Dr. Huntley's
Diagnosis
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Fasciculations are local muscle contractions representing the spontaneous discharge of a muscle fiber bundle innervated by a single motor nerve filament. These contractions cause visible dimpling or wavelike twitching of the skin, but they aren’t strong enough to cause a joint to move. They occur irregularly at frequencies ranging from once every several seconds to two or three times per second; infrequently, myokymia — continuous, rapid fasciculations that cause a rippling effect — may occur. Because fasciculations are brief and painless, they commonly go undetected or are ignored.
Benign, nonpathologic fasciculations are common and normal. They typically occur in tense, anxious, or overtired people and typically affect the eyelid, thumb, or calf. However, fasciculations may also indicate a severe neurologic disorder, most notably a diffuse motor neuron disorder that causes loss of control over muscle fiber discharge. They’re also an early sign of pesticide poisoning.
Begin by asking the patient about the nature, onset, and duration of the fasciculations. If the onset was sudden, ask about precipitating events such as exposure to pesticides. Pesticide poisoning, although uncommon, is a medical emergency requiring prompt and vigorous intervention. You may need to maintain airway patency, monitor the patient’s vital signs, give oxygen, and perform gastric lavage or induce vomiting.
If the patient isn’t in severe distress, find out if he has experienced sensory changes, such as paresthesia, or any difficulty speaking, swallowing, breathing, or controlling bowel or bladder function. Ask him if he’s in pain.
Explore the patient’s medical history for neurologic disorders, cancer, and recent infections. Also, ask him about his lifestyle, especially stress at home, on the job, or at school.
Ask the patient about his dietary habits and for a recall of his food and fluid intake in the recent past because electrolyte imbalances may also cause muscle twitching.
Perform a physical examination, looking for fasciculations while the affected muscle is at rest. Observe and test for motor and sensory abnormalities, particularly muscle atrophy and weakness, and decreased deep tendon reflexes. If you note these signs and symptoms, suspect motor neuron disease, and perform a comprehensive neurologic examination.
Coarse fasciculations usually begin in the small muscles of the hands and feet, and then spread to the forearms and legs. Widespread, symmetrical muscle atrophy and weakness may result in dysarthria; difficulty chewing, swallowing, and breathing; and, occasionally, choking and drooling.
Fasciculations of the face and tongue commonly appear early. Progressive signs and symptoms include dysarthria, dysphagia, hoarseness, and drooling. Eventually, weakness spreads to the respiratory muscles.
Coarse fasciculations, usually transient but occasionally persistent, accompany progressive muscle weakness, spasms, and atrophy. The patient may also exhibit decreased reflexes, paresthesia, coldness and cyanosis in the affected limbs, bladder paralysis, dyspnea, elevated blood pressure, and tachycardia.
Fasciculations may develop along with muscle atrophy and cramps, asymmetrically at first and then bilaterally as cord compression progresses. Motor and sensory changes distal to the tumor include weakness or paralysis, areflexia, paresthesia, and a tightening band of pain. Bowel and bladder control may be lost.
Ingestion of organophosphate or carbamate pesticides commonly produces an acute onset of long, wavelike fasciculations and muscle weakness that rapidly progresses to flaccid paralysis. Other common effects include nausea, vomiting, diarrhea, loss of bowel and bladder control, hyperactive bowel sounds, and abdominal cramping. Cardiopulmonary findings include bradycardia, dyspnea or bradypnea, and pallor or cyanosis. Seizures, visual disturbances (pupillary constriction or blurred vision), and increased secretions (tearing, salivation, pulmonary secretions, or diaphoresis) may also occur.
Prepare the patient for diagnostic studies, such as spinal X-rays, myelography, a computed tomography scan, magnetic resonance imaging, and electromyography with nerve conduction velocity tests. Prepare the patient for laboratory tests such as serum electrolyte levels. Help the patient with progressive neuromuscular degeneration to cope with activities of daily living, and provide appropriate assistive devices.
Fasciculations, particularly of the tongue, are an important early sign of Werdnig-Hoffmann disease.
Read excerpts from these other book chapters related to Seizures:
Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.
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More About This Book:
Title: Handbook of Signs & Symptoms (Third Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-402-1 
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