CMT 2
SENSORY SYMPTOM
NCV
- Born with normal or only minimally slowed
- Rapidly decline of NCV when the child is 3-5 years of age
- Markedly slow NCV
The CMAP amplitudes continue to diminish over time,
indicative of axon loss
DML at birth are commonly borderline abnormal.
- increase until 10 years, at which time there is little
further prolongation of the distal latencies
NERVE CONDUCTION STUDY IN CMT1
Hypertrophic nerve
CMT1a-“Onion blub formation”
Schwann cell perforation
CMT1b-“tomacula & uncompact myelin”
Charcot-Marie
Tooth Disease
Type 2
Charcot-Marie-Tooth Disease
Type 2 (Neuronal CMT)
The axonal autosomal dominant form
CMT2 : characterized by more neuronal or axonal
involvement than is seen in CMT1
Onset 2nd decades of life
6 subtype (CMT2A, 2B, 2C, 2D, 2E, 2X)
CMT2A,2B - common
CMT2C – occur vocal cord paralysis
Charcot-Marie-Tooth Disease
Type 2 (Neuronal CMT)
Clinical similar CMT1 , differential with CMT1 by NCS
In CMT2A/B compared to CMT1
- Less severe involvement of the intrinsic hand muscles
- More significant atrophy of the distal lower limbs &
weakness of the posterior tibial and calf muscles
- Complete lack of deep tendon reflex is found in only a small
percentage (20-50%)
- Pes cavus and hammer toe deformities are less common in CMT2A/B
ELECTROPHYSIOLOGIC FINDING IN CMT2
Motor NCS
NCV normal or only mildly reduced (usually in excess of
70% of the lower limit of normal or >38 m/s)
Distal motor latencies : normal or only mildly prolonged
CMAPs are usually absent or reduced in peroneal and
posterior tibialis m. (often preserved in the upper limbs)
NEEDLE EMG IN CMT2
Histopathology
small clusters of thinly myelinated fibers
loss of the large myelinated fibers
Axonal atrophy
Wallerian degeneration
Onion bulbs (rare)
Charcot-Marie
Tooth Disease
Type 3
Charcot-Marie-Tooth Disease
Type 3 (Dejerine-Sottas disease)
Congenital hypomyelination neuropathy
The most severe form of demyelinating CMT
Early onset with severe “hypertrophic” demyelination and
remyelination
Onset infancy or early childhood
Autosomal recessive (mutations in either the PMP-22, P0,
or EGR2 genes)
Charcot-Marie-Tooth Disease
Type 3 (Dejerine-Sottas disease)
Clinical presentation
Generalized weakness (distal muscles >proximal muscles)
or Hypotonia at birth
Arthrogryposis multiplex
In less severe case
- Delay in motor development, difficulty running and
jumping,and weakness(LE >UE)
- Weakness can progress Wheelchair dependent
Charcot-Marie-Tooth Disease
Type 3 (Dejerine-Sottas disease)
Clinical presentation
Peripheral nerve enlargement is noted in the majority of
patient
reduction in all sensory especially large myelinated fibers (i.e.,
vibration, proprioception)
limb and truncal ataxia (lack of sensory input)
Sensorineural hearing loss
Abnormal pupillary reaction to light
Arthrogryposis multiplex
ELECTROPHYSIOLOGIC FINDING IN CMT3
Histopathology
Hypomyelination with basal
lamina onion bulbs
Hypomyelination with
classic onion bulbs
Amyelination
Charcot-Marie
Tooth Disease
Type 4
Charcot-Marie-Tooth Disease
Type 4 (Refsum’s disease)
Clinical Features
Classical syndrome Vocal cord paresis &
- Peripheral polyneuropathies sensorineural deafness, facial
- Retinitis pigmentosa and diaphragmatic weakness
- Cerebellar ataxia Scoliosis and skeletal
- Elevated protein content in CSF deformities
- Associate Liver, kidney, and heart Many children become
disease may also develop wheelchair-dependent
Charcot-Marie-Tooth Disease
Type 4 (Refsum’s disease)
Clinical
Motor development is generally delayed
Weakness and atrophy are more prominent in the distal limbs.
Proximal muscles become affected by the end of the first decade
Mild sensory loss
Areflexia
ELECTROPHYSIOLOGIC FINDING IN CMT4
Motor NCS
DML are more prolonged (Male >female)
Temporal dispersion
- Non uniform slowing of NCV between different nerves
NEEDLE EMG IN CMT X
Histopathology
Mix axonal and demyelinating feature
few onion bulbs
ELECTROPHYSIOLOGIC FINDING IN CMT X