J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.52.5.681 on 1 May 1989. Downloaded from Letters 681 to the sink. She consumed 1-2 pitchers of did not include CT and MR studies or 2 Fitzsimmons JT. The hypothalamus and drink- water. Interictal EEG studies revealed inter- describe the pathological anatomy of this ing. Br Med Bull 1966;22:231-7. mittent epileptiform activity in the right ictal syndrome.' The neuroimaging studies 3 Martin JB, Reichlin S. The Neurohypophysis: Physiology and Disorders of Secretion. In: anterior region. Ictal EEG studies confirmed may have demonstrated an extratemporal Martin JB, Reichlin S: Clinical Neuro- the right anterior temporal localisation. Pos- structural abnormality associated with an endocrinology. Philadelphia, FA Davis tictally she appeared confused and did not aberration of water intake, such as a hypo- Company, 1987:79-81. recall test items presented to her during the thalamic lesion.' 4 Andersson B. Polydipsia, antidiuresis and milk ictus. She did, however, admit to her thirst The anterior and ventromedial hypo- ejection caused by hypothalamic stimula- and consumption of water. thalamus has an important role in thirst tion. In: Heller H, ed: Neurohypophysis. Electrolytes, serum and urine osmolality and water regulation.26 In addition, efferent London, Butterworth, 1957:131-140. and fasting blood glucose were normal. A from the amyg- 5 Stevenson JAF. Neural control of food and pathways hippocampus and water intake. In: Haymaker W et al(editors): computed tomography (CT) scan was nor- dala that project to the hypothalamus have The Hypothalamus. Springfield, Ill., CC mal. A magnetic resonance (MR) scan also been implicated in water balance and Thomas, 1969:524-621. showed an enlargement ofthe right temporal drinking behaviour.3" Stimulation and lesion 6 Andersson B, McCann SM. Drinking, horn of the lateral ventricle and suggested studies in the dog have implicated a role for antidiuresis and milk ejection from electrical atrophy of the right parahippocampal gyrus the anteroventral amygdala in thirst and stimulation within the hypothalamus of the (fig). The patient underwent an en bloc right water drinking behaviour.3 Amygdala goat. Acta Physiol Scand 1955;35:191-7. anterior temporal lobectomy. Hippocampal efferent fibres in the stria terminalis and 7 Brodal A. The Olfactory Pathways. In: Brodal sclerosis The neuronal converge A (editor): Neurological Anatomy, New was demonstrated. hippocampal efferents in the fornix York, Oxford University Press, 1981:658 loss and gliosis were widespread and prom- on the hypothalamus.' and 679. inent in the hippocampus, subiculum, and Thus, the hypothalamus is linked with dentate gyrus. The amygdala and the lateral limbic structures by a variety of multisynap- temporal neocortex were unremarkable. She tic pathways.' Epileptiform activity gen- has been asymptomatic and seizure free since erated in the temporal lobe may propogate surgery. into the hypothalamus and other structures The urge to pour and drink water has been implicated in thirst and water regulation, Single fibre and quantitative EMG study in documented rarely to occur as an ictal producing ictal manifestations of abnormal acute stage of human trichinosis Protected by copyright. behaviour in epilepsy. Remillard et al des- water seeking behaviour. cribed 20 patients with complex partial This study demonstrates that complex Sir: Human trichinosis is a parasitic infection epilepsy and ictal water drinking.' In these partial seizures, accompanied by mesiobasal now rarely reported, although the disease patients scalp recorded EEG demonstrated temporal lobe pathology, may indeed be has not been eradicated. Electro- electrographic seizure activity in the tem- associated with an ictal disturbance of water physiological information is scanty and poral lobe, and depth electrode studies drinking. The clinical and neuropathological usually only reports a myopathic pattern.'13 revealed the onset of seizure activity in the observations suggest that epileptiform We report the clinical findings, laboratory amygdala, hippocampus and parahippo- activity may propogate into regions that are manifestations and, particularly, the results campal gyrus in two patients.' This report synaptically remote from hippocampal path- ofa careful electrophysiological examination ology and produce ictal manifestations of in 10 patients with only mild neuromuscular abnormal water-seeking behaviour. This involvement by trichinosis. Correlation bet- case confirms the previous report regarding ween electrophysiological and laboratory the temporal lobe localisation of ictal thirst, findings was made. and in addition identified a pathological The symptoms began 4 to 16 days after lesion associated with this unusual ictal consuming home prepared wild boar behaviour.' sausages (table). A large number ofmembers of several families in the same small town GREGORY D CASCINO*t were affected, although most cases were http://jnnp.bmj.com/ THOMAS P SUTULAt almost asymptomatic. Ten patients (table) Francis M. Forster Epilepsy Center,* had diffuse myalgias of variable duration, William S. Middleton Memorial Veterans' and some of them had subjective weakness. Hospital, These 10 cases were electrophysiologically 2500 Overlook Terrace, evaluated early, in the second or third week Madison, Wisconsin 53705 after onset of the symptoms (mean = 17, SD University of Wisconsin Comprehensive 3 days). A second electrophysiological Epilepsy Program,t examination was performed in two patients, 600 Highland Avenue, 2 months (case 5) and 6 weeks (case 8) after on October 2, 2021 by guest. Madison, Wisconsin 53792, USA the first exploration, when the patients were Fig A coronal Ti weighted image magnetic already asymptomatic. resonance scan shows atrophy ofthe right The first manifestation of the disease was parahippocampalgyrus (arrow) and Referenmes often characterised by nausea, vomiting, enlargement ofthe right temporal horn ofthe abdominal cramp and diarrhoea, always I Remillard GM, Andermann F, Gloor P, Olivier had a vari- lateral ventricle (arrow). (Note the right A, Martin JB. Water-drinking as ictal followed by myalgias. Myalgias temporal lobe is on the left side ofthe behaviour in complex partial seizures. able duration, from 7 to 48 days. Subjective photograph.) Neurology 1981;31:1 17-24. weakness was a common symptom (seven J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.52.5.681 on 1 May 1989. Downloaded from 682 Letters Table Findings in 10 patients with mild trichinosis Mean % end- Mean Incuba- Mean Percentage amplitude Ratio plates jitter tion duration polyphasic T (m V) TIA (p V) nFD increased (ps) CK level Number Age period Fibril- MUP (% potentials (N= 215- (N=0 24- (N= 0 71- (N= jitter (N< (N<260 eosinophils No Sex (yr) (days) lation decreased) (N< 15%) 457) 044) 123) <2) (N< 10%) 395) IU) (N<500) I M 47 6 + 10 33 391 028 1 39 NP NP NP 1033 1008 2 M 22 8 + 20 25 394 0-27 145 NP NP NP 1351 1808 3 M 30 4 + 24 25 400 0-27 1 48 5 0 30 58 5 167 3200 4 M 27 10 + 15 20 517 0-27 1 91 NP NP NP 446 1230 5 F 61 9 + 45 45 NP NP NP 5 3 20 52 0 121 1410 6 M 31 7 + NP NP 479 0-29 1-65 4-2 15 48-3 173 2880 7 F 28 10 + 28 20 NP NP NP 3-8 20 39 9 483 1370 8 M 21 7 + 10 15 NP NP NP 2-6 10 43-8 1420 1130 9 F 48 14 + 35 30 536 034 1-57 3-1 10 37-8 1176 660 10 F 37 16 - NP NP 630 0-32 1-96 3-8 0 33-0 121 700 M =male; F=female. Fibrillation potentials (+ )= present; (- )=absent. Mean duration of the MUP (% decrease from normal mean) and percentage of polyphasic potentials in biceps brachii muscle. Automatic analysis of the EMG in biceps brachii muscle (T =number of turns; mean amplitude in mV. and T/A (yV) ratio). Single fibre EMG study in extensor digitorum communis muscle with data of nFD, percentage of end-plates with increased jitter and mean jitter values in ps. N = normal values; NP = not performed. cases), although examination only revealed it decreased from 52-0 to 38-4 ps and from 43-8 transmission of the reinnervating complex in one case and in another was doubtful. to 31-7 ps respectively. The remaining was still uncertain. The follow-up in two Clinical examination suggested that weak- patient refused a new EMG study. cases is consistent with this hypothesis, ness was mainly secondary to muscle pain. The motor and sensory conduction because it indicated a large rearrangement of Sensation and tendon reflexes were normal. velocities performed in upper and lower the motor unit (progressive increment in Other signs and symptoms were: periorbital limbs were within the normal range for age. nFD) and more stable transmission of Protected by copyright. the and facial oedema in all patients, fever in The laboratory and electrophysiological impulse, perhaps owing to the maturation of nine subjects, conjunctivitis in four cases, data were correlated (Spearman's correla- the sproutings. headache in three and paraesthesiae in only tion coefficient). Decrement of the MUPs The significant correlation between one patient. The number of eosinophils was duration was significantly (p < 0-01) decreased mean duration and raised CK raised in all cases, and CK values were correlated with the raised CK values. Sig- could be due to drop-out of muscle fibres in elevated in six (table) at the time of the first nificant correlation (p < 0-05) was also the acute phase ofthe disease. Early examin- electrophysiological examination. All cases found between nFD and mean jitter values. ation might explain the poor correlation were clinically asymptomatic 6-8 weeks after The main electrophysiological findings between enzymatic abnormalities, electro- the onset of the illness. The patients were reported here are consistent with myopathy physiological parameters and eosinophils treated with thiabendazole (25-50 mg/kg/ in all patients. EMG changes were mild to count.