REPETITIVE NERVE STIMULATION TEST

This 46 years old female, was evaluated for change in voice and difficulty in swallowing.

Had been seen by ENT specialists and referred for a neurological evaluation. A provisional diagnosis of MYASTHENIA GRAVIS was made and a REPETITIVE NERVE STIMULATION TEST PERFORMED results are shown below

Test was done both at rest and following exercise.

Significant decrease in CMAP amplitude (black arrow) was noted in right APB muscle, both at rest and post exercise. – This was an abnormal study suggestive of neuromuscular junction defect, post synaptic.

Following this test, patient was started on pyridostigmin 30 mg tid. Patient showed considerable improvement within few days of starting the medication.

A 24 years old female, with history of seizures for last 8 years. She was seizure free on treatment, and on withdrawal, she developed seizures. EEG (sleep deprived) revealed 3-4 Hz generalized spike and wave discharges, which increased during HV and PS . This confirmed the diagnosis of primary generalized epilepsy, and she has been advised to continue treatment.

He also had h/o nightmares and sleep talking. Parents also noticed a change in personality, had become (more aggressive) and child had poor concentration during the day with excessive sleepiness in the day.
There was history of frequent blocked nose with nasal allergies.

Overnight sleep study was performed.
Revealed increased hypopnoeas & apnoeas with oxygen desaturation.

Thus this case highlights the importance of detecting Sleep Disordered Breathing in children.

A young girl, 15 years old, student of class IX, studying in a boarding school, came to the Department of Sleep medicine at Ganga Ram Hospital with complaints of:

• increased sleep episodes since September 2006.
  
• fall in her grades
  

Her teachers reported that she had difficulty in waking up for class, would sleep during the classes and also after school hours. Often they found it difficult to wake her up and had to call her parents. Her parents consulted many local doctors but there was no improvement in her symptoms. Later she was brought to dept. of Sleep medicine, SGRH, New Delhi in April 2007.

A detailed evaluation revealed that her sleep rhythm was completely disrupted. She had delayed sleep onset by about 5-6 hrs. And admitted to a feeling restlessness in her legs with an urge to move them at sleep onset. She used to keep tossing and turning in bed, which slightly relieved her symptoms. She felt tired throughout the day with increased sleepiness. She responded positively for all the symptoms of Restless Legs Syndrome (children's criteria).

There was no family history of RLS. Her investigations revealed very low levels of Iron and Vitamin B12, she was given an Actigraph to wear around her ankle for 2 nights that showed increased leg movements with delayed sleep onset.

She was given iron and vit B12 supplements and a dopamine agonist.

On follow up 2 months later she has had no further episodes of increased sleep and there is a marked improvement in her school performance.

THUS IT IS ESSENTIAL TO MAKE THE RIGHT DIAGNOSIS, THEREBY GIVE APPROPRIATE TREATMENT.

A 51 years old male, presented with complaints of abnormal behavior in sleep for 6 years, These were accompanied with tongue bite and passage of urine in bed. He was given treatment for epilepsy with no change in symptoms. He also has high blood pressure for 6 year and diabetes for 10 years. On direct enquiry there is history of snoring with excessive daytime sleepiness. Considering all the above OBSTRUCTIVE SLEEP APNOEA was considered and patient was advised An overnight SLEEP STUDY. This revealed severe Obstructive Sleep Apnoea for which he has been advised to use CPAP & also lose weight.. Representative traces of sleep study are provided:

I am a 65 years old lady, have been having pain in my legs ,which increased in the evening,particulary when I lay down to sleep. Along with this I had difficulty in falling asleep, felt very tired in the morning, with no interest in house-work ,routine activities. I was prescribed antidepressants, sedatives for helping me to sleep and pain-killers for my leg pain. Investigations revealed Lumbar Canal Stenosis ,was advised physiotherapy and nerve conduction tests and electromyography. I met Dr. Bhatia, for the tests, she asked me certain questions regarding my symptoms,and diagnosed me to have RESTLESS LEGS SYNDROME ,for which I was prescribed a tablet at night. This controlled my pains, improved my sleep and also have been able to stop all the antidepressants and sedative medication