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pathways, respectively
Pathophysiology
• MRI
– Patients with Huntington disease (HD) and chorea-
acanthocytosis show decreased signal in the
neostriatum, caudate, and putamen. No significant
difference has been observed between these
diseases. The decreased neostriatal signal
corresponds to increased iron deposition.
Generalized atrophy, as well as focal atrophy of
the neostriatum, predominantly of the caudate, with
resulting enlargement of the frontal horns, follows the
initial findings of decreased neostriatal signal
Medical Care
Endocrine
• Hyperthyroidism
• Chorea gravidarum
• Hypoparathyroidism, pseudohypoparathyroidism
Immune/infectious
• Behçet disease
• Other infections - Pertussis, diphtheria, varicella
• Primary antiphospholipid antibody syndrome
• Sydenham chorea
• Systemic lupus erythematosus
• Bacterial endocarditis
• Herpes simplex encephalitis
• HIV related
• Infectious mononucleosis
• Lyme disease
• Mycoplasmal pneumonia
• Viral meningoencephalitis (eg, mumps, measles, varicella)
Vascular
• Arteriovenous malformation
• Basal ganglia infarction or hemorrhage
• Vasculopathies/vasculitis: Churg-Strauss syndrome[1] , moyamoya
Metabolic
• Hypocalcemia
• Hypoglycemia and hyperglycemia
• Hypomagnesemia
• Hyponatremia, hypernatremia, and central pontine myelinolysis
• Renal failure
Miscellaneous
• Cerebral palsy
• Head trauma
• Bronchopulmonary dysplasia (infantile chorea)
• Cardiopulmonary bypass - "Postpump chorea“
Neoplastic
• Primary and metastatic brain tumors
• Primary CNS lymphoma
Toxins – CO, Mg, organophosphate
Pathophysiology and General Principles in
Treatment of Chorea
• Sydenham chorea is the most common cause of acquired chorea in the young.
During the latter part of the twentieth century the number of reported cases of RF
in the United States increased. This resurgence appears to be associated with
strains of group A beta hemolytic streptococcal infection that are less likely to
cause symptomatic pharyngitis.
• In some outbreaks, chorea has been present in more than 30% of patients with
acute RF.
• The female-to-male ratio is approximately 2:1, and most patients present between
5-15 years of age.
Clinical features and course
• Serum antineuronal antibody titers have been found to decrease as the chorea
improves.
• In children who suffer a relapse, the increase in symptom severity correlates with a
rise in these neuronal antibodies.
Neuroimaging
• SC usually develops in those aged 3-13 years and is believed to result from
a preceding streptococcal infection.
The patient may have no history of rheumatic fever, and a
preceding streptococcal infection cannot always be documented. Infections
can be subclinical and often precede the development of neurologic
symptoms by age 1-6 months.
At least 25% of patients with SC fail to have serologic evidence of
prior infection.
• . Prednisone,
•
Children with SC require prophylaxis against
streptococcal infections until 18 years of age.
Chorea gravidarum
Background
• In general, about half the cases are idiopathic, with rheumatic fever
and antiphospholipid syndrome (APLS) underlying most of the
remainder.
Patient profile
• Willson and Preece noted that nearly 70% of their patients gave a previous
history of either rheumatic fever or chorea.
Of patients who present with chorea and no apparent carditis,
20% may develop rheumatic heart disease after 20 years.
Interestingly, 50% of patients with oral contraceptive-induced
chorea have a past history of chorea, which in 41% of cases is of rheumatic
origin.
Background
• is an incurable,
• adult-onset,
• autosomal dominant inherited disorder associated with
cell loss within a specific subset of neurons in the basal
ganglia and cortex.
• HD is named after George Huntington, the physician who described it as
hereditary chorea in 1872.
• Characteristic features of HD include
involuntary movements, dementia, and behavioral changes.
Pathophysiology
International
• The prevalence in most European countries ranges from
1.63-9.95 per 100,000 people. The prevalence of HD in
Finland and Japan is less than 1 per 100,000 people.
Mortality/Morbidity
• The normal estimated total body copper content is 50-100 mg, and the
average daily intake 2-5 mg, depending on an individual’s intake of legumes,
meats, shellfish, and chocolate.
• Copper is an important component of several metabolic enzymes , including
lysyl oxidase, cytochrome c oxidase, superoxide dismutase, and dopamine
beta-hydroxylase.
Age-related presentations
Kayser-Fleischer rings
Approach Considerations
Abdominal imaging
• Computed tomography (CT) scanning, magnetic resonance imaging
(MRI), ultrasonography, and nuclear medicine studies of the liver have
been uninformative, with findings neither specific nor sensitive for Wilson
disease.
Electrocardiography
• Resting electrocardiographic abnormalities include left ventricular or
biventricular hypertrophy, early repolarization, ST segment depression, T-
wave inversion, and various arrhythmias.
Serum Ceruloplasmin
• A characteristic "face of the giant panda" sign has been described, formed
by high signal intensity in the tegmentum (except for the red nucleus),
preserved signal intensity of the lateral portion of the pars reticulata of the
substantia nigra, and hypointensity of the superior colliculus.
PET Scanning
• Zinc and penicillamine are lifelong medications for patients with Wilson
disease. Dosages vary with the severity of the disorder.
• Another chelating agent is trientine, which may be more easily tolerated
than penicillamine.[1] Patients who do not respond to zinc therapy and
who have increased activities of liver enzymes should be identified so
that chelating agents may be added to the therapeutic regimen.
Class Summary
Trientine (Syprine)
• Trientine is an effective oral chelator used to induce cupruresis. It is useful for patients who
cannot tolerate penicillamine. It is indicated in Wilson disease if the initial presentation is
hepatic. It should be administered with zinc
Zinc (Galzin)
• Zinc is a cofactor for more than 70 types of enzymes. It is approved for patients initially
treated with a chelating agent. It should be used for maintenance after initial chelation
therapy. Zinc acetate is the drug of choice in presymptomatic, pregnant, pediatric populations,
and in some instance for maintenance in compliant patients who have undergone copper
chelation therapy
Prognosis
The major complications in patients with untreated Wilson disease are those
associated with acute liver failure, chronic hepatic dysfunction with either
portal hypertension or hepatocellular carcinoma, and the sometimes-
relentless course to cirrhosis, which is characterized by a progressive
lassitude, fatigue, anorexia, jaundice, spider angiomas, splenomegaly, and
ascites. Bleeding from varices, hepatic encephalopathy, hepatorenal
syndrome, and coagulation abnormalities occur as liver failure ensues.
Death occurs, generally at age 30 years, if emergent liver transplantation is
not performed.