- Email: [email protected]
MUSCLE BIOPSY FINDINGS OF POSSIBLE DIAGNOSTIC IMPORTANCE IN PRIMARY FIBROMYALGIA (FIBROSITIS, MYOFASCIAL SYNDROME)
1395 at Shipham organised by the Ministry of Agriculture, Fisheries and Food. Cadmium concentrations in some garden crops were often high but these were not generally major diet items in the village. Consequently, average intakes (200 Jig per week) were only moderately increased (U.K. average 140 Jig per week) and individual intakes rarely exceeded the W.H.O. provisional tolerable weekly intake of 400-500 Jig.4 It cannot be assumed, however, that there are grounds for complacency. Changes in lifestyle in the locality could modify exposure in the future; moreover the development of new and more sensitive laboratory methods may reveal evidence of health effects which cannot at present be detected. A continuing programme of surveillance and monitoring would therefore seem to be justified and has been recommended.
PATHOLOGICAL FINDINGS
study
Department of Child Health, Westminster Medical School,
D. BARLTROP C. D. STREHLOW
London SW1P 2AR
MUSCLE BIOPSY FINDINGS OF POSSIBLE DIAGNOSTIC IMPORTANCE IN PRIMARY FIBROMYALGIA (FIBROSITIS, MYOFASCIAL
SYNDROME) SIR,-In fifteen consecutive patients with primary fibromyalgia, fulfilling the diagnostic criteria of Yunus et al.,we have examined muscle taken by an open surgical method from tender areas. Routine histopathological, histochemical, and electronmicroscopic examinations were done. In nine cases trapezius muscle samples were also analysed spectrophotometrically for adenosine triphosphate, phosphocreatine, lactate, and glycogen. Fourteen patients were women. The mean age was 42 (range 20-62). In eleven cases focal loss ofNADH-diaphorase activity was found (moth-eaten appearance). Moth-eaten fibres were found in all nine samples from trapezius muscle and in two of the four from deltoid muscle. In two quadriceps samples no moth-eaten fibres were found. The moth-eaten fibres were evenly distributed over the whole cross-section in all but one biopsy specimen, and only type I fibres were affected. On average 9% of the fibres had a moth-eaten appearance (figure). The pathological findings are summarised in the table.
The most consistent and characteristic microscopic finding in muscle from tender areas was the even distribution of moth-eaten fibres over the whole cross-section. Electronmicroscopy of five specimens revealed abnormalities in all-namely, mitochondrial abnormalities (such as electron-dense inclusions and lack of inner membrane), myofibrillar Z-streaming, and cytoplasmic bodies. There was an abnormal relation between mitochondria and
myofibrils. The values for energy metabolites and glycogen were compared with values in fourteen healthy controls. The control samples were obtained from the quadriceps. Adenosine triphosphate and phosphocreatine were much reduced in the patients with fibromyalgia, lactate values were normal, but glycogen concentrations were below normal. Although the light microscopic and ultrastructural findings are unspecific, they do indicate that the muscle fibres are abnormal. Pathological changes have also been described by Yunus et al. An even distribution of moth-eaten fibres over the total cross-section of a muscle biopsy specimen in which other pathological findings are discrete, is a highly characteristic finding in the tender trapezius muscle of patients with primary fibromyalgia. The biopsy findings described may be of diagnostic importance. We do not know whether the findings represent a primary metabolic disturbance, or an overload myopathy secondary to a more or less continuous increase in muscle tension. Neuromuscular S-581 85
additives Ser no 4. Geneva: WHO, 1972.
M, Masi AT, Calabro JJ, Miller KA, Feitenbaum SL Primary fibromyalgia (fibrositis): Clinical study of 50 patients with matched normal controls Semiw Arthritis Rheum 1981, 11: 151-71.
1. Yunus
Staining for NADH-diaphorase. Focal loss of enzyme
activity
in fibres marked with
appearance). Inset (larger magmficatlOn): Fibre
mrerfibnllary
network.
to
arrows
(moth-eaten
left shows
normal
K. G. HÉNRIKSSON
Linköping, Sweden
A. BENGTSSON LARSSON F. LINDSTRÖM
Departments of Rheumatology and Surgery, University Hospital, Linköping Institute
Organisation. Evaluation of mercury, lead, cadmium, and the food amaranth, diethylpyrocarbonate and octyl gallate WHO Food Additives
4. World Health
Unit,
University Hospital,
J.
of Anatomy,
L.-E. THORNELL
University of Umeå
COXSACKIE B VIRUS INFECTION ASSOCIATED WITH HYPOPARATHYROIDISM IN A NEONATE
SIR,-We have seen a baby in whom myocarditis, meningitis, and transient hypoparathyroidism were associated with a Coxsackie B virus infection. A girl was born on May 10, 1979, at term, to healthy, unrelated parents. Birthweight was 2-6 kg and there were no dysmorphic features. The mother had had pyrexia and pharyngitis, unresponsive to antibiotics, for 3 days before and 2 days after delivery. The baby remained well until the fifth day when fever (38 -2°C) was noted without other clinical signs of infection. Within 24 h cardiac failure developed, with tachycardia, tachypnoea, and increasing liver size, which responded rapidly to digoxin and diuretics. A 3/6 pansystolic murmur was heard. The white cell count was 14-8x10/1 (55% neutrophils, 40% lymphocytes, 4% monocytes, 1% eosinophils). 12 h later the baby began to have multifocal clonic convulsions and was found to be profoundly hypocalcaemic and hypomagnesaemic (serum calcium 1-15 mmol/1, serum magnesium 0-4 mmol/1), and her phosphate was only 1 -68 mmol/l. The CSF contained 21 cellsll (all lymphocytes) and 6 red blood cells (normal range in neonate WBC <14x 106/1); there was insufficient material for protein or sugar estimations. Bacterial cultures of nose, throat, umbilicus, eye, blood, urine, and CSF were negative. Coxsackievirus type B4 was grown in tissue culture from the CSF and faeces. Serum neutralising antibody titres 2. Yunus M, Kalyanaraman UP, Kalyanaraman K, Masi AT, Berg BC. Microscopic and radioactive bone scan studies in primary fibromyalgia: Abstracts of VIII Pan-
American Congress of Rheumatology
Arthritis Rheum
1982; 25: (no 4) suppl: S146.
PATHOLOGICAL FINDINGS
study
Department of Child Health, Westminster Medical School,
D. BARLTROP C. D. STREHLOW
London SW1P 2AR
MUSCLE BIOPSY FINDINGS OF POSSIBLE DIAGNOSTIC IMPORTANCE IN PRIMARY FIBROMYALGIA (FIBROSITIS, MYOFASCIAL
SYNDROME) SIR,-In fifteen consecutive patients with primary fibromyalgia, fulfilling the diagnostic criteria of Yunus et al.,we have examined muscle taken by an open surgical method from tender areas. Routine histopathological, histochemical, and electronmicroscopic examinations were done. In nine cases trapezius muscle samples were also analysed spectrophotometrically for adenosine triphosphate, phosphocreatine, lactate, and glycogen. Fourteen patients were women. The mean age was 42 (range 20-62). In eleven cases focal loss ofNADH-diaphorase activity was found (moth-eaten appearance). Moth-eaten fibres were found in all nine samples from trapezius muscle and in two of the four from deltoid muscle. In two quadriceps samples no moth-eaten fibres were found. The moth-eaten fibres were evenly distributed over the whole cross-section in all but one biopsy specimen, and only type I fibres were affected. On average 9% of the fibres had a moth-eaten appearance (figure). The pathological findings are summarised in the table.
The most consistent and characteristic microscopic finding in muscle from tender areas was the even distribution of moth-eaten fibres over the whole cross-section. Electronmicroscopy of five specimens revealed abnormalities in all-namely, mitochondrial abnormalities (such as electron-dense inclusions and lack of inner membrane), myofibrillar Z-streaming, and cytoplasmic bodies. There was an abnormal relation between mitochondria and
myofibrils. The values for energy metabolites and glycogen were compared with values in fourteen healthy controls. The control samples were obtained from the quadriceps. Adenosine triphosphate and phosphocreatine were much reduced in the patients with fibromyalgia, lactate values were normal, but glycogen concentrations were below normal. Although the light microscopic and ultrastructural findings are unspecific, they do indicate that the muscle fibres are abnormal. Pathological changes have also been described by Yunus et al. An even distribution of moth-eaten fibres over the total cross-section of a muscle biopsy specimen in which other pathological findings are discrete, is a highly characteristic finding in the tender trapezius muscle of patients with primary fibromyalgia. The biopsy findings described may be of diagnostic importance. We do not know whether the findings represent a primary metabolic disturbance, or an overload myopathy secondary to a more or less continuous increase in muscle tension. Neuromuscular S-581 85
additives Ser no 4. Geneva: WHO, 1972.
M, Masi AT, Calabro JJ, Miller KA, Feitenbaum SL Primary fibromyalgia (fibrositis): Clinical study of 50 patients with matched normal controls Semiw Arthritis Rheum 1981, 11: 151-71.
1. Yunus
Staining for NADH-diaphorase. Focal loss of enzyme
activity
in fibres marked with
appearance). Inset (larger magmficatlOn): Fibre
mrerfibnllary
network.
to
arrows
(moth-eaten
left shows
normal
K. G. HÉNRIKSSON
Linköping, Sweden
A. BENGTSSON LARSSON F. LINDSTRÖM
Departments of Rheumatology and Surgery, University Hospital, Linköping Institute
Organisation. Evaluation of mercury, lead, cadmium, and the food amaranth, diethylpyrocarbonate and octyl gallate WHO Food Additives
4. World Health
Unit,
University Hospital,
J.
of Anatomy,
L.-E. THORNELL
University of Umeå
COXSACKIE B VIRUS INFECTION ASSOCIATED WITH HYPOPARATHYROIDISM IN A NEONATE
SIR,-We have seen a baby in whom myocarditis, meningitis, and transient hypoparathyroidism were associated with a Coxsackie B virus infection. A girl was born on May 10, 1979, at term, to healthy, unrelated parents. Birthweight was 2-6 kg and there were no dysmorphic features. The mother had had pyrexia and pharyngitis, unresponsive to antibiotics, for 3 days before and 2 days after delivery. The baby remained well until the fifth day when fever (38 -2°C) was noted without other clinical signs of infection. Within 24 h cardiac failure developed, with tachycardia, tachypnoea, and increasing liver size, which responded rapidly to digoxin and diuretics. A 3/6 pansystolic murmur was heard. The white cell count was 14-8x10/1 (55% neutrophils, 40% lymphocytes, 4% monocytes, 1% eosinophils). 12 h later the baby began to have multifocal clonic convulsions and was found to be profoundly hypocalcaemic and hypomagnesaemic (serum calcium 1-15 mmol/1, serum magnesium 0-4 mmol/1), and her phosphate was only 1 -68 mmol/l. The CSF contained 21 cellsll (all lymphocytes) and 6 red blood cells (normal range in neonate WBC <14x 106/1); there was insufficient material for protein or sugar estimations. Bacterial cultures of nose, throat, umbilicus, eye, blood, urine, and CSF were negative. Coxsackievirus type B4 was grown in tissue culture from the CSF and faeces. Serum neutralising antibody titres 2. Yunus M, Kalyanaraman UP, Kalyanaraman K, Masi AT, Berg BC. Microscopic and radioactive bone scan studies in primary fibromyalgia: Abstracts of VIII Pan-
American Congress of Rheumatology
Arthritis Rheum
1982; 25: (no 4) suppl: S146.