High CK Research Articles

A large‐scale nationwide newborn screening program for pompe disease in Taiwan: Towards effective diagnosis and treatment

The aim of this study was to: (a) analyze the results of a large-scale newborn screening program for Pompe disease, and (b) establish an effective diagnostic protocol to obtain immediate, valid diagnosis of infantile-onset Pompe disease (IOPD) to promote earlier treatment and better outcomes. In this study, 402,281 newborns were screened for Pompe disease from January 1, 2008 to May 1, 2012. Infants with low acid α-glucosidase (GAA) activity were referred to Taipei Veterans General Hospital for diagnostic confirmation. Physical examination, biochemical parameter (creatine kinase [CK], alanine transaminase, aspartate aminotransferase, and lactate dehydrogenase), and echocardiogram assessments were performed immediately to effectively differentiate IOPD from suspected late-onset Pompe disease (LOPD) or false-positive cases with pseudodeficiency mutation. Six infants with IOPD all presented with hypotonia, extremely low GAA enzyme activity (≤0.5 µmol/L/hr) in initial dried blood spot analysis, high CK (≥250 U/L), and high left ventricular mass index (LVMI, ≥80 g/m(2)). By analyzing these parameters, IOPD was distinguished effectively and immediately from suspected LOPD and false-positive cases. Except for the first referred case, five of the infants with IOPD received first-time enzyme replacement therapy (ERT) within 4 hr of admission and exhibited marked improvement. Our findings indicate that certain clinical manifestations (hypotonia, high CK, enlarged LVMI, and extremely low GAA enzyme activity in initial dried blood spot analysis) can help in the rapid and effective differentiation of patients with IOPD from other patient with low GAA activity. Such differentiation allows for the early application of first-time ERT and leads to better outcomes.

Regulation of hormonal responses of sweet pepper as affected by salinity and elevated CO2 concentration

This study examines the extent to which the predicted CO2 -protective effects on the inhibition of growth, impairment of photosynthesis and nutrient imbalance caused by saline stress are mediated by an effective adaptation of the endogenous plant hormonal balance. Therefore, sweet pepper plants (Capsicum annuum, cv. Ciclón) were grown at ambient or elevated [CO2] (400 or 800 µmol mol(-1)) with a nutrient solution containing 0 or 80 mM NaCl. The results show that, under saline conditions, elevated [CO2] increased plant dry weight, leaf area, leaf relative water content and net photosynthesis compared with ambient [CO2], whilst the maximum potential quantum efficiency of photosystem II was not modified. In salt-stressed plants, elevated [CO2 ] increased leaf NO3(-) concentration and reduced Cl(-) concentration. Salinity stress induced ABA accumulation in the leaves but it was reduced in the roots at high [CO2], being correlated with the stomatal response. Under non-stressed conditions, IAA was dramatically reduced in the roots when high [CO2] was applied, which resulted in greater root DW and root respiration. Additionally, the observed high CK concentration in the roots (especially tZR) could prevent downregulation of photosynthesis at high [CO2], as the N level in the leaves was increased compared with the ambient [CO2], under salt-stress conditions. These results demonstrate that the hormonal balance was altered by the [CO2], which resulted in significant changes at the growth, gas exchange and nutritional levels.

ELEVATED CREATINE KINASE SUGGESTS BETTER PROGNOSIS IN PATIENTS WITH AMYOTROPHIC LATERAL SCLEROSIS

BackgroundCreatine kinase (CK) is an enzyme found in skeletal muscles, myocardium and brain (CK–MM, CK–MB, and CK–BB isoenzymes respectively). In these tissues with high energy requirements, CK catalyses conversion of...

P.14.7 Anti-SRP antibody induces muscle cell lysis through complement mediated pathway

The signal recognition particle (SRP), an intracytoplasmic complex of ribonucleoprotein, binds to the endoplasmic reticulum (ER) localising signal sequences of elongating polypeptide chains during their synthesis and translocates nascent peptides to the ER membrane. Anti-SRP antibodies to one or more of the components have been associated with a necrotising autoimmune myopathy (NAM) characterised by severe subacute progressive proximal muscle weakness with very high serum CK levels. The muscle biopsies from such patients show abundant necrotic and regenerating fibres but only a sparse inflammatory infiltrate. These findings suggest that cytotoxic T cells and cell-mediated muscle fibre destruction are not involved. The possibility of a humoral mechanism has been proposed but this has not been investigated. In the present study, we utilised an in vitro human myoblast culture system to investigate a possible antibody-mediated cytotoxic mechanism of cell death. Anti-SRP positive sera from NAM patients or anti-SRP negative sera from healthy controls were incubated with myoblasts in the presence or absence of fresh complement. In the absence of complement, there was no difference in cell viability between two groups. In contrast, when complement was added, the survival of myoblasts incubated with anti-SRP positive serum was significantly reduced compared to cultures incubated with anti-SRP negative sera. In anti-SRP positive sera, we also observed complement deposition onto the membrane of normal human myoblast. Complement deposition was also observed on biopsies from three NAM patients who muscle sections were available. We conclude that one of the pathological pathways involved in muscle cell death in anti-SRP positive NAM is antibody-dependent complement mediated cell lysis. However, the possibility that more than one mechanism might be involved cannot be excluded and further studies would be helpful in understanding the pathogenesis of anti-SRP associated NAM.

P.2.14 Isolated cognitive abnormalities associated to DMD mutations

The dystrophinopathies are a group of X-linked muscle diseases caused by mutations in the DMD gene. Clinical phenotypes vary from asymptomatic high CK levels and cramps to severe progressive skeletal and cardiac muscle disorders such as Duchenne (DMD) and Becker (BMD) muscular dystrophies, and X-linked dilated cardiomyopathy (XLCM). About one third of patients present mental retardation. Most disease-responsible mutations are large intragenic rearrangements (exonic deletions and duplications) that account for 65–75% of cases, while the remaining cases are caused by single point mutations or small rearrangements [3,4]. In most patients, the clinical outcome can be predicted according to the reading-frame rule. The majority of DMD patients carry truncating mutations while BMD patients usually carry in-frame mutations allowing the expression of semi-functional dystrophins. We present a male patient 23 years old with mental retardation and no muscle weakness. The Western blot with Dys 1 and Dys 2 antibodies showed a reduced amount of dystrophin. An Inframe deletion of exons 56 and 57 was identified by MLPA and cDNA sequencing, affecting different dystrophin isoforms: Dp424m, Dp260, Dp140 and Dp116. In addition, we diagnosed three symptomatic female carriers of dystrophinopathy presenting isolated cognitive abnormalities without muscle involvement. Each of them carried DMD mutations (Duplication exons 13–27, Subexonic deletion exon 46 and Deletion exons 46–55, respectively). A study of X-chromosome inactivation was performed exhibiting a clear bias in the inactivation of the paternal chromosome: 99:1, 88:12 and 100:0, respectively. These cases suggest that isolated mental retardation could be more frequent than expected.

Cultural values at the individual level and the malleability of ways of knowing

This research tested the relationship between individuals cultural values and the malleability in their ways of knowing in two social contexts. Two hundred and ninety-two college students majoring in either business or social sciences initially received two priming conditions (two weeks apart) where they reflected on either their in-group or their out-group. Then, their adherences to ways of knowing: separate knowing (SK, being a devil’s advocate) and connected knowing (CK, being perspective taker) and cultural values: collectivist-horizontal, collectivist-vertical, individualist-horizontal and individualist-vertical were assessed. Analyses revealed a priming condition X ways of knowing X cultural values interaction. When students had their in-group in mind, their CK score was significantly higher than their SK score in all cultural categories. When students had their out-group in mind, their CK scores decreased to comparable levels of their SK score in all cultural values except horizontal-collectivist. Students with a dominant collectivist-horizontal values maintained higher CK scores compared with their SK scores in the out-group condition. Implications for perspective-taking and critical thinking are discussed.

Diagnostic algorithm and case conundrums: patients presenting with proximal muscle weakness

In the last years it has been observed that enzyme replacement therapy is mostly effective when the treatment is started at an early stage of the disease, before advanced damage has occurred in muscle fibers; consequently, the timing of diagnosis has acquired an increasingly important role, both in children and in adults. We are now aware that some LOPD cases may show for years only a persistent mild hyperCKemia with no signs or symptoms. Often the finding of high serum CK levels in this group of asymptomatic patients is incidental (visit in the emergency room for chest pain, preoperative investigations, detection of increased serum transaminases) and their diagnosis may be very difficult. Different is the case of patients who are seen when they start to manifest weakness, usually with onset in the pelvic girdle muscles. They usually report fatigue, exertional dyspnea (eg, in climbing stairs), difficulties to get up from the ground or sitting: however, these are very common symptoms, shared by a large number of primary or secondary neuromuscular disorders. In the absence of a family history of Pompe disease or a biopsy with typical vacuolar changes, the diagnosis is easily missed, and this explains the broad diagnostic delay still now registered, with consequences on ERT efficacy. Neuromuscular diseases that may present with isolated proximal weakness include lower motor neuron diseases (eg, spinal muscular atrophy), disimmune motor neuropathies, neuromuscular junction disorders (pre-and post-synaptic), and a large number of genetically defined (eg, progressive muscular dystrophies due to altered sarcolemma proteins, congenital myopathies, channellopathies) or acquired myopathies (inflammatory myopathies, toxic myopathies). Differential diagnosis is often difficult and expensive, and can be completed only in specialized tertiary centers. A diagnostic algorithm aimed to facilitate the evaluation of patients with limb-girdle muscular weakness is presented, to target the use of specific tests that can be implemented even in non-specialized structures (eg, units of general neurology or rheumatology) and allow an early detection of Pompe disease. A series of clinical cases is presented, to stimulate a discussion and to prove the validity of the algorithm.

Advances in imaging for the diagnosis and disease monitoring of Pompe disease

Imaging can play a role at different stages of Pompe disease. In most cases the clinical presentation and high CK level are very evocative and GAA activity testing is sufficient for the diagnosis. In some cases the clinical presentation is less typical and late onset or juvenile forms cannot be differentiated from limb girdle muscular dystrophies or congenital muscular dystrophies. In such cases previous descriptions of Whole body (WB) T1 weighted MRI images have shown very evocative patterns of most often affected or spared muscles. The most typically and frequently affected are tongue, scapulae fixators and especially sub-scapularis, trunk muscles like spine erectors, abdominal belt muscles and psoas. The most frequently spared are masticators, arm and forearms, and lower legs muscles. In most cases the disease is associated with complications like respiratory involvement and disabling muscle weakness. Imaging is not taken into account when considering treatment options. On the contrary, when the diagnosis is made after family screening or in patients with minor symptoms, the distribution and severity of muscles involvement established by WB MRI could influence the decision to treat. Stability over time or degradation could also impact this decision. MR description of initial distribution and progression of muscle involvement could also yield a better knowledge of the disease. Muscle biopsies are the best indicator of treatment efficacy but patient compliance could be very low if repeated follow-up biopsies were employed. Muscle imaging and especially MRI could offer the opportunity to quantify stability or progression of muscle involvement under therapy. To achieve this goal imaging has to be quantitative and not only qualitative. Quantification techniques can be developed to assess the amount of fat into muscles (DIXON) or to detect areas of muscle remodeling activity (T2 measurement). However WB MRI is useful to determine the areas where the quantification should be performed. In totally destroyed or spared muscles quantified imaging is not very pertinent. Other imaging modalities could also be used to detect regional fat increase. DEXA scanner is not only able to detect regional bone mineral density variations but also lean mass (muscles) and fat. Muscle imaging is not always the clue for the diagnosis but it can help for recognition of atypical clinical presentations, for understanding the natural history of the disease, for the determination of patients suited for treatment as a complement of other clinical and nonclinical parameters. Medical imaging techniques of quantification could help to analyze treatment efficacy.

Novel ANO5 mutations causing hyper‐CK‐emia, limb girdle muscular weakness and miyoshi type of muscular dystrophy

Mutations in the anoctamin 5 gene (ANO5) have been recently identified.They cause limb girdle muscular dystrophy (LGMD2L) and Miyoshi muscular dystrophy. Clinical findings of four unrelated patients are reviewed. Mutation detection was performed by direct sequencing of the ANO5 exons. We identified four novel mutations in the ANO5 gene. In one patient, a novel homozygous mutation (c.1965G>C). In three patients, the recurrent heterozygous exon 5 c.191dupA mutation is combined with other variants to form a compound heterozygous state: in two cases, novel splice site mutations in intron 5 (c.295-1G>A) and in intron 14 (c.1407+5G>A), and in one case, a novel missense mutation in exon 4 (c.172C>T). The cases reported here should help to better understand the important role of mutation screening in the ANO5 gene in patients with adult onset muscular dystrophy and very high CK levels.

Infarto agudo do miocárdio e injeção intramiocárdica experimental em cães: estudos clínico, enzimático, eletrocardiográfico e ecocardiográfico

Os eventos isquêmicos em cães são incomuns, porém podem estar sendo subnotificados. Avaliou-se o infarto agudo do miocárdio (IAM) clinicamente, por meio de eletrocardiografia (ECG), eletrocardiografia contínua (EC), ecocardiografia (ECO), enzima creatina quinase (CK), enzima creatina quinase fração MB (CK-MB) e anátomo-histologicamente em cães sem raça definida, e observou-se a ocorrência de arritmias após injeção intramiocárdia por EC. O IAM foi obtido após a ligadura da coronária descendente anterior. Os animais apresentaram ao ECO dilatação da câmara esquerda e aumento do índice de desempenho miocárdico. Ao ECG houve desnivelamento de ST nas derivações pré-cordiais V1 e V2. No EC observaram-se arritmias ventriculares graves e supradesnivelamento de ST. As enzimas CK e CK-MB aumentaram significativamente, sendo que os picos de CK-MB e de CK ocorreram seis horas e 12 horas, respectivamente, após o IAM. Na análise histológica constatou-se infarto da parede inferior do ventrículo esquerdo e substituição do tecido muscular por tecido fibroso. Avaliou-se a injeção intramiocárdica por EC que pode servir como via terapêutica cardíaca, não sendo observado aumento das arritmias ventriculares após a injeção no miocárdio infartado. O infarto em cães pode ser detectado pelos exames cardíacos disponíveis, e a injeção intramiocárdica é uma via terapêutica cardíaca possível.

Miyoshi-like distal myopathy with mutations in anoctamin 5 gene

Miyoshi myopathy is the most common form of recessive distal myopathy. Recessive mutations in the ANO5 gene have been recently identified in Northern Europe as a cause of non dysferlin-linked distal myopathy and limb girdle muscular dystrophy. We report here the first French cases of anoctamin 5 myopathy in 2 brothers presenting with a Miyoshi-like pattern. Comparing these patients with 12 other cases from the literature shows that all cases share a homogeneous clinical pattern, characterized by initial calf muscles involvement. Asymmetric muscle atrophy often precedes weakness. In this setting, high CK level and normal expression of dysferlin in muscle should lead to consider the diagnosis, which will be confirmed by ANO5 gene testing. The c.191dupA mutation, already reported as a founder mutation in Caucasian patients with anoctamin myopathies, was found in our family in a heterozygous state.

A novel form of immune inflammatory myopathy associated with antibodies to γ/δ sarcoglycan

Immune mediated inflammatory myopathies are a heterogeneous group of acquired diseases characterised by inflammation of skeletal muscle. In recent years, this group of conditions has become better characterised by the...

Two common mutations (p.Gln832X and c.663+1G>C) account for about a third of the DYSF mutations in Korean patients with dysferlinopathy

Dysferlinopathy refers to autosomal recessive muscular dystrophies caused by mutations in dysferlin gene (DYSF). It includes two major distinct disorders, Miyoshi myopathy and limb-girdle muscular dystrophy type 2B. Twenty-three Korean patients were recruited. Full sequence analysis of DYSF detected 10 novel and 9 known mutations. The p.Gln832X showed the highest allele frequency (10/46) as a unique recurrent mutation among Korean population, and two common mutations (p.Gln832X and c.663+1G>C) accounted for 34.8% of the identified mutations. Korean DYSF mutations appeared to cluster in the N-terminal region. Notably, none of homozygous mutations was found in this study. Clinical features were similar to previous reports showing onset in early adulthood, high serum CK and inflammatory reactions on muscle pathology. In Miyoshi myopathy, gastrocnemius muscle was first affected on muscle CT scans, and anterior lower legs and thigh muscles were then affected with disease progression. Despite the genetic variety of DYSF mutations, clinical features were rather invariable among the patients.

Hoarseness, Articulation Disorder and Hearing Impairment in Subjects with Hypothyroidism

Thyroid hormones target cardiovascular, neuromuscular, digestive, and metabolic systems, meaning that hypothyroidism may cause a wide variety of symptoms. Hypothyroidism is usually characterized by struma and myxedema. The absence of struma, however, may cause hypothyroidism to be mistaken for other organ disorders or normal aging-associated change. We report 2 cases of hypothyroidism without struma. Case 1 was a 76-year-old man seen for postnasal drip and ear stuffiness complicated by myocardial infarction, kidney dysfunction, and abnormally high CK. Case 2 was an 83-year-old man seen for prolonged dizziness, who also had heart failure and generalized edema. Neither patients responded well to a treatment and showed deteriorating truncal ataxia, increasing body weight, bradykinesia, bradyarthria, hoarseness, and impaired hearing. Case 2, also had edematous glottal change. Although no struma was seen, thyroid hormone levels were measured to determine the cause of hoarseness, showing high TSH and low fT3 and fT4 level. Case 1 was diagnosed with primary hypothyroidism, and Case 2 with secondary hypothyroidism. Hormonal therapy induced improvements in impaired hearing, previously considered a sign of aging, and in bradykinesia, truncal ataxia, and hoarseness. Hoarseness and bradyarthria were relieved regardless of glottal edema. Internal complications were also markedly alleviated. In case 1, impaired hearing worsened again after the mean stopped taking vitamin B12, but improved again when vitamin B12 was restarted. Articulation disorder in hypothyroidism presumably involves neuropathy and affecting from speech center to articulatory organs, including the glottis. Impaired hearing also presumably is caused by the same neuropathy depending on the vitamin B12 level.

Clinical features and new molecular findings in muscle phosphofructokinase deficiency (GSD type VII)

Muscle phosphofructokinase (PFKM) deficiency, a rare disorder of glycogen metabolism also known as glycogen storage disease type VII (GSDVII), is characterized by exercise intolerance, myalgias, cramps and episodic myoglobinuria associated with compensated hemolytic anaemia and hyperuricemia. We studied five patients with PFKM deficiency coming from different Italian regions. All probands showed exercise intolerance, hyperCKemia, cramps and myoglobinuria. One patient had a mild hypertrophic cardiomyopathy. Biochemical studies revealed residual PFK activity ranging from 1 to 5%. Molecular genetic analysis identified four novel mutations in the PFKM gene. In our series of patients, clinical and laboratory features were similar in all but one patient, who had an unusual phenotype characterized by 25years disease history, high CK levels, hypertrophic cardiomyopathy with paroxysmal atrial fibrillation without fixed muscle weakness.

P2.2 A benign form of MDC1A in Korean siblings with a novel LAMA2 mutation

Merosin-deficient congenital muscular dystrophy (MDC1A, MIM #607855) is characterized by early onset of profound muscle weakness in infancy, high CK level, and normal intelligence despite the diffuse white mater change in the brain. Although it is typically a disease of infancy or early childhood, there are some cases with much benign phenotypes. A 20-year-old man was evaluated for chronic non-progressive gait disturbance and diffuse white mater change on brain MRI. The birth histories were unremarkable.

Whole-body vibration training elevates creatine kinase levels in sedentary subjects

Whole body vibration (WBV) is an increasingly popular modality of muscle training, especially in sedentary subjects. We hypothesised that the vigorous muscle contractions elicited by WBV can cause muscle damage expressed as an elevation in muscle enzymes. Twenty inactive subjects, ten male and ten female, aged 22.7 ± 2.6, BMI 22.4 ± 2.1 were included based on the absence of regular physical activity as defined by international guidelines, and no history of recent trauma, musculoskeletal pathology, implanted prosthetics, cardiovascular disease or drug intake. The intervention consisted of one bout of high intensity WBV corresponding to a typical training session, involving all the major muscle groups. Plasma levels of muscle enzymes prior to and at 24, 48 and 96 hours post exercise (creatine kinase - CK, MB fraction, troponin I, aminotransferases and lactate dehydrogenase) were measured. In addition, blood lactate was assayed immediately after exercise. Delayed onset muscle soreness (DOMS) was evaluated using a visual analogical scale. Five participants (25%) showed a significant increase in post exercise CK levels (> double of baseline). Maximal value was 3520 U/l. No change was observed in CK-MB or troponin I. Lactate increased to 10.0 ± 2.4 in men and 6.9 ± 2.4 in women. All participants had some degrees of DOMS, without correlation to enzymatic changes. WBV can provoke high CK elevation in healthy, medication-free inactive subjects. Such an elevation is transient and harmless, but could be wrongly attributed to drug induced myopathy, as in patients treated with statins. Practitioners should bear this in mind before discontinuing a potential life saving drug.

Primary Signet-ring Cell/Histiocytoid Carcinoma of the Eyelid

Primary cutaneous signet-ring cell carcinomas are rare and aggressive neoplasms. These neoplasms have been mostly described in the eyelids, and more uncommonly, in the axillary skin. Histopathologically, the neoplasm seems to be composed of signet-ring cells or histiocytoid epithelial cells arranged in an Indian file growth pattern between collagen bundles of the dermis. Immunohistochemically, neoplastic cells expressed strong diffuse reactivity for CAM 5.2, CK7, high molecular weight CK, AE1/AE3 and MNF116 cytokeratins, carcinoembryonic antigen, epithelial membrane antigen, gross cystic disease fluid protein-15, p63, mucin-1 (MUC-1), BerEP4, and E-cadherin; moderate positivity for α-smooth muscle actin, tissue-specific transcription factor 1, MUC-2, Podoplanin, and N-cadherin; and weak positivity for epidermal growth factor receptor. Estrogen and progesterone receptors show positive results in some cases and negative results in others. The histopathologic and immunohistochemical features of primary signet-ring cell or histiocytoid carcinoma of the eyelid are closely similar to those of histiocytoid lobular carcinoma of the breast, and there are several examples of histiocytoid mammary carcinoma metastatic to the eyelids. Therefore, histopathologic differential diagnosis between primary and metastatic signet-ring cell or histiocytoid eyelid carcinomas is mandatory. In this study, we report our experience with the clinical, histopathologic, and immunohistochemical findings in 5 cases of primary signet-ring cell or histiocytoid carcinoma of the eyelid. We investigated the usefulness of p63, epidermal growth factor receptor, MUC-1, MUC-2, mammaglobin, and E-cadherin as immunohistochemical markers for this histopathologic differential diagnosis. Primary signet-ring cell carcinoma of the eyelid is an aggressive neoplasm that may develop regional or distant metastases, and therefore, it should be excised with wide margins.

Effects of Ginsenoside CK on Gastric Cancer SGC-7901 Cell Line and Endogenous VEGF Secreted by Tumor Cells

Objective To investigate the effects of Ginsenoside CK on the cell proliferation、cell cycle and endogenous VEGF of gastric cancer SGC-7901 cell line.Methods SGC-7901 cell line in cultural medium in vitro were given 50,25,12.5,6.25,3.125,1.5625 μg/ml Ginsenosde CK.The inhibitory rate of cell line was measured by MTT assay;cell apoptotic rate and cell phase were detected by flow Cytometry(FCM);the VEGF contents were detected by ELISA assay.Results It was found that Ginsenoside CK had significant inhibitory effect on the proliferation of SGC-7901 cell line,and this effect was dose-and-time-dependent;FCM assay indicated that apoptosis peak appeared evidently after the cells being interfered with Ginsenoside CK and most of cells were arrested in G0/G1 phase;The levels of VEGF in Ginsenoside CK groups were lower than that in the control group(P0.05).The level of VEGF in the groups of high concentration Ginsenoside CK were lower than that in the group of low concentration(P0.05),and the VEGF contents decrease with action time prolonging.Conclusion Ginsenoside CK dramatically inhibits proliferation of SGC-7901 cell line by inducing cell apoptosis and secretion of endogenous VEGF.Ginsenoside CK may become a potential drug in the prevention and treatment of gastric cancer.

Mixed connective tissue disease presenting as a peculiar myositis with poor muscle regeneration

Mixed connective tissue disease (MCTD) is a rheumatological disease which has to be distinguished from other entities causing inflammatory myopathy. The usual clinical presentation of inflammatory myopathy associated with connective tissue disease is not different from isolated polymyositis or dermatomyositis, i.e., subacute onset of proximal weakness affecting both upper and lower girdle with high serum CK level. Here we report a patient with MCTD/myositis overlap syndrome displaying an uncommon clinical presentation and a distribution of muscle weakness involving facial, neck and arm muscles with sparing of lower limbs. We also describe the scarcity of muscle regeneration signs on the muscle biopsy with complete absence of alkaline phosphatase positivity in the endomysial and permysial connective tissue as a novel finding of this condition.