LETTER TO THE EDITOR
|Year : 2021 | Volume
| Issue : 2 | Page : 173-174
Bilateral calf hypertrophy and isolated motor delay: think beyond muscular dystrophy
Ijas Hassan1, Singanamalla Bhanudeep1, Priyanka Madaan2, Monika Chhajed3, Lokesh Saini1
1 Pediatric Neurology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
2 Pediatric Neurology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India; Council of Scientific and Industrial Research, CSIR Complex, Library Avenue, Pusa, New Delhi, India
3 Chaitanya Hospital, Chandigarh, India
|Date of Submission||26-Jun-2020|
|Date of Acceptance||22-Oct-2020|
|Date of Web Publication||02-Jul-2021|
Dr. Lokesh Saini
Pediatric Neurology Unit, Department of Pediatrics, Advanced Pediatric Centre, Post Graduate Institute of Medical Education and Research, Chandigarh.
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Hassan I, Bhanudeep S, Madaan P, Chhajed M, Saini L. Bilateral calf hypertrophy and isolated motor delay: think beyond muscular dystrophy. J Pediatr Neurosci 2021;16:173-4
A 7-year-old boy presented with isolated motor development delay and toe-walking. He was born preterm (32 weeks), appropriate for gestational age and the rest of the antenatal and perinatal history was noncontributory. He could walk independently but had difficulty while running. He had no difficulty in getting up from the floor or climbing stairs. There was no history suggestive of involvement of neck, bulbar, facial, and proximal muscles of the upper limbs. Examination revealed normal head circumference, bilateral calf hypertrophy [Figure 1], and hyperreflexia at both knees with fixed contractures of bilateral ankles with an average intelligence quotient. He did not have an evident spasticity at joints (besides ankle with fixed contractures). A clinical diagnosis of spastic diplegia was confirmed. Neuroimaging revealed altered periventricular and peritrigonal white matter signal intensities suggestive of periventricular leukomalacia. Creatine kinase levels were within normal limits.
|Figure 1: Calf hypertrophy. The figure showing bilateral calf hypertrophy of lower limbs|
Click here to view
Spastic cerebral palsy (CP) is a group of nonprogressive motor disorder resulting from an insult to the growing brain. Children with spastic diplegic CP have a reduced medial gastrocnemius volume, which contributes to muscle weakness and loss of motor function., However, in some children, the calf muscles might undergo hypertrophy. The calf hypertrophy in children with spastic CP is due to the accumulation of hydroxyproline (aminoacid exclusive to collagen) in and around the perimysium and endomysium of the muscles. The synthesis of collagen depends on the neuronal activity, which brings changes in the structural and skeletal architecture of the skeletal muscles in children with spastic diplegia. The amount of collagen deposited correlates well with the severity of the disorder and plays a role in the development of contractures by forming cross-links.,
Bilateral calf hypertrophy (absolute/relative) has been typically described in neuromuscular disorders such as Duchenne and Becker muscular dystrophies, Spinal muscular atrophy (IIIa/IIIb), Pompe disease, sarcoglycanopathies, congenital muscular dystrophies, etc. It may rarely be seen in children with vitamin D deficiency, celiac disease, and autism spectrum disorders (secondary to habitual toe-walking) and as a physiological variant in athletic adolescents. Illustration of calf hypertrophy is usually based on subjective visual assessment, and it largely relies on the clinician’s experience. Therefore, it should be interpreted meticulously with respect to history to give it real meaning. Clinicians should be aware of this fact and should not give undue importance to this finding in a child with gait difficulties and rather plan their subsequent investigations based on history and rest of the examination.
IH and BS: Involved in patient care, conducted the literature review, and prepared the initial draft of the article. LS: Involved in patient care, critically reviewed the article, and provided intellectual input. PM and MC: Involved in patient care and helped in literature review.
This article was approved by the Departmental Review Board.
The authors thank the parents of the patient for pictures and for adding to the literature.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Barber L, Hastings-Ison T, Baker R, Barrett R, Lichtwark G. Medial gastrocnemius muscle volume and fascicle length in children aged 2 to 5 years with cerebral palsy. Dev Med Child Neurol 2011;53:543-8.
Fry NR, Gough M, McNee AE, Shortland AP. Changes in the volume and length of the medial gastrocnemius after surgical recession in children with spastic diplegic cerebral palsy. J Pediatr Orthop 2007;27:769-74.
Booth CM, Cortina-Borja MJ, Theologis TN. Collagen accumulation in muscles of children with cerebral palsy and correlation with severity of spasticity. Dev Med Child Neurol 2001;43:314-20.
Reimers CD, Schlotter B, Eicke BM, Witt TN. Calf enlargement in neuromuscular diseases: A quantitative ultrasound study in 350 patients and review of the literature. J Neurol Sci 1996;143:46-56.