A Video Atlas of Neuromuscular Disorders

Aziz Shaibani, M.D. is the director of the Nerve and Muscle Center of Texas and a Professor at the Baylor College of Medicine, Houston, Texas. He is board certified in neurology, neuromuscular medicine, neurophysiology, neuromuscular pathology and electrodiagnostic medicine. He previously served as the President of the Texas Neurological Society and Vice President of the Neuromuscular section of the American Academy of Neurology.

Foreword to the First Edition
Richard J. Barohn
Foreword to the First Edition
Anthony Amato

Contributors List
Introduction to the Third Edition

Chapter 1 Gait Disorders
Case 1.1 Bilateral Foot Drop
Case 1.2 Sensory Ataxia
Case 1.3 Spastic Gait
Case 1.4 Painful Leg Spasms
Case 1.5 Lateral Pelvic Tilting
Case 1.6 Bizarre Gait
Case 1.7 Proximal and Distal Weakness
Case 1.8 Wide-Based Gait
Case 1.9 Magnetic Gait
Case 1.10 Frequent Falls
Case 1.11 Chronic Progressive Gait Disorder With Ophthalmoplegia
Case 1.12 Spastic Gait
Case 1.13 Sensory Ataxia With Brisk Ankle Reflexes
Case 1.14 Familial Gait Spasticity
Case 1.15 Ataxia and Night Blindness
Case 1.16 Neuropathy and Nystagmus
Case 1.17 Progressive Bending
Case 1.18 Progressive Ataxia


Chapter 2 Ptosis
Case 2.1 Ophthalmoplegia and Proximal Weakness
Case 2.2 Delayed Eyes Opening
Case 2.3 Ptosis in the Elderly
Case 2.4 Unidirectional Diplopia
Case 2.5 Eye Closure and Facial Grimacing
Case 2.6 Symptoms Resolved After Prayer
Case 2.7 Myasthenia With Dilated Pupil
Case 2.8 Apraxia or Ptosis?
Case 2.9 Myasthenic Symptoms Worsened With Steroids
Case 2.10 Iatrogenic Ptosis
Case 2.11 Fixed Ptosis
Case 2.12 Familial Ptosis
Case 2.13 Respiratory Failure Induced by Steroids
Case 2.14 Watch Out for Steroids Complications
Case 2.15 Droopy Eyelid and Anisocoria
Case 2.16 A Wide Eye


Chapter 3 Diplopia
Case 3.1 Weak Lateral Rectus
Case 3.2 Medial Rectus Weakness
Case 3.3 Positive Edrophonium Test
Case 3.4 Myasthenia Gravis Mimicker
Case 3.5 Unifying Diagnosis Is Not Always Possible
Case 3.6 Penalty for Correction of Wrinkles
Case 3.7 Oblique Diplopia
Case 3.8 Ophthalmoplegia With Elevated CK
Case 3.9 Which Extraocular Movement Is First Affected in Myasthenia Gravis?
Case 3.10 Diplopia and Weight Loss
Case 3.11 Diplopia and Retro-Orbital Pain


Chapter 4 Ophthalmoplegia
Case 4.1 Floppy Baby With Ophthalmoplegia
Case 4.2 Bulgy Eyes and Heat Intolerance
Case 4.3 How Long Should MG Be Treated?
Case 4.4 Ophthalmoplegia and Respiratory Failure
Case 4.5 Demyelinating Neuropathy With Ophthalmoplegia
Case 4.6 Ptosis and Anisocoria
Case 4.7 Fluctuating EOM Weakness Without Diplopia
Case 4.8 Diplopia and Triceps Fatigability
Case 4.9 Droopy Eyelids and Fainting
Case 4.10 Ptosis Since Childhood
Case 4.11 Familial Ptosis
Case 4.12 Ophthalmoplegia With Cerebellar Ataxia and Demyelinating Neuropathy
Case 4.13 Recurrent Ptosis Since Childhood
Case 4.14 Ophthalmoplegia After Sinus Infection
Case 4.15 Can't Move Eyes or Open Them Widely
Case 4.16 Ophthalmoplegia Since Childhood

Chapter 5 Facial Weakness
Case 5.1 Muscle Stiffness and Syncope
Case 5.2 Facial Weakness and Elevated CSF Protein
Case 5.3 Resolution of Facial Weakness
Case 5.4 Unilateral Facial Weakness
Case 5.5 Facial Asymmetry After a Hurricane
Case 5.6 Could Never Blow a Balloon
Case 5.7 A Penalty for Facial Lift
Case 5.8 Weakness of Face and Fingers
Case 5.9 Nasal Speech
Case 5.10 Facial Twitching
Case 5.11 Inability to Sing and Kiss
Case 5.12 Crooked Smile Since Childhood
Case 5.13 Chronic Facial Weakness and Deafness
Case 5.14 Anarthria and Facial Weakness
Case 5.15 Facial Weakness and Inflammatory Myopathy
Case 5.16 Facial Numbness and Weakness

Chapter 6 Tongue Signs
Case 6.1 Slurred Speech and Trouble Swallowing
Case 6.2 Choking With Saliva
Case 6.3 Just a Lisp
Case 6.4 Grooved Tongue
Case 6.5 Familial Muscle Stiffness
Case 6.6 Tongue Twitching After Radiotherapy
Case 6.7 Unexpected Electromyography Finding
Case 6.8 Facial Twitching and Large Breasts
Case 6.9 Restless Tongue
Case 6.10 Neck Pain and Tongue Deviation
Case 6.11 Muscle Stiffness and Winter Weakness
Case 6.12 Ear Pain and Tongue Deviation

Chapter 7 Dysarthria
Case 7.1 Crying and Laughter
Case 7.2 Spastic Dysarthria
Case 7.3 Dysarthria Long After Radiotherapy
Case 7.4 Familial Dysarthria, Sensory Ataxia, and Elevated CK
Case 7.5 Cerebellar Ataxia and Tongue Fasciculations
Case 7.6 A Lisp During Divorce
Case 7.7 Thymectomy or Not?
Case 7.8 Morbidity in ALS: Can It Be Improved?
Case 7.9 A A Self-Medicated Myasthenic
Case 7.10 B The Patient in Case 7
Case 7.11 Tongue Fasciculations and Positive MG Serology

Chapter 8 Dysphonia
Case 8.1 Fluctuating Nasal Speech
Case 8.2 Chronic Nasal Speech
Case 8.3 Vocal Cord Paralysis and Distal Weakness
Case 8.4 Acute Hoarseness and Severe Arm Pain
Case 8.5 Dysarthria and Spasticity
Case 8.6 Refractory Dysphonia

Chapter 9 Dyspnea
Case 9.1 Persistent Respiratory Failure After a Car Accident
Case 9.2 Dyspnea and Scapular Winging

Chapter 10 Weakness of the Neck Muscles
Case 10.1 Inability to Hold Head Up
Case 10.2 Spotting Money in the Post Office
Case 10.3 Progressive Head Drop
Case 10.4 , B Dropped Head and Chewing Difficulty
Case 10.5 Dropped Head
Case 10.6 Fatal Familial Head Drop
Case 10.7 Debilitating Painful Neck Flexion

Chapter 11 Scapular Winging
Case 11.1 Scapular Winging and Lobulated Fibers
Case 11.2 Scapular Winging After Cervical Lymph Node Biopsy
Case 11.3 Progressive Scapular Winging and Shortness of Breath
Case 11.4 Scapular Winging and Deafness
Case 11.5 Scapular Winging and Bilateral Foot Drop
Case 11.6 Scapular Winging and Severe Shoulder Pain
Case 11.7 Subacute Scapular Winging and Weakness of Finger Flexors
Case 11.8 Familial Scapular Winging
Case 11.9 Scapular Winging and a CK of 2,000 IU/L

Chapter 12 Proximal Arm Weakness
Case 12.1 Proximal Arm Weakness and Fasciculations
Case 12.2 Proximal Weakness and Areflexia
Case 12.3 The Patient in Case 12.2 After Treatment
Case 12.4 Chronic Proximal Arm Weakness
Case 12.5 Proximal Arm Weakness and Cardiomyopathy
Case 12.6 Proximal Weakness and Hard Breasts
Case 12.7 Recurrent Proximal Weakness and Areflexia
Case 12.8 Progressive Proximal Weakness and Cardiomyopathy
Case 12.9 Unilateral-Onset Severe Biceps Weakness
Case 12.10 Chronic Unilateral Arm Atrophy
Case 12.11 Arms Weakness After Trauma
Case 12.12 Can't Raise Arms
Case 12.13 Progressive Arm Weakness and Atrophy
Case 12.14 Progressive Arm Weakness and Numbness
Case 12.15 Muscle Weakness and Rimmed Vacuoles

Chapter 13 Proximal Leg Weakness
Case 13.1 Proximal Weakness With Non-Inflammatory Muscle Necrosis
Case 13.2 Proximal Weakness and Sensory Ataxia
Case 13.3 Resolution of Weakness With Plasma Exchange
Case 13.4 Acute Myalgia and Elevated CK Level
Case 13.5 Necrotizing Myopathy Responding to Treatment
Case 13.6 A Diabetic With Thigh Pain and Weakness
Case 13.7 Quadriceps Weakness and Calf Hypertrophy
Case 13.8 Dystrophic Myopathy With Inflammation
Case 13.9 Thigh and Intercostal Pain
Case 13.10 Proximal Weakness and Hyperreflexia
Case 13.11 Proximal Weakness After Bone Marrow Transplantation
Case 13.12 Weakness Years After Thymectomy
Case 13.13 Fatigue and Weakness Since Childhood
Case 13.14 Toe Walking Since Childhood
Case 13.15 Chronic Proximal Legs Denervation
Case 13.16 Chronic Leg Weakness
Case 13.17 Muscle Weakness and Consanguineous Marriage of the Parents
Case 13.18 Progressive Leg Weakness
Case 13.19 Muscle Weakness and Cognitive Decline
Case 13.20 Weakness in a Patient With HIV Infection
Case 13.21 Myalgia and Muscle Weakness
Case 13.22 Muscle Weakness and Abnormal Genetic Testing

Chapter 14 Quadriceps Weakness
Case 14.1 Thigh Weakness and Big Calves
Case 14.2 Thigh Weakness
Case 14.3 IBM Diagnostic Criteria Were Met 15 Years Later
Case 14.4 Big but Weak Calves
Case 14.5 Progressive Weakness and Diffuse Denervation
Case 14.6 Progressive Calf Atrophy and Elevated CK
Case 14.7 Dancing Difficulty
Case 14.8 Leg Weakness and Areflexia
Case 14.9 Improved but Developed Swollen Legs After IVIG
Case 14.10 Severe Thigh Pain in a Non-Diabetic Patient
Case 14.11 Weakness and Atrophy of Quadriceps and Hamstrings
Case 14.12 Big Calves and Wasted Thighs
Case 14.13 Unusual Cause of Quadriceps Atrophy
Case 14.14 Painful Cramps and Atrophy of the Quadriceps Muscles
Case 14.15 Quadriceps Mitochondrial Myopathy

Chapter 15 Distal Arm Weakness
Case 15.1 Forearm Pain and Finger Weakness
Case 15.2 Hand and Finger Flexor Weakness and Myopathic EMG
Case 15.3 "Fish Mouth" Handshake and Facial Weakness
Case 15.4 A Fisherman Who Could Not Peel Shrimp Any More
Case 15.5 A Wrist Drop After a Long Flight
Case 15.6 Weak Hands and Congenital Cataract
Case 15.7 Finger Flexor Weakness and Quadriceps Sparing
Case 15.8 Hand Muscles Atrophy and Mild CK Elevation
Case 15.9 Right Hand Weakness
Case 15.10 Chronic Dysphagia and Hand Stiffness
Case 15.11 Chronic Bilateral Wrist Extensor Weakness
Case 15.12 Severe Chronic Dysphagia and Facial Weakness
Case 15.13 Loss of Pinch and Scapular Winging
Case 15.14 Declining Golf Performance
Case 15.15 Progressive Hand Weakness and Granuloma in Muscle Biopsy

Chapter 16 Distal Leg Weakness
Case 16.1 Foot Pain and Postural Syncope
Case 16.2 Asymmetric Painful Foot Drop
Case 16.3 Familial Distal Weakness
Case 16.4 A Recliner and Foot Drop
Case 16.5 Right Foot Drop and Inflammatory Muscle Biopsy
Case 16.6 Calf Atrophy and Moderately High CK Level
Case 16.7 Calf Atrophy and Mild CK Elevation
Case 16.8 Chronic Calf Atrophy
Case 16.9 Progressive Calf Atrophy and Hyperreflexia
Case 16.10 Progressive Bilateral Foot Weakness
Case 16.11 Familial Weakness of Plantar Flexors
Case 16.12 Leg Weakness and Weight Loss
Case 16.13 Chronic Bilateral Foot Drop
Case 16.14 Bilateral Foot Drop After Weight Loss

Chapter 17 Muscle Atrophy and Hypertrophy
Case 17.1 Painless Muscle Twitching
Case 17.2 Progressive Weakness and Abnormal Discharges
Case 17.3 Chronic Bilateral Foot and Wrist Drop
Case 17.4 Inability to Stand on Toes and High CK Level
Case 17.5 Foot Numbness and Calf Hypertrophy
Case 17.6 Calf Atrophy
Case 17.7 Big Calves and Remarkably Elevated CK Level

Chapter 18 Hyperreflexia
Case 18.1 Jaw Clonus
Case 18.2 Spastic Dysarthria
Case 18.3 Inappropriate Crying and Laughter

Chapter 19 Muscle Twitching
Case 19.1 Facial Twitching
Case 19.2 Stretching-Induced Muscle Contractions
Case 19.3 Muscle Twitching and Hyperreflexia

Chapter 20 Muscle Stiffness and Cramps
Case 20.1 Cramping and Hypertrophy of the Calves
Case 20.2 Stiff Back Muscles
Case 20.3 Stiff Person Syndrome After Treatment
Case 20.4 Muscle Cramps and Diarrhea
Case 20.5 Left Leg Stiffness and Falls
Case 20.6 Stiffness and Hypertrophy of the Thenar Muscles
Case 20.7 Silent Muscle Cramps
Case 20.8 Muscle Cramps and Foot Numbness
Case 20.9 Familial Muscle Stiffness and Spasms
Case 20.10 Muscle Cramps and Familial Bone Tumors
Case 20.11 Muscle Cramps Responding to IVIG

Chapter 21 Myotonia
Case 21.1 A Family With Muscle Stiffness
Case 21.2 Myalgia and Myotonia
Case 21.3 Hand Numbness and Diffuse Abnormal Discharges
Case 21.4 Persistent Hand Shaking
Case 21.5 Familial Sensitivity to Cold
Case 21.6 Stiffness That Gets Better With Use
Case 21.7 Episodic Weakness and Muscle Stiffness
Case 21.8 Muscle Stiffness and Abortions
Case 21.9 Asymptomatic Paramyotonia Congenita
Case 21.10 Familial Muscle Stiffness and Temporal Fullness
Case 21.11 Familial Myotonia and Normal DMPK Gene
Case 21.12 Stiffness of the Chewing Muscles

Chapter 22 Pseudoneurologic Syndromes
Case 22.1 Muscle Spasms and Facial Numbness
Case 22.2 Tremor After Divorce
Case 22.3 "Give Way" Weakness and Loss of Balance
Case 22.4 Dysarthria After a Car Accident
Case 22.5 Facial Weakness

Chapter 23 Numbness
Case 23.1 Intercostal Burning Pain
Case 23.2 Burning Pain in a Diabetic
Case 23.3 Patchy Sensory Loss
Case 23.4 Foot Numbness and Normal Ankle Reflexes
Case 23.5 Foot Pain and Orthostasis
Case 23.6 Inhalation for Fun
Case 23.7 Severe Proprioceptive Loss
Case 23.8 Foot Pain and Numbness

Chapter 24 Deformities
Case 24.1 Multiple Masses and Proximal Weakness
Case 24.2 Multiple Familial Masses and Foot Numbness
Case 24.3 Multiple Ruptured Tendons
Case 24.4 Tender Masses

Chapter 25 Fatigability
Case 25.1 Fatigability of Speech
Case 25.2 Fatigable Neck Muscles
Case 25.3 Myasthenia and Elevated CK Level
Case 25.4 Inability to Chew a Steak
Case 25.5 After Treatment With Plasma Exchange
Case 25.6 Fatigability of Triceps Muscle
Case 25.7 Familial Fatigue in Brothers

Chapter 26 Clinical Signs
Case 26.1 Eye Movement
Case 26.2 Facilitated Reflexes
Case 26.3 Hyperreflexia
Case 26.4 Poor Arm Abduction
Case 26.5 Triple Hump Sign and Bulging Abdomen
Case 26.6 Moving Umbilicus

Chapter 27 Skin Signs
Case 27.1 CIDP With Hypogonadism
Case 27.2 Skin Rash and Weight Loss
Case 27.3 Puffy Eyes and Skin Rash
Case 27.4 Foot Ulcer
Case 27.5 Skin Rash and Neuropathy
Case 27.6 Polymyositis and Ear Erosion
Case 27.7 Dilated Capillaries and Proximal Weakness
Case 27.8 Proximal Weakness, Asthma, and Skin Rash

Chapter 28 Electromyogram Findings
Case 28.1 Dysarthria and Paraspinal Spontaneous Activity
Case 28.2 Leg Pain and Spontaneous Fast Activity
Case 28.3 Skin Rash and Short-Duration Units
Case 28.4 Familial Neurogenic Firing
Case 28.5 Spontaneous Activity After Radiotherapy
Case 28.6 Chronic Familial Weakness
Case 28.7 Decelerating Motorcycle Engine

Chapter 29 Diagnostic Ultrasound in Neuromuscular Disorders
Authors: Hans Katzberg, MD, FRCPC; Lubna Daniyal, MD; Hamid Sadeghian, MD, FRCPC; and Monica de Carvalho Alcantara, MD, PhD
Case 29.1 Hand Numbness and Increased Median Nerve Cross-Sectional Area
Case 29.2 Distal, Symmetric Weakness and Nerve Swelling
Case 29.3 Leg Weakness, Atrophy, and Fasciculations
Case 29.4 Hand Weakness and Delayed Muscle Contraction (Myotonia)
Case 29.5 Ulnar Nerve and Increased Ultrasound Cross-Sectional Area
Case 29.6 Ankle Dorsiflexion Weakness After Weight Loss
Case 29.7 Ultrasound-Guided Muscle Biopsy
Case 29.8 Ultrasound-Assisted Lumbar Puncture
Case 29.9 Progressive Forearm Weakness, Atrophy, and Nerve Swelling
Case 29.10 Shortness of Breath and Unilateral Diaphragm Thickening
Case 29.11 Asymmetrical Shoulder Weakness, Atrophy, and Increased Echogenicity
Case 29.12 Progressive Arm Weakness and Preferential Involvement of Deep Finger Flexors
Case 29.13 Leg Weakness and Increased Ultrasound Echogenicity
Case 29.14 Limb Girdle Muscular Dystrophy Type 2B
Case 29.15 Muscle Cramps
Case 29.16 Myasthenia Gravis Intercostal Muscle
Case 29.17 GNE Myopathy
Case 29.18 Neurofibromatosis Type 1
Case 29.19 Segmental Diaphragm Contraction

Chapter 30 Muscle and Nerve Biopsies
Case 30.1 Muscle Biopsy
Case 30.2 Nerve Biopsy

Chapter 31 Virtual Visits: Pros and Cons
Case 31.1 Virtual Examination Challenges: Dysarthria
Case 31.2 Remote Examination Challenges: Amyotrophic Lateral Sclerosis
Case 31.3 Virtual Neuromuscular Exam Challenges: Diplopia

Chapter 32 Neuromuscular Complications of COVID-19 Infection and Vaccinations
Case 32.1 Progressive Symptoms After COVID-19
Case 32.2 Dizziness After COVID-19 Vaccination
Case 32.3 Myasthenia Gravis After COVID-19 Vaccination
Case 32.4 Right Arm Weakness After COVID-19
Case 32.5 Muscle Twitching Right After COVID-19 Vaccination