Frontal lobe dysfunction in sporadic hyperekplexia--case study and literature review.
Hyperekplexia (HE), or startle disease, is usually a familial disorder associated with mutations in the glycine receptor alpha1 subunit gene (GLRA1), characterised by exaggerated startle reactions to unexpected auditory, somaesthetic and visual stimuli. Non-familial cases may be idiopathic, or associated with pathology usually in the brainstem or rarely in the supratentorial compartment. The pathophysiological basis of HE is unclear. We report the case of a 40-year-old woman presenting with excessive startle response to unexpected stimuli and falls since the age of 16 years. There was no family history. She was initially diagnosed with epilepsy and started on phenytoin with no resolution of her symptoms. Clinical examination revealed hyperreflexia and an insecure broad-based gait but no other abnormalities. Routine comprehensive neuropsychological assessment revealed below average intelligence with signs of frontal lobe dysfunction. EEG showed non-specific abnormalities in the right frontal and central regions. A (99m)Tc-HMPAO SPET scan revealed hypoperfusion in the frontal (worse on the right) and temporal lobes and to a lesser extent in the basal ganglia. MRI was normal, as well as blood and CSF tests. No mutations were found in a genetic analysis of GLRA1. The patient improved partially with treatment by clonazepam. The localisation of the clinical and neuropsychological findings accord with the EEG and SPET scan abnormalities in our patient and corroborates previous reports. Appropriate neuropsychological testing and functional imaging enable more accurate delineation of the clinical phenotype of this rare disorder.
Department of Neurology, Essex Centre for Neurology & Neurosurgery, Oldchurch Hospital, Oldchurch Road, Romford, Essex RM7 0BE, UK.
Athanasios
A
Gaitatzis
Luke D
LD
Kartsounis
Svetislav
S
Gacinovic
Durval C
DC
Costa
Kirsten
K
Harvey
Robert J
RJ
Harvey
Rajith N
RN
de Silva
D000328:Adult; D000927:Anticonvulsants / Q000627:therapeutic use; D001927:Brain Diseases / Q000503:physiopathology*; D002998:Clonazepam / Q000627:therapeutic use; D004252:DNA Mutational Analysis / Q000379:methods; D004569:Electroencephalography / Q000379:methods; D005260:Female; D005625:Frontal Lobe / Q000473:pathology / Q000503:physiopathology*; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods; D009122:Muscle Hypertonia / Q000097:blood / Q000188:drug therapy / Q000235:genetics / Q000503:physiopathology*; D009483:Neuropsychological Tests / Q000706:statistics & numerical data; D016133:Polymerase Chain Reaction / Q000379:methods; D018009:Receptors, Glycine / Q000235:genetics; D013216:Reflex, Startle; D015899:Tomography, Emission-Computed, Single-Photon / Q000379:methods
D000927:Anticonvulsants; C000657604:GLRA1 protein, human; D018009:Receptors, Glycine; D002998:Clonazepam