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which was interpreted as indicative of glycogenosis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Biochemical investigations revealed normal activity of respiratory chain complexes&#46; Visually evoked potentials were noninformative&#46; Echocardiography was indicative of hypertrophic cardiomyopathy&#44; the left ventricular myocardium having abnormal texture&#46; The 24-hour ECG was normal&#46; In 2004 &#40;at age 48&#41; he presented with mild dysarthria and clinical myotonia but no muscle weakness&#46; This time needle EMG revealed myotonic discharges in the thenar muscles&#46; MD1 was diagnosed genetically on detection of a heterozygous CTG repeat expansion of 500&#46; Colonoscopy in 2006 &#40;age 49 years&#41; revealed a cecal tubular adenoma and gastroscopy in 2008 &#40;at age 52&#41; revealed Barrett esophagus&#46; He died suddenly during an episode of syncope in 2009 at age 52&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Three sisters &#40;II&#47;3&#44; II&#47;4&#44; and II&#47;5&#41; were also affected&#46; One sister &#40;II&#47;3&#41; manifested marked myotonia and died suddenly during sleep at age 45&#46; A second &#40;II&#47;4&#41; developed quadriparesis requiring a wheelchair&#44; and experienced a spontaneous rupture of the intestines&#44; dying from septic complications at age 52&#46; In both these sisters &#40;II&#47;3 and II&#47;4&#41; the diagnosis was genetically confirmed but detailed results are no longer available&#46; A third sister &#40;II&#47;5&#41; experienced recurrent syncopes of unknown cause but without other symptoms or signs and committed suicide for unknown reasons at age 40&#46; The 64-year-old fourth sister &#40;II&#47;6&#41; had a history of recurrent hyperCKemia&#44; hypothyroidism&#44; endometriosis&#44; hypertension&#44; and right-sided foot extensor weakness since at least the age of 55 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; The mother of these seven children &#40;I&#47;2&#41; required treatment for high blood pressure&#46; She experienced myocardial rupture leading to sudden cardiac death &#40;SCD&#41;&#46; The father &#40;I&#47;1&#41; of the seven was symptom-free but died from lymphoma&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">The presented family with MD1 is interesting for several reasons&#46; Firstly&#44; the index patient had a CTG repeat expansion &#60;100 and manifested exclusively with cardiogenic syncope and hyperCKemia&#46; Patients with 50&#8211;100 CTG repeats are frequently asymptomatic or develop only mild manifestations such as cataract&#44; ptosis&#44; or clinical myotonia&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1&#44;2</span></a> If these patients become symptomatic&#44; onset is later in life&#44; at ages ranging between 20 and 70 years&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> In a systematic study of 102 MD1 patients with small CTG expansions &#40;50&#8211;99 CTG repeats&#41;&#44; most patients were asymptomatic&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> Those who were symptomatic had developed cataracts&#44; myotonia&#44; excessive daytime sleepiness&#44; or myotonic discharges on needle EMG&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> None of these patients had developed cardiac symptoms&#44; but ECG abnormalities were recorded in 21&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> In an 11-year-old girl with a CTG expansion of 91 repeats&#44; MD1 manifested as myopathy&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> and a Japanese male with 60&#8211;70 CTG repeats developed mild weakness of the sternocleidomastoid muscle at age 66&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> In a study of 14 MD1 patients two had &#60;100 CTG repeats&#44; both of whom manifested with cataract and mild myotonia&#46; Both had reduced myocardial Doppler velocities but no cardiac symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> Only in patients with small expansions is there a negative correlation between expansion size and age at onset&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Secondly&#44; presumably cardiac manifestations of MD1 resulted in the sudden death of two family members &#40;II&#47;2 and II&#47;3&#41;&#46; In patient II&#47;2 no syncope had occurred until the one during which he died&#46; Patient II&#47;5 was living in Switzerland&#44; which is why no information about the cause of her recurrent syncopes was available&#44; but she did not have a central nervous system disorder&#46; Since cerebral causes of syncope were largely excluded in all three sibs with syncope or SCD&#44; the syncopes were attributed to a cardiac rather than a neurologic cause&#46; Most likely&#44; syncopes in patients II&#47;1&#44; II&#47;2&#44; and II&#47;5 are attributable to cardiac arrhythmias&#44; although confirmation by standard or long-term ECG is lacking&#46; However&#44; even small CTG expansions of 60&#8211;70 repeats may manifest with ECG abnormalities&#44; such as an increased His-ventricular interval&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Thirdly&#44; the brother in whom MD1 was first diagnosed in this family &#40;II&#47;2&#41; did not present with a myopathic face&#44; frontal baldness&#44; or limb weakness at onset and did not show spontaneous activity at any of the sites investigated on needle EMG&#46; His difficulties in closing his mouth properly in 1998 may have been the beginning of facial manifestations&#44; but he developed typical clinical features of MD1 during the following six years&#46; Late onset of clinical manifestations &#40;at the age of 35&#41; and absence of a typical myopathic face may also be due to the relatively small CTG expansion in this patient&#46; Absence of myotonic or pseudomyotonic discharges on EMG is not unusual and may depend on the recording site and disease duration&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Fourthly&#44; muscle biopsy in the brother &#40;II&#47;2&#41; of the index patient &#40;II&#47;1&#41; revealed a marked increase in glycogen deposition&#44; which is an unusual finding&#46; Though increased lipid deposition has been occasionally reported in MD1&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> increased glycogen deposition is rare&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> Granula containing glycogen seem to be particularly increased in patients with congenital MD1&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> Interpretation of the muscle biopsy as indicative of glycogenosis was misleading and delayed the correct diagnosis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">This case shows that MD1 with &#60;100 CTG repeats may exclusively manifest cardiologically&#44; that family screening for MD1 is important even in asymptomatic patients&#44; and that MD1 may initially manifest with atypical clinical features&#46; Muscle biopsy in MD1 may be misleading and may indicate glycogenosis&#46; Close cardiac follow-up is important if MD1 manifests cardiologically to prevent syncope or SCD&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Protection of human and animal subjects</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Confidentiality of data</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Right to privacy and informed consent</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            0 => "Trinucleotide disorder"
            1 => "Curschman-Steinert disease"
            2 => "Myotonic dystrophy"
            3 => "Cardiac involvement"
            4 => "Ventricular arrhythmias"
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            0 => "Perturba&#231;&#227;o trinucleotide"
            1 => "Doen&#231;a de Curshman-Steinert"
            2 => "Distrofia miot&#243;nica"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Syncope and palpitations as the only initial manifestations of myotonic dystrophy type 1 &#40;MD1&#41; due to a CTG expansion of 50&#8211;100 repeats have not been reported&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case report</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In a 55-year-old female with a family history of MD1 and a personal history of a single syncope&#44; palpitations&#44; and hyperCKemia&#44; 70 CTG repeats were detected in the <span class="elsevierStyleItalic">DMPK</span> gene&#46; Her brother had presented atypical clinical&#44; electromyographic&#44; and muscle biopsy features since the age of 35 but had been diagnosed with MD1 after he later developed typical distal myotonia&#46; He died suddenly during an episode of syncope at the age of 53&#46; A sister with clinical myotonia died suddenly during sleep at the age of 45 and a second sister with quadriparesis died from complications of intestinal rupture at age 52&#46; A third sister committed suicide at age 40 after developing recurrent syncopes&#44; while a fourth sister had hyperCKemia and foot-extensor weakness&#46; The mother of these five affected children died suddenly from myocardial rupture&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">MD1 with &#60;100 CTG repeats may exclusively manifest cardiologically&#46; Family screening for MD1 is important even in asymptomatic patients&#46; MD1 may initially manifest without typical features&#44; while muscle biopsy may be misleading and indicate glycogenosis&#46; Close cardiac follow-up is important if MD1 manifests cardiologically to prevent syncope or sudden cardiac death&#46;</p></span>"
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        "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introdu&#231;&#227;o</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Na distrofia miot&#243;nica tipo 1 &#40;DM1&#41; devido a expans&#227;o CTG 50-100 n&#227;o foram reportadas at&#233; ao momento s&#237;ncope e palpita&#231;&#245;es como manifesta&#231;&#245;es iniciais da mesma&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Caso cl&#237;nico</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Numa mulher de 55 anos com hist&#243;ria familiar de DM 1 e antecedentes de um &#250;nico epis&#243;dio s&#237;ncopal&#44; palpita&#231;&#245;es e hiper CKemia&#44; foi detetada uma expans&#227;o de <span class="elsevierStyleItalic">CTG-repeat</span> de 70 no gene DMPK&#46; O irm&#227;o apresentava desde os 35 anos caracter&#237;sticas cl&#237;nicas&#44; eletromiogr&#225;ficas e nas bi&#243;psias musculares at&#237;picas tendo-lhe sido diagnosticada DM 1 ap&#243;s ter desenvolvido mais tarde miotonia distal t&#237;pica&#46; Morreu subitamente no contexto duma s&#237;ncope aos 53 anos&#46; Uma irm&#227; com miotonia cl&#237;nica morreu subitamente aos 45 anos durante o sono&#46; Uma segunda irm&#227; com quadriparesia morreu de complica&#231;&#245;es de rotura do intestino aos 52 anos&#46; Uma terceira irm&#227; cometeu suic&#237;dio aos 40 anos ap&#243;s ter desenvolvido s&#237;ncopes recorrentes&#46; Uma quarta irm&#227; tinha hiper CKemia e fraqueza muscular nos p&#233;s&#46; A m&#227;e destes 5 filhos afetados morreu subitamente de rotura do mioc&#225;rdio&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclus&#227;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A DM1 com CTG-repeat expans&#227;o &#60; 100 pode manifestar-se exclusivamente do ponto de vista cardiol&#243;gico&#46; O rastreio familiar para DM1 &#233; importante mesmo nos doentes assintom&#225;ticos&#46; A DM1 pode manifestar-se inicialmente sem caracter&#237;sticas t&#237;picas de DM1&#46; A bi&#243;psia muscular na DM1 pode ser enganadora e indicar glicogenose&#46; Um seguimento card&#237;aco rigoroso &#233; importante se a DM1 se manifesta sob o ponto de vista cardiol&#243;gico para prevenir a s&#237;ncope ou morte s&#250;bita&#46;</p></span>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Pedigree of the presented family&#46; CK&#58; creatine kinase&#59; SCD&#58; sudden cardiac death&#59; y&#58; years&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Neuropathology of the muscle biopsy&#46; H&#38;E staining &#40;A&#41; shows discrete fiber size variation&#44; fiber splitting and internalized nuclei&#59; Oil-red-O staining &#40;B&#41; shows increased lipid accumulation&#59; PAS-staining &#40;C&#41; shows storage of excess glycogen&#59; Excess glycogen deposits are also detectable at an ultrastructural level within and between the fibers &#40;A-C&#41; &#215;20 magnification &#40;D&#41; &#215; 3000 magnification&#46;</p>"
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Case report
Syncope and hyperCKemia as minimal manifestations of short CTG repeat expansions in myotonic dystrophy type 1
Síncope e hiper CKemia como manifestações mínimas de expansões short CTG-repeat na distrofia miotónica 1
Josef Finsterer
Corresponding author
fifigs1@yahoo.de

Corresponding author.
, Claudia Stöllberger, Martin Gencik, Romana Höftberger, Jasmin Rahimi, Johannes Mokocki
Kar Vienna, Vienna, Austria
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    "titulo" => "Syncope and hyperCKemia as minimal manifestations of short CTG repeat expansions in myotonic dystrophy type 1"
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        "autoresLista" => "Josef Finsterer, Claudia St&#246;llberger, Martin Gencik, Romana H&#246;ftberger, Jasmin Rahimi, Johannes Mokocki"
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        "titulo" => "S&#237;ncope e hiper CKemia como manifesta&#231;&#245;es m&#237;nimas de expans&#245;es <span class="elsevierStyleItalic">short CTG-repeat</span> na distrofia miot&#243;nica 1"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Neuropathology of the muscle biopsy&#46; H&#38;E staining &#40;A&#41; shows discrete fiber size variation&#44; fiber splitting and internalized nuclei&#59; Oil-red-O staining &#40;B&#41; shows increased lipid accumulation&#59; PAS-staining &#40;C&#41; shows storage of excess glycogen&#59; Excess glycogen deposits are also detectable at an ultrastructural level within and between the fibers &#40;A-C&#41; &#215;20 magnification &#40;D&#41; &#215; 3000 magnification&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Clinical manifestations in patients with myotonic dystrophy type 1 &#40;MD1&#41; carrying a CTG expansion of 50&#8211;100 repeats are usually mild and include ptosis or cataract&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1&#8211;3</span></a> Syncope has occasionally been described as a manifestation of MD1<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">4&#44;5</span></a> but syncope and palpitations as the only initial manifestations of MD1 due to a CTG expansion of 50&#8211;100 repeats have not been reported&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">The index patient &#40;II&#47;1&#41; is a 55-year-old female&#44; height 165 cm&#44; weight 58 kg&#44; with a history of a single syncope four years earlier and recurrent early morning palpitations since then&#44; treated by beta-blockers &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; She had a family history of MD1 and was referred for assessment of genetic status&#46; She reported daytime sleepiness but her clinical neurologic and cardiological exam was completely normal&#46; Blood tests&#44; however&#44; revealed hyperCKemia of 264 U&#47;l &#40;normal 26&#8211;145 U&#47;l&#41;&#46; Work-up for the syncope in 2014&#44; including cerebral magnetic resonance imaging&#44; carotid ultrasound&#44; and electroencephalogram&#44; was normal&#46; Cardiologic examination including telemetry and echocardiography was uninformative&#46; On standard ECG incomplete right bundle branch block was recorded once&#46; Genetic testing by PCR revealed a heterozygous CTG expansion of 70 repeats in the <span class="elsevierStyleItalic">DMPK</span> gene&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Her family history was noteworthy for at least five sibs affected out of a total of six &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Her brother &#40;II&#47;2&#41; manifested at onset in 1991 &#40;age 35&#41; with reduced motility of the tongue and difficulty with chewing and closing his mouth&#46; Following these abnormalities he developed myotonia of both hands&#44; daytime sleepiness&#44; easy fatigability&#44; and adynamia&#46; Starting in 1998 &#40;age 42&#41; he reported permanent tiredness and aching muscles after exercise&#46; A clinical neurologic exam at that time revealed wasting of the tongue edges&#44; tongue fasciculations&#44; clinical myotonia&#44; and wasting of the thighs&#46; Blood tests revealed hyperlipidemia&#44; mild hyperCKemia of 204 U&#47;l &#40;normal &#60;172 U&#47;l&#41;&#44; and mild elevation of gamma-glutamyl-transpeptidase &#40;57 U&#47;l&#59; normal &#60;55 U&#47;l&#41;&#46; Ischemic exercise testing and lactate stress testing were normal&#46; Needle electromyography &#40;EMG&#41; showed marked myopathic alterations but no spontaneous activity&#46; Muscle biopsy revealed a myopathic syndrome with accumulation of fat and particularly glycogen&#44; which was interpreted as indicative of glycogenosis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Biochemical investigations revealed normal activity of respiratory chain complexes&#46; Visually evoked potentials were noninformative&#46; Echocardiography was indicative of hypertrophic cardiomyopathy&#44; the left ventricular myocardium having abnormal texture&#46; The 24-hour ECG was normal&#46; In 2004 &#40;at age 48&#41; he presented with mild dysarthria and clinical myotonia but no muscle weakness&#46; This time needle EMG revealed myotonic discharges in the thenar muscles&#46; MD1 was diagnosed genetically on detection of a heterozygous CTG repeat expansion of 500&#46; Colonoscopy in 2006 &#40;age 49 years&#41; revealed a cecal tubular adenoma and gastroscopy in 2008 &#40;at age 52&#41; revealed Barrett esophagus&#46; He died suddenly during an episode of syncope in 2009 at age 52&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Three sisters &#40;II&#47;3&#44; II&#47;4&#44; and II&#47;5&#41; were also affected&#46; One sister &#40;II&#47;3&#41; manifested marked myotonia and died suddenly during sleep at age 45&#46; A second &#40;II&#47;4&#41; developed quadriparesis requiring a wheelchair&#44; and experienced a spontaneous rupture of the intestines&#44; dying from septic complications at age 52&#46; In both these sisters &#40;II&#47;3 and II&#47;4&#41; the diagnosis was genetically confirmed but detailed results are no longer available&#46; A third sister &#40;II&#47;5&#41; experienced recurrent syncopes of unknown cause but without other symptoms or signs and committed suicide for unknown reasons at age 40&#46; The 64-year-old fourth sister &#40;II&#47;6&#41; had a history of recurrent hyperCKemia&#44; hypothyroidism&#44; endometriosis&#44; hypertension&#44; and right-sided foot extensor weakness since at least the age of 55 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; The mother of these seven children &#40;I&#47;2&#41; required treatment for high blood pressure&#46; She experienced myocardial rupture leading to sudden cardiac death &#40;SCD&#41;&#46; The father &#40;I&#47;1&#41; of the seven was symptom-free but died from lymphoma&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">The presented family with MD1 is interesting for several reasons&#46; Firstly&#44; the index patient had a CTG repeat expansion &#60;100 and manifested exclusively with cardiogenic syncope and hyperCKemia&#46; Patients with 50&#8211;100 CTG repeats are frequently asymptomatic or develop only mild manifestations such as cataract&#44; ptosis&#44; or clinical myotonia&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1&#44;2</span></a> If these patients become symptomatic&#44; onset is later in life&#44; at ages ranging between 20 and 70 years&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> In a systematic study of 102 MD1 patients with small CTG expansions &#40;50&#8211;99 CTG repeats&#41;&#44; most patients were asymptomatic&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> Those who were symptomatic had developed cataracts&#44; myotonia&#44; excessive daytime sleepiness&#44; or myotonic discharges on needle EMG&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> None of these patients had developed cardiac symptoms&#44; but ECG abnormalities were recorded in 21&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> In an 11-year-old girl with a CTG expansion of 91 repeats&#44; MD1 manifested as myopathy&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> and a Japanese male with 60&#8211;70 CTG repeats developed mild weakness of the sternocleidomastoid muscle at age 66&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> In a study of 14 MD1 patients two had &#60;100 CTG repeats&#44; both of whom manifested with cataract and mild myotonia&#46; Both had reduced myocardial Doppler velocities but no cardiac symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> Only in patients with small expansions is there a negative correlation between expansion size and age at onset&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Secondly&#44; presumably cardiac manifestations of MD1 resulted in the sudden death of two family members &#40;II&#47;2 and II&#47;3&#41;&#46; In patient II&#47;2 no syncope had occurred until the one during which he died&#46; Patient II&#47;5 was living in Switzerland&#44; which is why no information about the cause of her recurrent syncopes was available&#44; but she did not have a central nervous system disorder&#46; Since cerebral causes of syncope were largely excluded in all three sibs with syncope or SCD&#44; the syncopes were attributed to a cardiac rather than a neurologic cause&#46; Most likely&#44; syncopes in patients II&#47;1&#44; II&#47;2&#44; and II&#47;5 are attributable to cardiac arrhythmias&#44; although confirmation by standard or long-term ECG is lacking&#46; However&#44; even small CTG expansions of 60&#8211;70 repeats may manifest with ECG abnormalities&#44; such as an increased His-ventricular interval&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Thirdly&#44; the brother in whom MD1 was first diagnosed in this family &#40;II&#47;2&#41; did not present with a myopathic face&#44; frontal baldness&#44; or limb weakness at onset and did not show spontaneous activity at any of the sites investigated on needle EMG&#46; His difficulties in closing his mouth properly in 1998 may have been the beginning of facial manifestations&#44; but he developed typical clinical features of MD1 during the following six years&#46; Late onset of clinical manifestations &#40;at the age of 35&#41; and absence of a typical myopathic face may also be due to the relatively small CTG expansion in this patient&#46; Absence of myotonic or pseudomyotonic discharges on EMG is not unusual and may depend on the recording site and disease duration&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Fourthly&#44; muscle biopsy in the brother &#40;II&#47;2&#41; of the index patient &#40;II&#47;1&#41; revealed a marked increase in glycogen deposition&#44; which is an unusual finding&#46; Though increased lipid deposition has been occasionally reported in MD1&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> increased glycogen deposition is rare&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> Granula containing glycogen seem to be particularly increased in patients with congenital MD1&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> Interpretation of the muscle biopsy as indicative of glycogenosis was misleading and delayed the correct diagnosis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">This case shows that MD1 with &#60;100 CTG repeats may exclusively manifest cardiologically&#44; that family screening for MD1 is important even in asymptomatic patients&#44; and that MD1 may initially manifest with atypical clinical features&#46; Muscle biopsy in MD1 may be misleading and may indicate glycogenosis&#46; Close cardiac follow-up is important if MD1 manifests cardiologically to prevent syncope or SCD&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Protection of human and animal subjects</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Confidentiality of data</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Right to privacy and informed consent</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Syncope and palpitations as the only initial manifestations of myotonic dystrophy type 1 &#40;MD1&#41; due to a CTG expansion of 50&#8211;100 repeats have not been reported&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case report</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In a 55-year-old female with a family history of MD1 and a personal history of a single syncope&#44; palpitations&#44; and hyperCKemia&#44; 70 CTG repeats were detected in the <span class="elsevierStyleItalic">DMPK</span> gene&#46; Her brother had presented atypical clinical&#44; electromyographic&#44; and muscle biopsy features since the age of 35 but had been diagnosed with MD1 after he later developed typical distal myotonia&#46; He died suddenly during an episode of syncope at the age of 53&#46; A sister with clinical myotonia died suddenly during sleep at the age of 45 and a second sister with quadriparesis died from complications of intestinal rupture at age 52&#46; A third sister committed suicide at age 40 after developing recurrent syncopes&#44; while a fourth sister had hyperCKemia and foot-extensor weakness&#46; The mother of these five affected children died suddenly from myocardial rupture&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">MD1 with &#60;100 CTG repeats may exclusively manifest cardiologically&#46; Family screening for MD1 is important even in asymptomatic patients&#46; MD1 may initially manifest without typical features&#44; while muscle biopsy may be misleading and indicate glycogenosis&#46; Close cardiac follow-up is important if MD1 manifests cardiologically to prevent syncope or sudden cardiac death&#46;</p></span>"
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        "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introdu&#231;&#227;o</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Na distrofia miot&#243;nica tipo 1 &#40;DM1&#41; devido a expans&#227;o CTG 50-100 n&#227;o foram reportadas at&#233; ao momento s&#237;ncope e palpita&#231;&#245;es como manifesta&#231;&#245;es iniciais da mesma&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Caso cl&#237;nico</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Numa mulher de 55 anos com hist&#243;ria familiar de DM 1 e antecedentes de um &#250;nico epis&#243;dio s&#237;ncopal&#44; palpita&#231;&#245;es e hiper CKemia&#44; foi detetada uma expans&#227;o de <span class="elsevierStyleItalic">CTG-repeat</span> de 70 no gene DMPK&#46; O irm&#227;o apresentava desde os 35 anos caracter&#237;sticas cl&#237;nicas&#44; eletromiogr&#225;ficas e nas bi&#243;psias musculares at&#237;picas tendo-lhe sido diagnosticada DM 1 ap&#243;s ter desenvolvido mais tarde miotonia distal t&#237;pica&#46; Morreu subitamente no contexto duma s&#237;ncope aos 53 anos&#46; Uma irm&#227; com miotonia cl&#237;nica morreu subitamente aos 45 anos durante o sono&#46; Uma segunda irm&#227; com quadriparesia morreu de complica&#231;&#245;es de rotura do intestino aos 52 anos&#46; Uma terceira irm&#227; cometeu suic&#237;dio aos 40 anos ap&#243;s ter desenvolvido s&#237;ncopes recorrentes&#46; Uma quarta irm&#227; tinha hiper CKemia e fraqueza muscular nos p&#233;s&#46; A m&#227;e destes 5 filhos afetados morreu subitamente de rotura do mioc&#225;rdio&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclus&#227;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A DM1 com CTG-repeat expans&#227;o &#60; 100 pode manifestar-se exclusivamente do ponto de vista cardiol&#243;gico&#46; O rastreio familiar para DM1 &#233; importante mesmo nos doentes assintom&#225;ticos&#46; A DM1 pode manifestar-se inicialmente sem caracter&#237;sticas t&#237;picas de DM1&#46; A bi&#243;psia muscular na DM1 pode ser enganadora e indicar glicogenose&#46; Um seguimento card&#237;aco rigoroso &#233; importante se a DM1 se manifesta sob o ponto de vista cardiol&#243;gico para prevenir a s&#237;ncope ou morte s&#250;bita&#46;</p></span>"
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Revista Portuguesa de Cardiologia (English edition)
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