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Benign Fasciculations Responsive to Gabapentin

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Benign Fasciculations Responsive to Gabapentin Arq Neuropsiquiatr 2007;65(4-A):1015-1017 BENIGN FASCICULATIONS RESPONSIVE TO GABAPENTIN Cassiano Mateus Forcelini1, Francisco Tellechea Rotta2, Naiana Posenato1, Joana Stella Rovani3, Paulo Sérgio Crusius1, Adroaldo Baseggio Mallmann1, Cláudio Albano Seibert1, Marcelo Ughini Crusius1, Charles Carazzo1, Cassiano Ughini Crusius 1, Eduardo Goellner1, Jean Ragnini1, Sâmia Yasin Wayhs1 ABSTRACT - Fasciculations are symptoms present in a broad spectrum of conditions, ranging from normal manifestations to motor neuron diseases. They also represent the main picture of benign fasciculation syn- drome. We report a case of such syndrome: a 48-years-old woman complaining about fasciculations for three decades who remained with the symptoms even after the compensation of a disclosed hyperthyroid- ism. The introduction of gabapentin rendered control of her fasciculations. The available data in the liter- ature about the therapeutic approaches for fasciculations are revised, as long as the rare reports of evolu- tion from patients with “benign” fasciculations to cases of amyotrophic lateral sclerosis, underlining the im- portance of following the patients with fasciculations. KEY WORDS: benign fasciculations, gabapentin, motor neuron disease, amyotrophic lateral sclerosis. Fasciculações benignas responsivas à gabapentina RESUMO - Fasciculações são sintomas presentes em um amplo espectro de condições, desde manifestações normais até doenças do neurônio motor. Elas representam também o principal aspecto da síndrome de fas- ciculações benignas. Relatamos um caso desta síndrome: uma paciente de 48 anos com queixas de fascicu- lações por três décadas que, mesmo após a compensação de um quadro de hipertireoidismo, permaneceu com os sintomas. A introdução de gabapentina levou a controle das fasciculações. Os dados disponíveis na literatura sobre as abordagens terapêuticas para fasciculações são revisados, assim como os raros relatos de evolução de pacientes com fasciculações “benignas” para casos de esclerose lateral amiotrófica, salientan- do a importância do seguimento dos pacientes com fasciculações. PALAVRAS-CHAVE: fasciculações benignas, gabapentina, doenças do neurônio motor, esclerose lateral amiotrófica. Fasciculations are visible rapid slight contractions scarse, a fact that turns important any report of suc- that occur spontaneously in an intermittent manner cessful treatment. in voluntary muscle fi bres1. They are due to twitch- es of bundles of muscle fi bers, most probably motor CASE units2. Fasciculations may arise both in the peripheral A 48-year-old white woman looked for neurologic ad- and in the central portion of the motor neuron, and vice with a complaint of trembles in the muscles of her arms, probably represent changes in the conductive prop- legs, trunk, neck, and face since she was teenager. She re- erties of the ionic gates, i.e., fl uctuations in the ionic ported that the trembles had become slightly more intense gradients along the axonal membranes, a fact dem- in the last ten years, provoking a discomfort in her muscles and making her to be ashamed of wearing short clothes in onstrated by some experimental studies3. Fascicula- the summer beacause the surrounding people could notice tions are present in a broad spectrum of clinical con- the trembles. She denied any other current or past disease, ditions, some of them ominous illnesses as motor neu- and had three pregnancies which elapsed without abnor- ron diseases. They may also be an occasional normal malities. On the last months before the neurologic consulta- manifestation in many people or the continuous main tion she had begun to feel fatigue and was loosing weight. picture of benign entities. At the time of the fi rst neurologic consultation a com- Therapeutic approaches for fasciculations are plementary investigation was ordered. The electromyog- 1Institute of Neurology and Neurosurgery, Passo Fundo RS, Brazil; 2Neurophysiologist; 3 Medicine student. Received 14 November 2006, received in fi nal form 8 June 2007. Accepted 8 August 2007. Dr. Cassiano Mateus Forcelini - Rua Paissandu 1644 / 302 - 99010-120 Passo Fundo RS - Brasil. E-mail: [email protected] [email protected] 1015 Benign fasciculations: gabapentin Arq Neuropsiquiatr 2007;65(4-A) Forcelini et al. raphy (EMG) revealed widespread fasciculation potentials mon in men, have a predilection for hands and feet during the muscle rest, without any other abnormality. The and may be related to the height, weight, and anxi- following blood tests rendered normal results: blood counts, ety6. In this setting, no other pathological signs like erythrocyte sedimentation rate, fasting glucose, uric acid, weakness or muscle atrophy are apparent. The EMG total and fractional cholesterol, triglycerides, tests for syph- must be normal, except by fasciculation potentials. ilis and human immunodefi ciency virus, creatinine, electro- lytes (sodium, potassium, magnesium, and calcium), ala- A myriad of clinical and neurological conditions nine aminotransferase, aspartate aminotransferase, and can present with fasciculations5,6, but are generally bilirubin. The creatine kinase (CK) presented variable re- accompanied by other symptoms and signs that aid sults which oscillated between the normal range and slight- to ascertain the diagnosis. For instance, fasciculations ly increased leves (from to 113.0 to 337.0 U/L). The only tests that were clearly abnormal were those of thyroid function: may be associated with acute viral infections or ex- thyroid-stimulating hormone (TSH) was 0.01 μUl/mL (nor- ceptionally be a delayed manifestation of poliomyeli- mal range from 0.3 to 5.0), free thyroxine (FT4) 3.46 ng/dL tis or myelitis7, hyperthyroidism (thyrotoxicosis), nerve (from 0.75 to 1.8), total thyroxine (T4) 13.8 μg/dL (from 5.0 to root or trunk compression5, or cervical spondylosis5. If 12.0), and total triiodothyronine (T3) 308.0 ng/dL (from 75.0 the associated symptoms and signs of the “benign” to 220.0). On the other hand, both antimicrosomal and an- conditions are absent, fasciculation may present a dif- tithyroglobulin antibobies showed normal results. fi cult but important diagnostic problem5. Even the After the diagnosis of hyperthyroidism, propylthiouracil focal distribution of fasciculations in some muscles, 100 mg PO a day was initiated. In the following fi ve months the tests of thyroid function returned to normal range but a fact that could resemble a restricted neurological the fasciculations remained unchanged. Face to the suspi- disease, is not a categorical benign sign since motor cion of benign fasciculation syndrome, gabapentin was in- neuron diseases not rarely begin with local involve- troduced based on the report of Romano concerning the ment and widespread afterwards. benefi ts of its use in the control of fasciculations in patients An illness generally considered benign is the mus- with amyotrophic lateral sclerosis (ALS)4. Its doses were 8 gradually increased until the patient noticed the disappear- cular pain-fasciculation syndrome , also called benign 9 ance of fasciculations, which was reached with 400 mg TID. fasciculation syndrome . The clinical pattern of benign The patient has been accompanied for fi ve years, and fasciculations frequently includes muscle cramps and no other clinical or neurological abnormality has appeared local pain, symptoms that may worsen with physical in this period. She tells that if she takes gabapentin only a activity and lessen with rest. Occasionally, some pa- few hours after the time prescribed fasciculations resume. tients also complain about numbness or tingling8. She presently has to obey the 8 hours interval between each dose of the drug. No evidence of weakness or muscle wast- The differential diagnosis of benign fasciculation ing has been detected during this period. syndrome must be accomplished with judgement6, since it includes other entities that may present solely DISCUSSION with fasciculations in the beginning, but can devel- Fasciculations generally are visible and occur spon- op more ominous symptoms and signs later. Indeed, taneously in an intermittent manner in voluntary some patients initially diagnosed as having benign muscle fi bres, but may be imperceptible when occur- muscle fasciculations may evolve to motor neuron ing in deep muscles1. When observed in the EMG they disease10,11. Fortunately, such evolution is not the rule are called fasciculation potentials. These are sponta- but underlines the importance of accompanying these neous motor unit potentials of fi ve to twelve milli- patients for at least fi ve years. It was suggested that seconds` duration, of widely varying amplitude (300 fasciculations represent a state of hyperexcitability microvolts – 2 millivolts) and occurring irregularly at that precedes the neuron death in case of motor neu- a rate of approximately 1-50/min5. ron disease12. This is the more serious condition that manifest with such symptoms. Its adult paradigm is In many people fasciculations can be normally ALS, a fatal illness which combines fasciculations with found in voluntary muscles, generally in a focal and progressive muscle weakness and wasting, often with episodic manner. The face and limbs are commonly a focal beginning but with posterior spread to most, affected. Most of those who have such manifestations if not all, skeletal muscles of the body. ALS common- do not search medical advice since they are unaware ly comprises a few years from the fi rst symptoms to of them, or consider them normal. Members
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