Physical Medicine and Rehabilitation for Limb-Girdle Muscular Dystrophy Differential Diagnoses

  • Author: Vinod Sahgal, MD, MS; Chief Editor: Denise I Campagnolo, MD, MS   more...
 
Updated: Jan 18, 2012
 
 

Diagnostic Considerations

Acute polio

Chronic inflammatory myopathies

Malignancy

Metabolic and congential myopathies

Mixed connective-tissue disease

Polyarteritis

Primary lateral sclerosis

Rheumatoid arthritis

Steroid-induced myopathy

Duchenne muscular dystrophy: Duchenne or Becker dystrophies tend to manifest in childhood with a male predominance, calf hypertrophy, scoliosis, and marked elevation of CK levels. Sex-linked recessive inheritance and the demonstration of absence or alteration of dystrophin confirm the diagnosis of these disorders. Approximately 60% of cases are sporadic; thus, muscle biopsy is an important diagnostic tool.

Scleroderma, polymyositis, and dermatomyositis: Differentiation from scleroderma, polymyositis, and dermatomyositis may be made by their clinical courses, which are often characterized by more rapid progression, involvement of skin and neck muscles, and dysphagia.

Polymyositis: Electromyography (EMG) in patients with polymyositis reveals polyphasic and fibrillation potentials, as well as myopathic potentials and positive sharp waves. A clinical response to steroids solidifies the diagnosis of polymyositis.

Chronic spinal muscular atrophy: This is another entity that can have proximal weakness and elevated CK levels; however, neurogenic changes seen during EMG may include fibrillation and fasciculation potentials and a reduced recruitment pattern, as well as giant action potentials. Muscle biopsy results showing target fibers and group atrophy with angular fibers also help confirm this diagnosis.

Metabolic and congenital myopathies (eg, central core disease, nemaline centronuclear myopathy, congenital fiber-type disproportion): These may appear clinically similar to limb-girdle muscular dystrophy (LGMD) syndrome, but all of these conditions have typical diagnostic muscle biopsy findings that show central cores, nemaline rods, centronuclear fibers of congenital fiber-type disproportions, and sarcoplasmic body myopathy. Onset is also generally at an early age, and a more diffuse distribution of weakness occurs.

In summary, evaluation of a patient with LGMD syndrome must take into consideration an accurate clinical history with special emphasis on family history; a detailed physical examination; laboratory investigation, including CK; EMG; and possibly, muscle biopsy, molecular genetic studies, and an evaluation of the absence or alteration of dystrophin.

Differential Diagnoses

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Contributor Information and Disclosures
Author

Vinod Sahgal, MD, MS  Chairman, Department of Physical Medicine and Rehabilitation Services, The Cleveland Clinic Foundation; Professor, Department of Physical Medicine and Rehabilitation, Ohio State University

Vinod Sahgal, MD, MS is a member of the following medical societies: American Academy of Neurology, American Academy of Physical Medicine and Rehabilitation, American Congress of Rehabilitation Medicine, American Medical Association, and American Spinal Injury Association

Disclosure: Nothing to disclose.

Coauthor(s)

Steven Reger, PhD, CP  Professor, Department of Industrial and Manufacturing Engineering, Cleveland State University; Director of Rehabilitation Technology, Department of Physical Medicine and Rehabilitation, Cleveland State University

Steven Reger, PhD, CP is a member of the following medical societies: Association for Academic Psychiatry and New York Academy of Sciences

Disclosure: Nothing to disclose.

Specialty Editor Board

Elizabeth A Moberg-Wolff, MD  Medical Director, Pediatric Rehabilitation Medicine Associates

Elizabeth A Moberg-Wolff, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine and American Academy of Physical Medicine and Rehabilitation

Disclosure: Medtronic Neurological None Speaking and teaching

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Kat Kolaski, MD  Assistant Professor, Departments of Orthopedic Surgery and Pediatrics, Wake Forest University School of Medicine

Kat Kolaski, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine and American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Kelly L Allen, MD  Medical Director, Medevals

Disclosure: Nothing to disclose.

Chief Editor

Denise I Campagnolo, MD, MS  Director of Multiple Sclerosis Clinical Research and Staff Physiatrist, Barrow Neurology Clinics, St Joseph's Hospital and Medical Center; Investigator for Barrow Neurology Clinics; Director, NARCOMS Project for Consortium of MS Centers

Denise I Campagnolo, MD, MS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, and Consortium of Multiple Sclerosis Centers

Disclosure: Teva Neuroscience Honoraria Speaking and teaching; Serono-Pfizer Honoraria Speaking and teaching; Genzyme Corporation Grant/research funds investigator; Biogen Idec Grant/research funds investigator; Genentech, Inc Grant/research funds investigator; Eli Lilly & Company Grant/research funds investigator; Novartis investigator; MSDx LLC Grant/research funds investigator; BioMS Technology Corp Grant/research funds investigator; Avanir Pharmaceuticals Grant/research funds investigator

Additional Contributors

The editors wish to thank Suneet Sahgal, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, Northwestern University Medical School, for his previous association with this article.

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Hematoxylin and eosin stain. Note the variation in fiber size. Necrotic fiber is shown with many nuclei (magnification 250X).
Marked endomysial fibrosis with atrophic and hypertrophic fibers.
Hematoxylin and eosin stain. Note the splitting of the fiber.
Gomori trichrome stain. Note the variation in fiber size and subsarcolemmal vacuoles, central nuclei, and subsarcolemmal collection of trichrome-positive material.
Light type I and dark type IIA fibers.
Electron micrograph showing abnormal mitochondria, a large lysosomal body, and a central nucleus.
Electron micrograph showing mitochondria with paracrystalline inclusions and lamellar bodies
Electron micrograph showing streaming of band Z and splitting of the muscle fiber. A central nucleus is surrounded by a collection of small mitochondria.
Trichrome stain. Note variation in fiber size. Necrotic fiber giant fibers and cytoplasmic inclusions.
Dystrophin-glycoprotein complex bridges the inner cytoskeleton (F-actin) and the basal lamina. Mutations in all sarcoglycans, in dysferlin, and in caveolin-3, as well as mutations that cause abnormal glycosylation of alpha-dystroglycan, can result in limb-girdle muscular dystrophy.
 
 
 
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