A Case of Peripheral Nerve Hyperexcitability Syndrome Pretended as Infective Endocarditis: Case Report

A Case of Peripheral Nerve Hyperexcitability Syndrome Pretended as Infective Endocarditis: Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A Case of Peripheral Nerve Hyperexcitability Syndrome Pretended as Infective Endocarditis: Case Report Sepehr Omoomi, Majid Ghasemi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5791843/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 18 You are reading this latest preprint version Abstract Background: The peripheral nerve hyperexcitability (PNH) syndromes cause repetitive spontaneous electrical discharges in peripheral nerves (mainly motor axons), which leads to the increased activity of the innervated area. PNH syndromes develop various motor, sensory, and autonomous symptoms, of which motor symptoms are the most considerable, including cramps, fasciculations, and myokymia. The PNH syndromes are classified into cramp-fasciculation syndrome, neuromyotonia (Isaacs syndrome), and Morvan’s syndrome. Morvan syndrome is associated with the involvement of the central nervous system (CNS). PNH syndromes primarily result from dysfunction of voltage-gated potassium channels (VGKC), mainly due to autoantibodies. Alternative causes have been proposed, including potential infectious origins. Previous studies have associated staphylococcal abscesses and Hepatitis B Virus (HBV) infections with the pathogenesis of Isaacs syndrome rather than Morvan’s syndromes. Case Presentation: We present a case of VGKC-antibody-positive PNH presented by symptoms such as fatigue, fever, chills, dyspnea, weight loss, hyperhidrosis, spontaneous muscle spasms, and cramps in the lower limbs. Central Nervous System (CNS) involvement included hallucinations, sleep disorders, confusion, and mood alterations, along with vegetation in the right atrium as detected by echocardiography. The patient initially received a two-week course of antibiotic therapy for suspected infective endocarditis (IE) and bacteremia. Subsequently, due to persistent symptoms despite antibiotic treatment, electromyography (EMG) was performed, revealing anti-VGKC antibodies. The patient then underwent several plasma exchanges and was prescribed carbamazepine, resulting in a significant improvement in their condition. Conclusion: This case shares similarities with previous cases of PNH syndrome (especially Morvan’s syndromes) triggered by infections other than previously reported, suggesting that autoantibodies against pathogens may be responsible for the manifestation of PNH syndrome. Moreover, the dramatic response to plasmapheresis and removal of antibodies, as well as positive Anti-CASPR2 auto-antibody, confirms our diagnosis. Peripheral Nerve Hyperexcitability Neuromyotonia Morvan’s Syndrome Infective Endocarditis Bacteremia Introduction Peripheral nerve hyperexcitability (PNH) is a term that refers to a heterogeneous group of disorders originating from the motor axons of the peripheral nervous system (PNS) and presents with muscle cramps, fasciculations, myokymia, and pseudo-myotonia, the most common symptoms amongst them. These disorders differentiate themselves from the central nervous system (CNS) and muscle disorders with similar presentation and different needle electromyography features (EMG) ( 1 ). The PNH syndromes can be artificially divided into primary and secondary based on the presence of the defined peripheral nervous system disorder. Primary PNH syndromes cause widespread signs and symptoms with motor, sensory, and autonomic origin. However, secondary PNH syndromes are the consequences of recognized systemic diseases. They can manifest in diffuse (e.g., Inflammatory demyelinating polyneuropathies) or focal regions (e.g., entrapment or radiation-induced) with less severity. The primary PNH syndromes are cramp-fasciculation syndrome (CFS), Isaac’s, and Morvan’s syndrome ( 2 , 3 ). The PNH syndromes are caused by spontaneous repetitive discharges, leading to the increased activity of the muscles innervated by the motor neurons. Ectopic discharges lead to the positive sensory symptoms, including paresthesia and numbness. Discharges also impact the autonomic nervous system, which leads to autonomic manifestation, including hyperhidrosis, abdominal cramps, dramatic blood pressure alteration, orthostatic hypotension, and symptoms of CNS involvement like hallucination, sleep disorders, confusion, and mood alteration ( 1 – 5 ). The main EMG finding in PNH syndromes are spontaneous repetitive myokymic and neuromyotonic discharges, being composed of all or part of motor unit potentials presenting in two (doublets), three (triplets), and multiple bursts (multiplet) of discharges. The firing frequency of the burst potentials is in a wide range of 5-300 Hz ( 6 ). The pathological mechanism responsible for the PNH disorders is assumed to be the voltage-gated potassium channelopathies mainly accumulated in the terminal segments of the peripheral nerves. In this regard, auto-immune mediated, genetic, toxins, drugs, infection, vaccination, and other causes are assumed to be responsible ( 1 , 2 , 7 – 14 ). The prior studies revealed that the pathophysiology of this condition is predominantly closely related to voltage-gated potassium channels (VGKC). Indeed, autoantibodies against the Contactin-associated protein-like 2 (CASPR2) and Leucine-rich glioma-inactivated 1 (LGI1), main components of the VGKC complex of the presynaptic membrane of the neuromuscular junctions, play a significant role in the pathogenesis of the PNH syndromes ( 15 – 17 ). Meanwhile, several genes are linked to the development of the PNH syndromes, with the predominance of autosomal recessive inheritance ( 18 ). The management of the PNH syndromes can be summarized in symptomatic and immunomodulatory treatments in mild and severe disease courses, respectively. Membrane stabilizing agents, including voltage-gated sodium channel blockers, are effective in muscle stiffness relieve. Meanwhile, plasma exchange (PE), intravenous immunoglobulin G, high doses of corticosteroids, and immunosuppressive agents are considerable in complicated diseases with auto-immune origin ( 1 , 19 , 20 ). A case of PNH syndrome misdiagnosed as an IE is presented. Case Presentation A 59-year-old male was referred with the primary complaint of remaining excessive weight loss, hyperhidrosis, spontaneous muscle spasms, fasciculations, and cramps in his lower limbs following two weeks of antibiotic therapy due to fatigue, fever, chills, dyspnea, and possible IE. He also reported spontaneous muscle contractions in lower limbs, fever, chills, excessive sweating, blood pressure alteration, fatigue, insomnia, slurred speech, and generalized muscle weakness, which improved slightly following antibiotic therapy. However, excessive sweating, insomnia, muscle weakness, fasciculations, slurred speech, and spontaneous muscle spasms remained. The patient has been experiencing persistent fluctuations in systolic blood pressure, ranging from 60–180 mmHg, along with symptoms such as excessive sweating, weight loss of about 9 kilograms, and muscle weakness and cramps. His medical history includes recent antibiotic therapy (vancomycin and meropenem) due to suspicious bacteremia and a prior removal of a truncal lipoma ten years ago. Further investigations during his recent hospitalization revealed a 3.6mm hypoechoic nodule in the left lobe of the thyroid (T4 moderately suspicious). Additionally, 4mm and 3mm nephrolithiasis were found in the right and left renal calyces, respectively. The patient reported no concurrent use of tobacco or alcohol but had a history of using them previously. There were no reported sensitivities to food or drugs, no family history of similar signs or symptoms in relatives, and no past drug history. The patient underwent several diagnostic procedures, including Abdominopelvic CT with contrast, Brain CT with contrast, Chest X-ray (CXR), and laboratory procedures, including Complete Blood Counts (CBC), thyroid function tests, kidney, liver, lipid profile, Cerebrospinal Fluid (CSF) analysis, electrolytes, blood cultures, and urine cultures following initiation of antibiotic therapy. The patient underwent two consecutive trans-thoracic echocardiography (TTE). The first revealed vegetation in the right atrium in a size of 1.1*0.9mm. The second TTE, a week later, revealed mild pleural effusion, prominent crista terminalis in the right atrium roof, no apparent vegetation on valves, and tachycardia. His physical examination revealed bilateral moderate proximal muscle weakness of extremities (3/5), normal Deep Tendon Reflexes, fasciculation, and myokymia in his lower limbs. Cranial, sensory, cerebellum, and gait examinations revealed no significant abnormality. He also had hypertrophied calf muscles and dysautonomia, which caused excessive sweating, blood pressure changes, and weight loss. An EMG was done, and it revealed mild length-dependent sensory/motor polyneuropathy along with peripheral nerve hyperexcitability findings. It revealed fasciculation and myotonic discharges mainly in the gastrocnemius muscle and first dorsal interosseous of the hand in needle EMG (Table 1 – 3 ). Further, extensive and serial laboratory tests were obtained. The Anti-CASPR2, Anti LGI-1, as well as, para-neoblastic, and autoimmune panels were obtained. The thorough workup revealed elevation of the Anti-CASPR2 titer (Titer: 1:320, which results with a titer 1: <10 was considered nonsignificant). He was treated with several courses of PE treatment, which improved muscle weakness, myokymia, sweating, and wide-ranged SBP fluctuations dramatically. Meanwhile, carbamazepine was used for symptomatic treatment of fasciculations. Table 1 Sensory NCS Sensory NCS * Nerve / Sites Onset L. Peak L. Pk Amp Amp Pk-Pk Duration Lat Diff ms ms µV µV ms ms L MEDIAN - Digit II 1. Wrist 3.60 4.90 30.9 40.8 3.75 3.60 L ULNAR - Digit V 1. Wrist 3.40 4.30 15.0 16.8 2.70 3.40 L SURAL - Lat Malleolus 1. Calf 0.00 R SURAL - Lat Malleolus 1. Calf 0.00 • NCS: Nerve Conduction Study Table 2 Motor NCS Motor NCS * Nerve / Sites Latency Ampl. Dur. Area Ampl. % Dur.%. Area% Distance Lat Diff Velocity ms mV ms mVms % % % cm ms m/s L MEDIAN - APB 1. Wrist 4.75 13.0 8.05 59.1 100 100 100 4.75 2. Elbow 10.10 12.2 8.50 58.2 93.5 106 98.6 26 5.35 48.6 Path 3 − 1 L ULNAR - ADM 1. Wrist 3.40 7.2 7.95 31.5 100 100 100 3.40 2. B.Elbow 8.30 6.1 8.55 28.4 83.9 108 90 27 4.90 55.1 Path 3 − 1 L COMM PERONEAL - EDB 1. Ankle 4.70 1.8 7.10 10.5 100 100 100 4.70 2. Fib Head 11.95 1.6 7.15 6.9 71.3 101 65.8 33 7.25 45.5 Path 3 − 1 R COMM PERONEAL - EDB 1. Ankle 3.45 1.4 8.60 19.8 100 100 100 3.45 2. Fib Head 12.80 1.4 7.05 19.6 101 82 99 34 9.35 36.4 Path 3 − 1 L TIBIAL (KNEE) - AH 1. Ankle 5.35 5.0 6.45 26.0 100 100 100 5.35 2. Knee 15.15 5.0 7.65 29.6 99.9 119 114 38 9.80 38.8 Path 3 − 1 R TIBIAL (KNEE) - AH 1. Ankle 4.45 5.3 7.00 35.0 100 100 100 4.45 2. Knee 16.80 5.3 5.65 34.5 74.3 80.7 98.6 41 12.35 33.2 Path 3 − 1 • NCS: Nerve Conduction Study Table 3 Needle EMG Needle EMG * EMG Summary Table Spontaneous MUAP Recruitment IA Fib PSW Fasc Myotonic dis. Amp Dur. PPP Pattern L. TIB ANTERIOR N None None None None N N N N L. GASTROCN (MED) N None None 2+ (slow) 1+ N N N N R. GASTROCN (MED) N None None 2+ (slow) 1+ N N N N L. FIRST D INTEROSS N None None 1+ 2+ N N N N L. BICEPS N None None 1+ None N N N N • EMG: Electromyography Discussion The PNH syndromes are infrequent disorders characterized by spontaneous repetitive discharges in PNS neurons, mainly axonal motor neurons, causing positive muscle phenomena, sensory, and autonomic symptoms. The PNH syndromes are primarily present in primary forms (predominantly Isaac’s, Morvan’s, and CFS) and are considered to have widespread origins. In this regard, prior studies revealed the pathogenic roles of the genetic, para-neoblastic, auto-immune-mediated, post-infection-mediated, post-vaccination-mediated, metal poisoning, and toxins in the pathogenesis of the PNH syndromes ( 1 – 3 ). In this study, we presented a patient with anti-CASPR2 antibody positive PNH syndrome with evidence of slow potassium channel dysfunction revealed by EMG study, including visible myokymia in calf muscles, myokymic discharges on EMG, marked after-discharge of F-wave following stimulation, and evidence of slow potassium current in nerve excitability test following possible bacteremia. The CASPR2 and LGI1, the main components of VGKC, are widely expressed in the CNS and PNS. Our patient was referred with symptoms of insomnia, wide fluctuation in blood pressure, tachycardia, excessive sweating, muscle fasciculation, and cramps in lower limbs were assumed to be caused by autoantibodies against CASPR2 in the thalamus, locus coeruleus, and presynaptic VGKCs in the PNS ( 4 , 5 ). Insignificant radiological workups, including CXR, Abdominopelvic CT with contrast, and trans thoracic echocardiographic studies ruled out malignancy and paraneoplastic origin of the PNH syndrome in this patient. Meanwhile, insignificant serologic findings and lack of a history of prevalent comorbid diseases seen in PNH syndromes (i.e., celiac disease, Hashimoto thyroiditis, Vit B12 deficiency, vitiligo, Addison disease, Rheumatoid arthritis, and …) ( 21 – 23 ), and the onset of sign and symptoms following the bacteremia, as well as, dramatic improvement of fever, chills, and dyspnea following antibiotic therapy, we considered the PNH syndrome associated with bacteremia. It is considered that the pathophysiology of the PNH syndromes is closely related to the autoimmune origins rather than the mentioned origins. Prior studies revealed the presence of autoantibodies against the VGKC main complex, including CASPR2 and LGI-1. These VGKCs are widely expressed in the presynaptic membrane of the neuromuscular junction both in the CNS and PNS, including neurons of the thalamus, hypothalamus, locus coeruleus, and raphe nuclei. LGI1, a secreted neuronal protein that is strongly expressed in the hippocampus, associates specifically with Kv1.1 subunits in CNS presynaptic terminals, while CASPR2 is a transmembrane protein with an extracellular sequence essential for co-localization of Kv1.1 and 1.2 at the juxtaparanodes. Dysregulation of these receptors in the hippocampus, hypothalamus, and locus coeruleus leads to deteriorating impacts on memory formation, arousal/sleep cycle, and dysautonomia (i.e., excessive sweating, tachycardia, wide fluctuation of blood pressure), respectively ( 4 , 5 , 15 , 17 , 24 , 25 ). Prior reports revealed the pathogenic role of genetic mutations and their co-existence with lower motor neuron diseases in hereditary and acquired PNH syndromes ( 26 ). Experiments with VGKC subunit Kv1.1 mutations in animals displayed neuromyotonic and myokymic discharges with the same frequencies and phenotypes observed in PNH patients ( 27 ). Further, transfection of Xenopus oocytes with mutated Kv1.1 subunit channels leads to significantly smaller VGKC currents, as compared to those transfected with wild-type Kv1.1 channels, supporting the genetic origin. Further, KCNA1 gene loss of function mutation with autosomal dominant inheritance leads to episodic ataxia type 1 syndrome with continuous myokymia and generalized ataxia symptoms ( 28 ). Prior studies revealed the association of the HINT1 mutation with autosomal recessive (AR) axonal neuropathy with neuromyotonia manifests with a distal, slowly progressive, mainly motor neuropathy ( 10 ). Meanwhile, the presence of spinal muscular atrophy, as well as Schwartz-Jampel syndrome inherited by the HSPG2 mutation, with AR inheritance, supports the genetic origin of the disorder ( 26 , 29 , 30 ). Prior studies revealed that the underlying neoplasm and para-neoplastic syndromes have been significant risk factors in the pathogenesis of PNH syndromes. In this regard, thymoma is considered the most common among them ( 23 ). Tumor antigens could trigger the immune system to produce antibodies that react against VGKC, making it a marker of onco-neuronal disorders ( 23 ). This explains the occurrence of autoimmune neurological paraneoplastic disorders in patients with PNH syndrome. In this regard, a low-positive titer of anti-VGKC antibodies has been detected in various types of cancer, including thymoma, lung cancer, Hodgkin lymphoma, plasmacytoma, lymphoblastic lymphoma, hemangioblastoma, ovarian cancer, and bladder cancer ( 31 – 36 ). Prior studies revealed the association of infection with the onset of Isaac’s syndrome. In this regard, the association of staphylococcal infection with Isaac’s syndrome was investigated ( 9 ). A prior study showed that Isaac’s syndrome can be associated with Staphylococcal infection in which the symptoms rapidly disappeared following an abscess treatment. Therefore, it was suggested that Isaacs syndrome in this patient was a manifestation of peripheral nerve irritation caused by humoral antibodies triggered by S. aureus infection. In this regard, they found an oligoclonal band in the CSF fluid analysis. However, no anti-VGKC antibody was found. Prior studies revealed the association of chronic active HBV with the onset of Isaac’s Syndrome ( 37 ). In this study, the diagnostic procedures manifest only the co-existence of Hepatitis B and Isaac’s syndrome. Following the short course of plasmapheresis and phenytoin, the patient was treated with complete remission. Moreover, literature revealed the association of HBV infection with immunological diseases, including vasculitis (i.e., polyarthritis nodosa), cryoglobulinemia, Henoch-Schoenlein purpura, and Guillan-Barre syndrome ( 38 – 40 ). Therefore, it was suggested that Isaac’s syndrome was the manifestation of peripheral nerve irritation caused by humoral antibodies triggered by HBV. Further, a prior study revealed the onset of PNH syndromes with severe peripheral and central manifestation, including agitation and insomnia, following one month after an episode of enteroviral pericarditis and responded well to immunotherapy. However, both Anti-CASPR2 and Anti-LGI1 were undetectable ( 25 ). Recent studies indicate that silver and lead poisoning, as well as the gold used in treating rheumatoid arthritis, may also contribute to the pathogenesis and onset of PNH syndromes ( 41 ). Meanwhile, herbicides, insecticides, toluene, alcohol, snake venom, human papillomavirus, and wasp sting mediate the onset of PNH syndrome in susceptible patients, presumably via auto-immune mechanisms ( 2 , 7 , 11 , 13 , 42 , 43 ). Conclusion In this study, we describe a patient who developed PNH syndrome following bacteremia. The patient experienced dysautonomia symptoms, such as weight loss, excessive sweating, and wide fluctuations in blood pressure, as well as bilateral lower limb fasciculation and myokymia. The fever, chills, and dyspnea improved significantly with antibiotic therapy, while the neurological and electrophysiological symptoms improved with plasmapheresis. This case shares similarities with previous cases of PNH syndrome triggered by infections, suggesting that autoantibodies against pathogens may be responsible for the manifestation of PNH syndrome. Moreover, the dramatic response to plasmapheresis and removal of antibodies, as well as positive Anti-CASPR2 auto-antibody, confirms our diagnosis. Abbreviations PNH Peripheral Nerve Hyperexcitability CNS Central Nervous System VGKC voltage-gated potassium channel PNS Peripheral Nervous System HBV Hepatitis B Virus EMG Electromyography CFS Cramp-Fasciculation Syndrome CASPR2 Contactin-associated protein-like 2 LGI1 Leucine-rich glioma-inactivated 1 PE Plasma Exchange IE Infective Endocarditis CXR Chest X-ray CBC Complete Blood Count CSF Cerebrospinal Fluid TTE Trans-Thoracic Echocardiography NCS Nerve Conduction Study CT Computed Tomography AR Autosomal Recessive Declarations Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of Interest The authors report no conflicts of interest. Declaration of competing interest There are no competing interests to declare. Data availability: Data will be made available on request. Ethical Approval and Consent to Participate: As this study is a case report, it did not require formal ethical approval. However, written consent was obtained from the patient and can be provided upon request. Authors Contribution: Majid Ghasemi: Writing – review & editing, Writing – original draft, Resources, Investigation, Data curation, Conceptualization. Sepehr Omoomi: Writing – review & editing, Writing – original draft, Resources, Investigation, Data curation, Conceptualization. References Katirji B. Peripheral nerve hyperexcitability. Handbook of Clinical Neurology. 2019;161:281 – 90. Küçükali CI, Kürtüncü M, Akçay Hİ, Tüzün E, Öge AE. Peripheral nerve hyperexcitability syndromes. Rev Neurosci. 2015;26(2):239–51. De Wel B, Claeys KG. Neuromuscular hyperexcitability syndromes. Curr Opin Neurol. 2021;34(5):714–20. Epure DA, Ioghen MR, Roza E, Teleanu RI. A case report of Morvan syndrome, the unique clinical pattern of a rare disease. Ro J Neurol. 2020;19(1):54–6. Patel AN, Patel PK, Desai J, Oakley K, Reddy P. A rare phenomenon of isaacs syndrome: a case report. Cureus. 2023;15(1). Hutto SK, Harrison TB. Electrodiagnostic Assessment of Hyperexcitable Nerve Disorders. Neurol Clin. 2021;39(4):1083–96. Hatami M, Förster M, Weyers V, Räuber S, Meuth SG, Kremer D. Neuromyotonia with central nervous system lesions following quadrivalent human papilloma virus vaccination. Vaccines. 2022;10(7):1132. Liebenthal JA, Rezania K, Nicholas MK, Lukas RV. Paraneoplastic nerve hyperexcitability. Neurol Res. 2015;37(6):553–9. Liu YC, Wu ZA, Wang SJ, Shan DE, Lin KP. Transient syndrome of continuous muscle fiber activity associated with staphylococcal infection. Mov Disord. 1998;13(3):609–11. Zimoń M, Baets J, Almeida-Souza L, De Vriendt E, Nikodinovic J, Parman Y, et al. Loss-of-function mutations in HINT1 cause axonal neuropathy with neuromyotonia. Nat Genet. 2012;44(10):1080–3. Chaurasia R, Abbas A, Shukla R. Toxin induced continuous muscle fiber activity syndrome. Annals Neurosciences. 2010;15(4):118–9. Grisold W, Mamoli B. The syndrome of continuous muscle fibre activity following gold therapy. J Neurol. 1984;231:244–9. Turner M, Madkhana A, Ebers G, Clover L, Vincent A, McGavin G, et al. Wasp sting induced autoimmune neuromyotonia. J Neurol Neurosurg Psychiatry. 2006;77(5):704–5. Vincent A, Irani SR. Caspr2 antibodies in patients with thymomas. J Thorac Oncol. 2010;5(10):S277–80. Lancaster E, Huijbers MG, Bar V, Boronat A, Wong A, Martinez-Hernandez E, et al. Investigations of caspr2, an autoantigen of encephalitis and neuromyotonia. Ann Neurol. 2011;69(2):303–11. Poliak S, Salomon D, Elhanany H, Sabanay H, Kiernan B, Pevny L, et al. Juxtaparanodal clustering of Shaker-like K + channels in myelinated axons depends on Caspr2 and TAG-1. J Cell Biol. 2003;162(6):1149–60. Lai M, Huijbers MG, Lancaster E, Graus F, Bataller L, Balice-Gordon R, et al. Investigation of LGI1 as the antigen in limbic encephalitis previously attributed to potassium channels: a case series. Lancet Neurol. 2010;9(8):776–85. Browne DL, Gancher ST, Nutt JG, Brunt ER, Smith EA, Kramer P, et al. Episodic ataxia/myokymia syndrome is associated with point mutations in the human potassium channel gene, KCNA1. Nat Genet. 1994;8(2):136–40. Elovaara I, Apostolski S, Van Doorn P, Gilhus N, Hietaharju A, Honkaniemi J, et al. EFNS guidelines for the use of intravenous immunoglobulin in treatment of neurological diseases: EFNS task force on the use of intravenous immunoglobulin in treatment of neurological diseases. Eur J Neurol. 2008;15(9):893–908. Skeie G, Apostolski S, Evoli A, Gilhus N, Hart I, Harms L, et al. Guidelines for the treatment of autoimmune neuromuscular transmission disorders. Eur J Neurol. 2006;13(7):691–9. Hart IK, Waters C, Vincent A, Newland C, Beeson D, Pongs O, et al. Autoantibodies detected to expressed K + channels are implicated in neuromyotonia. Annals Neurology: Official J Am Neurol Association Child Neurol Soc. 1997;41(2):238–46. Taylor PW. Isaacs' syndrome (autoimmune neuromyotonia) in a patient with systemic lupus erythematosus. J Rhuematol. 2005;32(4):757–8. Maddison P, Neuromyotonia. Clin Neurophysiol. 2006;117(10):2118–27. Irani SR, Alexander S, Waters P, Kleopa KA, Pettingill P, Zuliani L, et al. Antibodies to Kv1 potassium channel-complex proteins leucine-rich, glioma inactivated 1 protein and contactin-associated protein-2 in limbic encephalitis, Morvan’s syndrome and acquired neuromyotonia. Brain. 2010;133(9):2734–48. Eikeland BA, Patient with Double-Negative VGKC. Peripheral Nerve Hyperexcitability, and Central Nervous System Symptoms: A Postinfectious Autoimmune Disease. Case Rep Neurol Med. 2020;2020(1):3579419. Lance J. Association of lower motor neuron disorders with fasciculation, neuromyotonia and myoclonus. Australian Pediatr J. 1988;24:113–5. Toyka Kv ZIELASEKJ, RICKER K, ADLKOFER K, SUTER U. Hereditary neuromyotonia: a mouse model associated with deficiency or increased gene dosage of the PMP22 gene. J Neurol Neurosurg Psychiatry. 1997;63(6):812. Servettini I, Talani G, Megaro A, Setzu MD, Biggio F, Briffa M et al. An activator of voltage-gated K + channels Kv1. 1 as a therapeutic candidate for episodic ataxia type 1. Proceedings of the National Academy of Sciences. 2023;120(31):e2207978120. Echaniz-Laguna A, Rene F, Marcel C, Bangratz M, Fontaine B, Loeffler JP, et al. Electrophysiological studies in a mouse model of Schwartz–Jampel syndrome demonstrate muscle fiber hyperactivity of peripheral nerve origin. Muscle Nerve. 2009;40(1):55–61. Bauché S, Boerio D, Davoine C-S, Bernard V, Stum M, Bureau C, et al. Peripheral nerve hyperexcitability with preterminal nerve and neuromuscular junction remodeling is a hallmark of Schwartz-Jampel syndrome. Neuromuscul Disord. 2013;23(12):998–1009. Viallard J-F, Vincent A, Moreau J-F, Parrens M, Pellegrin J-L, Ellie E. Thymoma-associated neuromyotonia with antibodies against voltage-gated potassium channels presenting as chronic intestinal pseudo-obstruction. Eur Neurol. 2005;53(2):60–3. Rana SS, Ramanathan RS, Small G, Adamovich B. Paraneoplastic Isaacs' syndrome: a case series and review of the literature. J Clin Neuromuscul Dis. 2012;13(4):228–33. Paterson RW, Zandi MS, Armstrong R, Vincent A, Schott JM. Clinical relevance of positive voltage-gated potassium channel (VGKC)-complex antibodies: experience from a tertiary referral centre. J Neurol Neurosurg Psychiatry. 2014;85(6):625–30. Fleisher J, Richie M, Price R, Scherer S, Dalmau J, Lancaster E. Acquired neuromyotonia heralding recurrent thymoma in myasthenia gravis. JAMA Neurol. 2013;70(10):1311–4. Issa SS, Herskovitz S, Lipton RB. Acquired neuromyotonia as a paraneoplastic manifestation of ovarian cancer. Neurology. 2011;76(1):100–1. Partanen V, Soininen H, Saksa M, Riekkinen P. Electromyographic and nerve conduction findings in a patient with neuromyotonia, normocalcemic tetany and small-cell lung cancer. Acta Neurol Scand. 1980;61(4):216–26. Basiri K, Fatehi F. Isaacs syndrome associated with chronic hepatitis B infection: a case report. Neurol Neurochir Pol. 2009;43:388–90. Shin JI, Lee JS. Hepatitis B virus infection and Henoch–Schönlein purpura: Comment. 2007. Chroni E, Thomopoulos C, Papapetropoulos S, Paschalis C, Karatza CL. A case of relapsing Guillain-Barré syndrome associated with exacerbation of chronic hepatitis B virus hepatitis. J Neurovirol. 2003;9:408–10. Laura Penagos M, Luisa Calle M, Óscar Santos M. Extrahepatic Manifestations of Hepatitis B. 2016. Petiot P, Charles N, Vial C, McGregor B, Aimard G, Trillet M, et al. Neurological complications caused by gold salts. Nosologic report apropos of a case. Rev Neurol. 1993;149(10):562–5. Devathasan G, Low D, Teoh P, Wan S, Wong P. Complications of chronic glue (toluene) abuse in adolescents. Aust N Z J Med. 1984;14(1):39–43. Caress JB, Walker FO. The spectrum of ectopic motor nerve behavior: from fasciculations to neuromyotonia. Neurologist. 2002;8(1):41–6. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5791843","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":400926329,"identity":"d629f8bc-0be8-4030-af63-87d364b476d9","order_by":0,"name":"Sepehr Omoomi","email":"","orcid":"","institution":"Department of Neurology \u0026 Isfahan Neurosciences Research Center, Faculty of Medical Sciences, Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Sepehr","middleName":"","lastName":"Omoomi","suffix":""},{"id":400926330,"identity":"c56ea1e8-a779-4f8d-808d-e3cf3541baa0","order_by":1,"name":"Majid Ghasemi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYDACCTh5sEH6R4UNTIRYLQxn0ojWAgHSjG2HCWuRj25+/OFjjkU0f+PhxtuFbecT+2c3H3zAUGMTjUuL4Z1jZpIzt0nkzjhwsNl6xrnbiTPuHEs2YDiWltuAS8uMBDNmXqCWhgMH2yR4ym4nNtzIMZNgbDiMR0v6589/gVrmg7WwnUucT0iLvESOgTQjUMsGoBZpnrYDiRsIaTGQyCmT7AVq2Qj0i+WMM8nGG2+kJRsk4PGL/Iz0zR9+bqvLnXfj+MMbHyrsZOfdSD744EONDW5bDsBYEhCWI1hlAg7lYFvgZvFDWPZ4FI+CUTAKRsEIBQC7bGqK1wHlRAAAAABJRU5ErkJggg==","orcid":"","institution":"Department of Neurology \u0026 Isfahan Neurosciences Research Center, Faculty of Medical Sciences, Isfahan University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Majid","middleName":"","lastName":"Ghasemi","suffix":""}],"badges":[],"createdAt":"2025-01-08 21:23:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5791843/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5791843/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":73647017,"identity":"5d86a2db-f82f-4a27-a37d-74bfce1ead03","added_by":"auto","created_at":"2025-01-13 09:00:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":851993,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5791843/v1/bb8de2a8-9af5-42ba-a1b0-a8f9ced588bd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Case of Peripheral Nerve Hyperexcitability Syndrome Pretended as Infective Endocarditis: Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePeripheral nerve hyperexcitability (PNH) is a term that refers to a heterogeneous group of disorders originating from the motor axons of the peripheral nervous system (PNS) and presents with muscle cramps, fasciculations, myokymia, and pseudo-myotonia, the most common symptoms amongst them. These disorders differentiate themselves from the central nervous system (CNS) and muscle disorders with similar presentation and different needle electromyography features (EMG) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe PNH syndromes can be artificially divided into primary and secondary based on the presence of the defined peripheral nervous system disorder. Primary PNH syndromes cause widespread signs and symptoms with motor, sensory, and autonomic origin. However, secondary PNH syndromes are the consequences of recognized systemic diseases. They can manifest in diffuse (e.g., Inflammatory demyelinating polyneuropathies) or focal regions (e.g., entrapment or radiation-induced) with less severity. The primary PNH syndromes are cramp-fasciculation syndrome (CFS), Isaac\u0026rsquo;s, and Morvan\u0026rsquo;s syndrome (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe PNH syndromes are caused by spontaneous repetitive discharges, leading to the increased activity of the muscles innervated by the motor neurons. Ectopic discharges lead to the positive sensory symptoms, including paresthesia and numbness. Discharges also impact the autonomic nervous system, which leads to autonomic manifestation, including hyperhidrosis, abdominal cramps, dramatic blood pressure alteration, orthostatic hypotension, and symptoms of CNS involvement like hallucination, sleep disorders, confusion, and mood alteration (\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe main EMG finding in PNH syndromes are spontaneous repetitive myokymic and neuromyotonic discharges, being composed of all or part of motor unit potentials presenting in two (doublets), three (triplets), and multiple bursts (multiplet) of discharges. The firing frequency of the burst potentials is in a wide range of 5-300 Hz (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe pathological mechanism responsible for the PNH disorders is assumed to be the voltage-gated potassium channelopathies mainly accumulated in the terminal segments of the peripheral nerves. In this regard, auto-immune mediated, genetic, toxins, drugs, infection, vaccination, and other causes are assumed to be responsible (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11 CR12 CR13\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The prior studies revealed that the pathophysiology of this condition is predominantly closely related to voltage-gated potassium channels (VGKC). Indeed, autoantibodies against the Contactin-associated protein-like 2 (CASPR2) and Leucine-rich glioma-inactivated 1 (LGI1), main components of the VGKC complex of the presynaptic membrane of the neuromuscular junctions, play a significant role in the pathogenesis of the PNH syndromes (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Meanwhile, several genes are linked to the development of the PNH syndromes, with the predominance of autosomal recessive inheritance (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe management of the PNH syndromes can be summarized in symptomatic and immunomodulatory treatments in mild and severe disease courses, respectively. Membrane stabilizing agents, including voltage-gated sodium channel blockers, are effective in muscle stiffness relieve. Meanwhile, plasma exchange (PE), intravenous immunoglobulin G, high doses of corticosteroids, and immunosuppressive agents are considerable in complicated diseases with auto-immune origin (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). A case of PNH syndrome misdiagnosed as an IE is presented.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 59-year-old male was referred with the primary complaint of remaining excessive weight loss, hyperhidrosis, spontaneous muscle spasms, fasciculations, and cramps in his lower limbs following two weeks of antibiotic therapy due to fatigue, fever, chills, dyspnea, and possible IE. He also reported spontaneous muscle contractions in lower limbs, fever, chills, excessive sweating, blood pressure alteration, fatigue, insomnia, slurred speech, and generalized muscle weakness, which improved slightly following antibiotic therapy. However, excessive sweating, insomnia, muscle weakness, fasciculations, slurred speech, and spontaneous muscle spasms remained. The patient has been experiencing persistent fluctuations in systolic blood pressure, ranging from 60\u0026ndash;180 mmHg, along with symptoms such as excessive sweating, weight loss of about 9 kilograms, and muscle weakness and cramps. His medical history includes recent antibiotic therapy (vancomycin and meropenem) due to suspicious bacteremia and a prior removal of a truncal lipoma ten years ago.\u003c/p\u003e \u003cp\u003eFurther investigations during his recent hospitalization revealed a 3.6mm hypoechoic nodule in the left lobe of the thyroid (T4 moderately suspicious). Additionally, 4mm and 3mm nephrolithiasis were found in the right and left renal calyces, respectively. The patient reported no concurrent use of tobacco or alcohol but had a history of using them previously.\u003c/p\u003e \u003cp\u003eThere were no reported sensitivities to food or drugs, no family history of similar signs or symptoms in relatives, and no past drug history. The patient underwent several diagnostic procedures, including Abdominopelvic CT with contrast, Brain CT with contrast, Chest X-ray (CXR), and laboratory procedures, including Complete Blood Counts (CBC), thyroid function tests, kidney, liver, lipid profile, Cerebrospinal Fluid (CSF) analysis, electrolytes, blood cultures, and urine cultures following initiation of antibiotic therapy. The patient underwent two consecutive trans-thoracic echocardiography (TTE). The first revealed vegetation in the right atrium in a size of 1.1*0.9mm. The second TTE, a week later, revealed mild pleural effusion, prominent crista terminalis in the right atrium roof, no apparent vegetation on valves, and tachycardia.\u003c/p\u003e \u003cp\u003eHis physical examination revealed bilateral moderate proximal muscle weakness of extremities (3/5), normal Deep Tendon Reflexes, fasciculation, and myokymia in his lower limbs. Cranial, sensory, cerebellum, and gait examinations revealed no significant abnormality. He also had hypertrophied calf muscles and dysautonomia, which caused excessive sweating, blood pressure changes, and weight loss.\u003c/p\u003e \u003cp\u003eAn EMG was done, and it revealed mild length-dependent sensory/motor polyneuropathy along with peripheral nerve hyperexcitability findings. It revealed fasciculation and myotonic discharges mainly in the gastrocnemius muscle and first dorsal interosseous of the hand in needle EMG (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Further, extensive and serial laboratory tests were obtained. The Anti-CASPR2, Anti LGI-1, as well as, para-neoblastic, and autoimmune panels were obtained. The thorough workup revealed elevation of the Anti-CASPR2 titer (Titer: 1:320, which results with a titer 1: \u0026lt;10 was considered nonsignificant).\u003c/p\u003e \u003cp\u003eHe was treated with several courses of PE treatment, which improved muscle weakness, myokymia, sweating, and wide-ranged SBP fluctuations dramatically. Meanwhile, carbamazepine was used for symptomatic treatment of fasciculations.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSensory NCS\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSensory NCS\u003c/span\u003e\u003csup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e*\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNerve / Sites\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eOnset L.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ePeak L.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003ePk Amp\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eAmp Pk-Pk\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eDuration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eLat Diff\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ems\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ems\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026micro;V\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026micro;V\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003ems\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003ems\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eL MEDIAN - Digit II\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1. Wrist\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eL ULNAR - Digit V\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1. Wrist\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eL SURAL - Lat Malleolus\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1. Calf\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eR SURAL - Lat Malleolus\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1. Calf\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e\u0026bull; NCS: Nerve Conduction Study\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMotor NCS\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eMotor NCS\u003c/span\u003e\u003csup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e*\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNerve / Sites\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLatency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eAmpl.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eDur.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eArea\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eAmpl. %\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eDur.%.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eArea%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003eDistance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003eLat Diff\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003eVelocity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ems\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003emV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003ems\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003emVms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003ecm\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003ems\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003em/s\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eL MEDIAN - APB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1. Wrist\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e59.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2. Elbow\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e93.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e98.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e5.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e48.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePath 3\u0026thinsp;\u0026minus;\u0026thinsp;1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eL ULNAR - ADM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1. Wrist\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2. B.Elbow\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e83.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e55.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePath 3\u0026thinsp;\u0026minus;\u0026thinsp;1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eL COMM PERONEAL - EDB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1. Ankle\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2. Fib Head\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e71.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e65.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e7.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e45.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePath 3\u0026thinsp;\u0026minus;\u0026thinsp;1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eR COMM PERONEAL - EDB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1. Ankle\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2. Fib Head\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e9.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e36.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePath 3\u0026thinsp;\u0026minus;\u0026thinsp;1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eL TIBIAL (KNEE) - AH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1. Ankle\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e5.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2. Knee\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e99.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e9.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e38.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePath 3\u0026thinsp;\u0026minus;\u0026thinsp;1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eR TIBIAL (KNEE) - AH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1. Ankle\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2. Knee\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e74.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e80.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e98.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e12.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e33.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePath 3\u0026thinsp;\u0026minus;\u0026thinsp;1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e• NCS: Nerve Conduction Study\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNeedle EMG\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"10\" nameend=\"c10\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eNeedle EMG\u003c/span\u003e\u003csup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e*\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEMG Summary Table\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c10\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSpontaneous\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e\u003cb\u003eMUAP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003eRecruitment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eFib\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003ePSW\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eFasc\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eMyotonic dis.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eAmp\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eDur.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003ePPP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003ePattern\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eL. TIB ANTERIOR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eL. GASTROCN (MED)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2+ (slow)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eR. GASTROCN (MED)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2+ (slow)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eL. FIRST D INTEROSS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eL. BICEPS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e• EMG: Electromyography\u003c/h3\u003e\n"},{"header":"Discussion","content":"\u003cp\u003eThe PNH syndromes are infrequent disorders characterized by spontaneous repetitive discharges in PNS neurons, mainly axonal motor neurons, causing positive muscle phenomena, sensory, and autonomic symptoms. The PNH syndromes are primarily present in primary forms (predominantly Isaac\u0026rsquo;s, Morvan\u0026rsquo;s, and CFS) and are considered to have widespread origins. In this regard, prior studies revealed the pathogenic roles of the genetic, para-neoblastic, auto-immune-mediated, post-infection-mediated, post-vaccination-mediated, metal poisoning, and toxins in the pathogenesis of the PNH syndromes (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, we presented a patient with anti-CASPR2 antibody positive PNH syndrome with evidence of slow potassium channel dysfunction revealed by EMG study, including visible myokymia in calf muscles, myokymic discharges on EMG, marked after-discharge of F-wave following stimulation, and evidence of slow potassium current in nerve excitability test following possible bacteremia. The CASPR2 and LGI1, the main components of VGKC, are widely expressed in the CNS and PNS. Our patient was referred with symptoms of insomnia, wide fluctuation in blood pressure, tachycardia, excessive sweating, muscle fasciculation, and cramps in lower limbs were assumed to be caused by autoantibodies against CASPR2 in the thalamus, locus coeruleus, and presynaptic VGKCs in the PNS (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Insignificant radiological workups, including CXR, Abdominopelvic CT with contrast, and trans thoracic echocardiographic studies ruled out malignancy and paraneoplastic origin of the PNH syndrome in this patient. Meanwhile, insignificant serologic findings and lack of a history of prevalent comorbid diseases seen in PNH syndromes (i.e., celiac disease, Hashimoto thyroiditis, Vit B12 deficiency, vitiligo, Addison disease, Rheumatoid arthritis, and \u0026hellip;) (\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), and the onset of sign and symptoms following the bacteremia, as well as, dramatic improvement of fever, chills, and dyspnea following antibiotic therapy, we considered the PNH syndrome associated with bacteremia.\u003c/p\u003e \u003cp\u003eIt is considered that the pathophysiology of the PNH syndromes is closely related to the autoimmune origins rather than the mentioned origins. Prior studies revealed the presence of autoantibodies against the VGKC main complex, including CASPR2 and LGI-1. These VGKCs are widely expressed in the presynaptic membrane of the neuromuscular junction both in the CNS and PNS, including neurons of the thalamus, hypothalamus, locus coeruleus, and raphe nuclei. LGI1, a secreted neuronal protein that is strongly expressed in the hippocampus, associates specifically with Kv1.1 subunits in CNS presynaptic terminals, while CASPR2 is a transmembrane protein with an extracellular sequence essential for co-localization of Kv1.1 and 1.2 at the juxtaparanodes. Dysregulation of these receptors in the hippocampus, hypothalamus, and locus coeruleus leads to deteriorating impacts on memory formation, arousal/sleep cycle, and dysautonomia (i.e., excessive sweating, tachycardia, wide fluctuation of blood pressure), respectively (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePrior reports revealed the pathogenic role of genetic mutations and their co-existence with lower motor neuron diseases in hereditary and acquired PNH syndromes (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Experiments with VGKC subunit Kv1.1 mutations in animals displayed neuromyotonic and myokymic discharges with the same frequencies and phenotypes observed in PNH patients (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Further, transfection of \u003cem\u003eXenopus\u003c/em\u003e oocytes with mutated Kv1.1 subunit channels leads to significantly smaller VGKC currents, as compared to those transfected with wild-type Kv1.1 channels, supporting the genetic origin. Further, KCNA1 gene loss of function mutation with autosomal dominant inheritance leads to episodic ataxia type 1 syndrome with continuous myokymia and generalized ataxia symptoms (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Prior studies revealed the association of the HINT1 mutation with autosomal recessive (AR) axonal neuropathy with neuromyotonia manifests with a distal, slowly progressive, mainly motor neuropathy (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Meanwhile, the presence of spinal muscular atrophy, as well as Schwartz-Jampel syndrome inherited by the HSPG2 mutation, with AR inheritance, supports the genetic origin of the disorder (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePrior studies revealed that the underlying neoplasm and para-neoplastic syndromes have been significant risk factors in the pathogenesis of PNH syndromes. In this regard, thymoma is considered the most common among them (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Tumor antigens could trigger the immune system to produce antibodies that react against VGKC, making it a marker of onco-neuronal disorders (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). This explains the occurrence of autoimmune neurological paraneoplastic disorders in patients with PNH syndrome. In this regard, a low-positive titer of anti-VGKC antibodies has been detected in various types of cancer, including thymoma, lung cancer, Hodgkin lymphoma, plasmacytoma, lymphoblastic lymphoma, hemangioblastoma, ovarian cancer, and bladder cancer (\u003cspan additionalcitationids=\"CR32 CR33 CR34 CR35\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePrior studies revealed the association of infection with the onset of Isaac\u0026rsquo;s syndrome. In this regard, the association of staphylococcal infection with Isaac\u0026rsquo;s syndrome was investigated (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). A prior study showed that Isaac\u0026rsquo;s syndrome can be associated with Staphylococcal infection in which the symptoms rapidly disappeared following an abscess treatment. Therefore, it was suggested that Isaacs syndrome in this patient was a manifestation of peripheral nerve irritation caused by humoral antibodies triggered by S. aureus infection. In this regard, they found an oligoclonal band in the CSF fluid analysis. However, no anti-VGKC antibody was found. Prior studies revealed the association of chronic active HBV with the onset of Isaac\u0026rsquo;s Syndrome (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). In this study, the diagnostic procedures manifest only the co-existence of Hepatitis B and Isaac\u0026rsquo;s syndrome.\u003c/p\u003e \u003cp\u003eFollowing the short course of plasmapheresis and phenytoin, the patient was treated with complete remission. Moreover, literature revealed the association of HBV infection with immunological diseases, including vasculitis (i.e., polyarthritis nodosa), cryoglobulinemia, Henoch-Schoenlein purpura, and Guillan-Barre syndrome (\u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Therefore, it was suggested that Isaac\u0026rsquo;s syndrome was the manifestation of peripheral nerve irritation caused by humoral antibodies triggered by HBV. Further, a prior study revealed the onset of PNH syndromes with severe peripheral and central manifestation, including agitation and insomnia, following one month after an episode of enteroviral pericarditis and responded well to immunotherapy. However, both Anti-CASPR2 and Anti-LGI1 were undetectable (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRecent studies indicate that silver and lead poisoning, as well as the gold used in treating rheumatoid arthritis, may also contribute to the pathogenesis and onset of PNH syndromes (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Meanwhile, herbicides, insecticides, toluene, alcohol, snake venom, human papillomavirus, and wasp sting mediate the onset of PNH syndrome in susceptible patients, presumably via auto-immune mechanisms (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this study, we describe a patient who developed PNH syndrome following bacteremia. The patient experienced dysautonomia symptoms, such as weight loss, excessive sweating, and wide fluctuations in blood pressure, as well as bilateral lower limb fasciculation and myokymia. The fever, chills, and dyspnea improved significantly with antibiotic therapy, while the neurological and electrophysiological symptoms improved with plasmapheresis. This case shares similarities with previous cases of PNH syndrome triggered by infections, suggesting that autoantibodies against pathogens may be responsible for the manifestation of PNH syndrome. Moreover, the dramatic response to plasmapheresis and removal of antibodies, as well as positive Anti-CASPR2 auto-antibody, confirms our diagnosis.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePNH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePeripheral Nerve Hyperexcitability\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCNS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCentral Nervous System\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVGKC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003evoltage-gated potassium channel\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePNS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePeripheral Nervous System\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHBV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHepatitis B Virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEMG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eElectromyography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCFS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCramp-Fasciculation Syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCASPR2\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eContactin-associated protein-like 2\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLGI1\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLeucine-rich glioma-inactivated 1\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePlasma Exchange\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInfective Endocarditis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCXR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eChest X-ray\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCBC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComplete Blood Count\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCSF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCerebrospinal Fluid\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTTE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTrans-Thoracic Echocardiography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNCS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNerve Conduction Study\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed Tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAutosomal Recessive\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of competing interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData will be made available on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to Participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs this study is a case report, it did not require formal ethical approval. However, written consent was obtained from the patient and can be provided upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contribution:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMajid Ghasemi:\u0026nbsp;\u003c/strong\u003eWriting \u0026ndash; review \u0026amp; editing, Writing \u0026ndash; original draft, Resources, Investigation, Data curation, Conceptualization. \u003cstrong\u003eSepehr Omoomi:\u0026nbsp;\u003c/strong\u003eWriting \u0026ndash; review \u0026amp; editing, Writing \u0026ndash; original draft, Resources, Investigation, Data curation, Conceptualization.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKatirji B. Peripheral nerve hyperexcitability. Handbook of Clinical Neurology. 2019;161:281\u0026thinsp;\u0026ndash;\u0026thinsp;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eK\u0026uuml;\u0026ccedil;\u0026uuml;kali CI, K\u0026uuml;rt\u0026uuml;nc\u0026uuml; M, Ak\u0026ccedil;ay Hİ, T\u0026uuml;z\u0026uuml;n E, \u0026Ouml;ge AE. Peripheral nerve hyperexcitability syndromes. Rev Neurosci. 2015;26(2):239\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Wel B, Claeys KG. Neuromuscular hyperexcitability syndromes. Curr Opin Neurol. 2021;34(5):714\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEpure DA, Ioghen MR, Roza E, Teleanu RI. A case report of Morvan syndrome, the unique clinical pattern of a rare disease. Ro J Neurol. 2020;19(1):54\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel AN, Patel PK, Desai J, Oakley K, Reddy P. A rare phenomenon of isaacs syndrome: a case report. Cureus. 2023;15(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHutto SK, Harrison TB. Electrodiagnostic Assessment of Hyperexcitable Nerve Disorders. Neurol Clin. 2021;39(4):1083\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHatami M, F\u0026ouml;rster M, Weyers V, R\u0026auml;uber S, Meuth SG, Kremer D. Neuromyotonia with central nervous system lesions following quadrivalent human papilloma virus vaccination. Vaccines. 2022;10(7):1132.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiebenthal JA, Rezania K, Nicholas MK, Lukas RV. Paraneoplastic nerve hyperexcitability. Neurol Res. 2015;37(6):553\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu YC, Wu ZA, Wang SJ, Shan DE, Lin KP. Transient syndrome of continuous muscle fiber activity associated with staphylococcal infection. Mov Disord. 1998;13(3):609\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZimoń M, Baets J, Almeida-Souza L, De Vriendt E, Nikodinovic J, Parman Y, et al. Loss-of-function mutations in HINT1 cause axonal neuropathy with neuromyotonia. Nat Genet. 2012;44(10):1080\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChaurasia R, Abbas A, Shukla R. Toxin induced continuous muscle fiber activity syndrome. Annals Neurosciences. 2010;15(4):118\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrisold W, Mamoli B. The syndrome of continuous muscle fibre activity following gold therapy. J Neurol. 1984;231:244\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTurner M, Madkhana A, Ebers G, Clover L, Vincent A, McGavin G, et al. Wasp sting induced autoimmune neuromyotonia. J Neurol Neurosurg Psychiatry. 2006;77(5):704\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVincent A, Irani SR. Caspr2 antibodies in patients with thymomas. J Thorac Oncol. 2010;5(10):S277\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLancaster E, Huijbers MG, Bar V, Boronat A, Wong A, Martinez-Hernandez E, et al. Investigations of caspr2, an autoantigen of encephalitis and neuromyotonia. Ann Neurol. 2011;69(2):303\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePoliak S, Salomon D, Elhanany H, Sabanay H, Kiernan B, Pevny L, et al. Juxtaparanodal clustering of Shaker-like K\u0026thinsp;+\u0026thinsp;channels in myelinated axons depends on Caspr2 and TAG-1. J Cell Biol. 2003;162(6):1149\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLai M, Huijbers MG, Lancaster E, Graus F, Bataller L, Balice-Gordon R, et al. Investigation of LGI1 as the antigen in limbic encephalitis previously attributed to potassium channels: a case series. Lancet Neurol. 2010;9(8):776\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrowne DL, Gancher ST, Nutt JG, Brunt ER, Smith EA, Kramer P, et al. Episodic ataxia/myokymia syndrome is associated with point mutations in the human potassium channel gene, KCNA1. Nat Genet. 1994;8(2):136\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElovaara I, Apostolski S, Van Doorn P, Gilhus N, Hietaharju A, Honkaniemi J, et al. EFNS guidelines for the use of intravenous immunoglobulin in treatment of neurological diseases: EFNS task force on the use of intravenous immunoglobulin in treatment of neurological diseases. Eur J Neurol. 2008;15(9):893\u0026ndash;908.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkeie G, Apostolski S, Evoli A, Gilhus N, Hart I, Harms L, et al. Guidelines for the treatment of autoimmune neuromuscular transmission disorders. Eur J Neurol. 2006;13(7):691\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHart IK, Waters C, Vincent A, Newland C, Beeson D, Pongs O, et al. Autoantibodies detected to expressed K\u0026thinsp;+\u0026thinsp;channels are implicated in neuromyotonia. Annals Neurology: Official J Am Neurol Association Child Neurol Soc. 1997;41(2):238\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaylor PW. Isaacs' syndrome (autoimmune neuromyotonia) in a patient with systemic lupus erythematosus. J Rhuematol. 2005;32(4):757\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaddison P, Neuromyotonia. Clin Neurophysiol. 2006;117(10):2118\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIrani SR, Alexander S, Waters P, Kleopa KA, Pettingill P, Zuliani L, et al. Antibodies to Kv1 potassium channel-complex proteins leucine-rich, glioma inactivated 1 protein and contactin-associated protein-2 in limbic encephalitis, Morvan\u0026rsquo;s syndrome and acquired neuromyotonia. Brain. 2010;133(9):2734\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEikeland BA, Patient with Double-Negative VGKC. Peripheral Nerve Hyperexcitability, and Central Nervous System Symptoms: A Postinfectious Autoimmune Disease. Case Rep Neurol Med. 2020;2020(1):3579419.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLance J. Association of lower motor neuron disorders with fasciculation, neuromyotonia and myoclonus. Australian Pediatr J. 1988;24:113\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eToyka Kv ZIELASEKJ, RICKER K, ADLKOFER K, SUTER U. Hereditary neuromyotonia: a mouse model associated with deficiency or increased gene dosage of the PMP22 gene. J Neurol Neurosurg Psychiatry. 1997;63(6):812.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eServettini I, Talani G, Megaro A, Setzu MD, Biggio F, Briffa M et al. An activator of voltage-gated K\u0026thinsp;+\u0026thinsp;channels Kv1. 1 as a therapeutic candidate for episodic ataxia type 1. Proceedings of the National Academy of Sciences. 2023;120(31):e2207978120.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEchaniz-Laguna A, Rene F, Marcel C, Bangratz M, Fontaine B, Loeffler JP, et al. Electrophysiological studies in a mouse model of Schwartz\u0026ndash;Jampel syndrome demonstrate muscle fiber hyperactivity of peripheral nerve origin. Muscle Nerve. 2009;40(1):55\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBauch\u0026eacute; S, Boerio D, Davoine C-S, Bernard V, Stum M, Bureau C, et al. Peripheral nerve hyperexcitability with preterminal nerve and neuromuscular junction remodeling is a hallmark of Schwartz-Jampel syndrome. Neuromuscul Disord. 2013;23(12):998\u0026ndash;1009.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eViallard J-F, Vincent A, Moreau J-F, Parrens M, Pellegrin J-L, Ellie E. Thymoma-associated neuromyotonia with antibodies against voltage-gated potassium channels presenting as chronic intestinal pseudo-obstruction. Eur Neurol. 2005;53(2):60\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRana SS, Ramanathan RS, Small G, Adamovich B. Paraneoplastic Isaacs' syndrome: a case series and review of the literature. J Clin Neuromuscul Dis. 2012;13(4):228\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePaterson RW, Zandi MS, Armstrong R, Vincent A, Schott JM. Clinical relevance of positive voltage-gated potassium channel (VGKC)-complex antibodies: experience from a tertiary referral centre. J Neurol Neurosurg Psychiatry. 2014;85(6):625\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFleisher J, Richie M, Price R, Scherer S, Dalmau J, Lancaster E. Acquired neuromyotonia heralding recurrent thymoma in myasthenia gravis. JAMA Neurol. 2013;70(10):1311\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIssa SS, Herskovitz S, Lipton RB. Acquired neuromyotonia as a paraneoplastic manifestation of ovarian cancer. Neurology. 2011;76(1):100\u0026ndash;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePartanen V, Soininen H, Saksa M, Riekkinen P. Electromyographic and nerve conduction findings in a patient with neuromyotonia, normocalcemic tetany and small-cell lung cancer. Acta Neurol Scand. 1980;61(4):216\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBasiri K, Fatehi F. Isaacs syndrome associated with chronic hepatitis B infection: a case report. Neurol Neurochir Pol. 2009;43:388\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShin JI, Lee JS. Hepatitis B virus infection and Henoch\u0026ndash;Sch\u0026ouml;nlein purpura: Comment. 2007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChroni E, Thomopoulos C, Papapetropoulos S, Paschalis C, Karatza CL. A case of relapsing Guillain-Barr\u0026eacute; syndrome associated with exacerbation of chronic hepatitis B virus hepatitis. J Neurovirol. 2003;9:408\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaura Penagos M, Luisa Calle M, \u0026Oacute;scar Santos M. Extrahepatic Manifestations of Hepatitis B. 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePetiot P, Charles N, Vial C, McGregor B, Aimard G, Trillet M, et al. Neurological complications caused by gold salts. Nosologic report apropos of a case. Rev Neurol. 1993;149(10):562\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDevathasan G, Low D, Teoh P, Wan S, Wong P. Complications of chronic glue (toluene) abuse in adolescents. Aust N Z J Med. 1984;14(1):39\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaress JB, Walker FO. The spectrum of ectopic motor nerve behavior: from fasciculations to neuromyotonia. Neurologist. 2002;8(1):41\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Peripheral Nerve Hyperexcitability, Neuromyotonia, Morvan’s Syndrome, Infective Endocarditis, Bacteremia","lastPublishedDoi":"10.21203/rs.3.rs-5791843/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5791843/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eThe peripheral nerve hyperexcitability (PNH) syndromes cause repetitive spontaneous electrical discharges in peripheral nerves (mainly motor axons), which leads to the increased activity of the innervated area. PNH syndromes develop various motor, sensory, and autonomous symptoms, of which motor symptoms are the most considerable, including cramps, fasciculations, and myokymia. The PNH syndromes are classified into cramp-fasciculation syndrome, neuromyotonia (Isaacs syndrome), and Morvan\u0026rsquo;s syndrome. Morvan syndrome is associated with the involvement of the central nervous system (CNS). PNH syndromes primarily result from dysfunction of voltage-gated potassium channels (VGKC), mainly due to autoantibodies. Alternative causes have been proposed, including potential infectious origins. Previous studies have associated staphylococcal abscesses and Hepatitis B Virus (HBV) infections with the pathogenesis of Isaacs syndrome rather than Morvan\u0026rsquo;s syndromes.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e \u003cp\u003eWe present a case of VGKC-antibody-positive PNH presented by symptoms such as fatigue, fever, chills, dyspnea, weight loss, hyperhidrosis, spontaneous muscle spasms, and cramps in the lower limbs. Central Nervous System (CNS) involvement included hallucinations, sleep disorders, confusion, and mood alterations, along with vegetation in the right atrium as detected by echocardiography. The patient initially received a two-week course of antibiotic therapy for suspected infective endocarditis (IE) and bacteremia. Subsequently, due to persistent symptoms despite antibiotic treatment, electromyography (EMG) was performed, revealing anti-VGKC antibodies. The patient then underwent several plasma exchanges and was prescribed carbamazepine, resulting in a significant improvement in their condition.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eThis case shares similarities with previous cases of PNH syndrome (especially Morvan\u0026rsquo;s syndromes) triggered by infections other than previously reported, suggesting that autoantibodies against pathogens may be responsible for the manifestation of PNH syndrome. Moreover, the dramatic response to plasmapheresis and removal of antibodies, as well as positive Anti-CASPR2 auto-antibody, confirms our diagnosis.\u003c/p\u003e","manuscriptTitle":"A Case of Peripheral Nerve Hyperexcitability Syndrome Pretended as Infective Endocarditis: Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-13 08:44:28","doi":"10.21203/rs.3.rs-5791843/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-03-22T11:16:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-14T16:26:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-05T00:24:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-28T18:03:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-27T09:43:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"196929866711571360926797404673673694483","date":"2025-02-26T01:45:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-25T23:58:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-23T08:49:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"287927610332190392633297012917243822211","date":"2025-02-23T07:37:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"187080174779684082634323947051264542723","date":"2025-02-23T06:15:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"160275189537107398950769351570348692879","date":"2025-02-15T08:51:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"261516569090609665519797546274637292414","date":"2025-02-15T07:28:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"200859715989527791334016825611113414771","date":"2025-02-15T06:25:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-02-15T05:55:32+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-01-09T22:01:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-09T13:21:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-09T13:19:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neurology","date":"2025-01-08T21:11:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e168ab39-098b-4b19-83f4-d85a1453cf85","owner":[],"postedDate":"January 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-04-13T11:08:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-13 08:44:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5791843","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5791843","identity":"rs-5791843","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}