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甲亢所致的腹部震颤
作者:赵莲花[1] 
单位:天津市泰达医院[1]  
文章号:W133408  
2019/2/8 10:01:38    
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  甲状腺功能亢进症(甲亢)是一般人群的常见疾病,神经系统症状可为首次表现。神经系统症状包括认知异常和癫痫发作,运动障碍(如舞蹈病和震颤),以及周围神经系统症状(包括肌病和神经病)。78%的甲亢患者有震颤,通常为肢体震颤。我们在此报告一例甲亢患者的孤立性腹部震颤,其不同于肚皮舞者的运动障碍。 Case repo rt    病例报道     一位64岁男性出现全腹痛。

  甲状腺功能亢进症(甲亢)是一般人群的常见疾病,神经系统症状可为首次表现。神经系统症状包括认知异常和癫痫发作,运动障碍(如舞蹈病和震颤),以及周围神经系统症状(包括肌病和神经病)。78%的甲亢患者有震颤,通常为肢体震颤。我们在此报告一例甲亢患者的孤立性腹部震颤,其不同于肚皮舞者的运动障碍。

 

Case report    病例报道

 

   一位64岁男性出现全腹痛。他最近因蛋白尿被诊断为膜性肾病(抗磷脂酶A2受体抗体阴性)。口服药物有瑞舒伐他汀和氨氯地平。浅层和深层的腹部跳动诱发了腹前壁震颤(视频在Neurology.org上)。震颤动作迅速、规律(10-15Hz),触压容易诱发。触诊并未加重疼痛。该患者为孤立的腹部震颤,只在平躺和触诊时发生。头部和四肢均未受累。深吸气或Valsalva等动作不会诱发震颤。患者无注意力不集中,反应敏捷。

 

  脑、脊髓、腹部MRI均正常。游离T3为20.7pmol/L(正常2.7-7),T4为51.5pmol/L(正常9.9-20.1),促甲状腺激素减低,<0.05mU/L(正常0.15-3.2)。甲状腺过氧化物酶抗体效价196 IU/mL(正常35 IU/mL)。钙、镁等电解质正常。用甲亢平治疗甲状腺功能亢进后,腹部震颤和肾病综合征均完全缓解。8周后患者甲状腺功能恢复正常。

 

Discussion   讨   论

 

  腹壁运动障碍(肚皮舞者的运动障碍,膈肌颤动)是一种以缓慢的痛性扭动为特征的罕见症状。它被认为是由于一侧膈肌阵挛性抽搐引起的非自主的,反复的,有节奏的,伴疼痛的波动性腹部运动。其核心特征是在吸气和呼气时的膈肌的快速阵挛性收缩和舒张,并且与脊髓病变、腹部手术后或抗精神病药物的迟发反应相关。可能该患者的痛性腹部运动与肚皮舞者的运动障碍是一致的,但它并不缓慢或呈蠕动状。

 

  触压可通过牵张肌腱/反射引起肌肉阵挛。因此,尽管不太可能,腹部运动可能与阵挛相关的深部腹肌的牵张反射有关。也可能是腹部触诊引起肌腱牵张反射从而导致“震颤”。但在其余的神经系统检查或神经影像学检查中未发现相应的脊髓或皮质脊髓束病变的证据。未行肌电图和膈肌超声检查,但可能有助于区分震颤和肌阵挛。

 

  震颤可随体位而变化。例如一些帕金森病(PD)患者,当他们的手臂处于特定位置或当手臂受压时,震颤会增加。此外,腹部震颤也曾经被描述为PD的罕见症状,但表面肌电图记录了右侧腹直肌的5-6Hz静止性震颤,与该患者压力诱发的震颤不同。

甲状腺功能亢进还与其他过度运动障碍有关,包括舞蹈病和肌阵挛。舞蹈病是甲亢症的一种罕见并发症,发病率不足2%。它很少影响躯干,发生于突然运动引起的阵发性发作,但通常它的分布部位随机,不像该患者那样有节奏。孤立的躯干肌阵挛(如痉挛性躯干屈曲)病例在甲状腺功能亢进中也有报道,但运动是腰部的缓慢屈曲(1-2Hz),全天无任何固定模式。与甲亢震颤的自然病程一致,经甲状腺功能亢进症治疗后,肌阵挛完全缓解。

 

  该患者的腹部过度运动障碍很可能是甲亢性震颤。甲亢性震颤通常是高频和低振幅,主要表现为涉及面部、头部以及四肢的动作。它类似于一种夸张的生理性震颤,在临床上和肌电上都类似于广泛性焦虑加重的生理性震颤。应用普萘洛尔治疗有效,提示β-肾上腺素功能增强是潜在的发病机制。甲亢时很少有孤立的腹部震颤报道,本病例突显了甲亢时运动障碍的多样性。

 

中英部分

 

  Hyperthyroidism is a common medical condition in the general population and neurologic symptoms can be the first presentation. Neurologic manifestations include cognitive abnormalities and seizures, movement disorders such as chorea and tremors, and peripheral nervous system conditions including myopathy and neuropathy. Tremor, usually limb tremor, has been observed in 78% of patients with thyrotoxicosis. Here we report isolated abdominal tremor, reminiscent but different from belly dancer’s dyskinesia, in a patient with thyrotoxicosis.

 

  甲状腺功能亢进症(甲亢)是一般人群的常见疾病,神经系统症状可为首次表现。神经系统症状包括认知异常和癫痫发作,运动障碍(如舞蹈病和震颤),以及周围神经系统症状(包括肌病和神经病)。78%的甲亢患者有震颤,通常为肢体震颤。我们在此报告一例甲亢患者的孤立性腹部震颤,其不同于肚皮舞者的运动障碍。

 

Case report    病例报道

 

  A 64-year-old man presented with generalized abdominal pain. He had recently been diagnosed with membranous nephropathy (antiphospholipase-A2 receptor antibody negative) with nephrotic-range proteinuria. Medications included rosuvastatin and amlodipine. Superficial and deep abdominal palpitation elicited a tremor of the anterior abdominal wall (video at Neurology.org). The movement was fast, rhythmic (10–15 Hz), and pressure-sensitive. Pain was not worsened by palpation. This was an isolated abdominal tremor occurring only when recumbent and upon palpation. There was no involvement of the head or limbs. Dynamic maneuvers such as deep inspiration or Valsalva did not induce the tremor. There was no distractibility. His reflexes were brisk.

 

   一位64岁男性出现全腹痛。他最近因蛋白尿被诊断为膜性肾病(抗磷脂酶A2受体抗体阴性)。口服药物有瑞舒伐他汀和氨氯地平。浅层和深层的腹部跳动诱发了腹前壁震颤(视频在Neurology.org上)。震颤动作迅速、规律(10-15Hz),触压容易诱发。触诊并未加重疼痛。该患者为孤立的腹部震颤,只在平躺和触诊时发生。头部和四肢均未受累。深吸气或Valsalva等动作不会诱发震颤。患者无注意力不集中,反应敏捷。

 

  MRI of brain, spinal cord, and abdomen were normal. Free T3 was 20.7 pmol/L (normal 2.7–7) and T4 was 51.5 pmol/L (normal 9.9–20.1) Thyroidstimulating hormone was suppressed below 0.05mU/L (normal 0.15–3.2). Thyroid peroxidase antibody titer was 196 IU/mL (normal ,35 IU/mL). Electrolyte levels including calcium and magnesium were within normal limits. Both the abdominal tremor and nephrotic syndrome completely resolved with treatment of thyrotoxicosis with carbimazole. The patient became euthyroid within 8 weeks.

 

  脑、脊髓、腹部MRI均正常。游离T3为20.7pmol/L(正常2.7-7),T4为51.5pmol/L(正常9.9-20.1),促甲状腺激素减低,<0.05mU/L(正常0.15-3.2)。甲状腺过氧化物酶抗体效价196 IU/mL(正常35 IU/mL)。钙、镁等电解质正常。用甲亢平治疗甲状腺功能亢进后,腹部震颤和肾病综合征均完全缓解。8周后患者甲状腺功能恢复正常。

 

Discussion   讨   论

 

  Abdominal wall dyskinesia (belly dancer’s dyskinesia, diaphragmatic flutter) is a rare entity characterized by slow painful writhing movements. It is thought to be due to myoclonic jerks of the hemi diaphragm causing involuntary, repetitive, usually painful and rhythmic undulating abdominal movements. The core feature is a rapid myoclonic contraction and release of the diaphragm usually with inspiration and expiration and is associated with spinal cord pathology, post abdominal surgery, or post neuroleptic exposure (tardive). It is possible that our patient’s painful abdominal movements were consistent with belly dancer’s dyskinesia; however, it was not slow or writhing.

 

  腹壁运动障碍(肚皮舞者的运动障碍,膈肌颤动)是一种以缓慢的痛性扭动为特征的罕见症状。它被认为是由于一侧膈肌阵挛性抽搐引起的非自主的,反复的,有节奏的,伴疼痛的波动性腹部运动。其核心特征是在吸气和呼气时的膈肌的快速阵挛性收缩和舒张,并且与脊髓病变、腹部手术后或抗精神病药物的迟发反应相关。可能该患者的痛性腹部运动与肚皮舞者的运动障碍是一致的,但它并不缓慢或呈蠕动状。

 

  Pressure can cause clonus by stretching the tendon/reflex. Therefore it is possible, although unlikely, that the abdominal movement could have been due to a deep abdominal stretch reflex with associated clonus. Perhaps a tendon stretch reflex may have been triggered by deep abdominal palpation resulting in“tremor.” However, there was no evidence of associated spinal or corticospinal tract disease in the rest of the neurologic examination or neuroimaging. EMG and diaphragmatic ultrasound were not performed but may have helped distinguish tremor from myoclonus.

 

  触压可通过牵张肌腱/反射引起肌肉阵挛。因此,尽管不太可能,腹部运动可能与阵挛相关的深部腹肌的牵张反射有关。也可能是腹部触诊引起肌腱牵张反射从而导致“震颤”。但在其余的神经系统检查或神经影像学检查中未发现相应的脊髓或皮质脊髓束病变的证据。未行肌电图和膈肌超声检查,但可能有助于区分震颤和肌阵挛。

 

  Tremor can vary with position. For example, some patients with Parkinson disease (PD) notice their tremor increases when their arm is in a particular position or when there is pressure on the arm. Moreover, abdominal tremor has also been described as a rare symptom in PD and surface EMG recorded a 5–6Hz rest tremor in the right rectus abdominis as opposed to a pressure-induced tremor as in our patient.

 

  震颤可随体位而变化。例如一些帕金森病(PD)患者,当他们的手臂处于特定位置或当手臂受压时,震颤会增加。此外,腹部震颤也曾经被描述为PD的罕见症状,但表面肌电图记录了右侧腹直肌的5-6Hz静止性震颤,与该患者压力诱发的震颤不同。

 

  Thyrotoxicosis is also associated with other hyperkinetic movement disorders including chorea and myoclonus. Chorea, a rare complication of hyperthyroidism, occurs in fewer than 2% of patients. It can rarely affect the trunk and occur in paroxysms precipitated by sudden movements but it is usually random in its distribution and not rhythmic as in our patient. Isolated cases of truncal myoclonus such as spasmodic truncal flexion have also been described in thyrotoxicosis, but the movement is a slow flexion at the waist (1–2 Hz) occurring without any pattern throughout the day. Similarly to the natural history of thyrotoxic tremor, the myoclonus completely abated with correction of hyperthyroidism.

 

  甲状腺功能亢进还与其他过度运动障碍有关,包括舞蹈病和肌阵挛。舞蹈病是甲亢症的一种罕见并发症,发病率不足2%。它很少影响躯干,发生于突然运动引起的阵发性发作,但通常它的分布部位随机,不像该患者那样有节奏。孤立的躯干肌阵挛(如痉挛性躯干屈曲)病例在甲状腺功能亢进中也有报道,但运动是腰部的缓慢屈曲(1-2Hz),全天无任何固定模式。与甲亢震颤的自然病程一致,经甲状腺功能亢进症治疗后,肌阵挛完全缓解。

 

  This hyperkinetic movement disorder of the abdomen is most likely a thyrotoxic tremor. Thyrotoxic tremor is typically high-frequency and low-amplitude, primarily seen with action involving the face and head as well as the limbs. It resembles an exaggerated physiologic tremor and is similar both clinically and electomyographically to physiologic tremor aggravated by generalized anxiety. It can respond dramatically to propranolol, implicating an underlying heightened β-adrenergic state as the causative mechanism. Isolated abdominal tremor has rarely been described in the thyrotoxic state, highlighting the diverse spectrum of movement disorders within this condition.

 

  该患者的腹部过度运动障碍很可能是甲亢性震颤。甲亢性震颤通常是高频和低振幅,主要表现为涉及面部、头部以及四肢的动作。它类似于一种夸张的生理性震颤,在临床上和肌电上都类似于广泛性焦虑加重的生理性震颤。应用普萘洛尔治疗有效,提示β-肾上腺素功能增强是潜在的发病机制。甲亢时很少有孤立的腹部震颤报道,本病例突显了甲亢时运动障碍的多样性。

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赵莲花
单位:天津市泰达医院
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