Brief Summary: August 5, 2006, Wujdan Alali, the two years old baby from Saudi Arabia, was admitted into our hospital for suffering from cerebral palsy, poor development, inability to sit, inability to speak, feeble neck which could not support the head. Furthermore, her fontanel could not close naturally. After treatment in our hospital for about 40 days, the little girl started to speak something. The strength of her legs improved so she can sit well and walk a few steps. Her neck also became strong enough to support her head and the fontanel is closed. Her weight increased 2 kilos.

Name: Wujdan Alali                                                                                                 Sex: Female

Profession: No                                                                                                          Nationality: Saudi Arabia

Date of Admission: August 5, 2006                                                                         Age: 1 year and 10 months

Complainer of history: The patient’s parents             

Chief complaint: The patient suffered dyskinesia and logopathy for 9 months and her condition became worse for 3 months.

Present illness: The patient had a high fever (38.9℃) without any obvious cause when she was 8 months old. During the high fever she always lost consciousness for about one hour without vomiting or spasm. Her parents sent her to a local hospital where the doctor gave her nothing except cold application to lower the temperature. After they returned home, she began to have intermittent high fever which the average temperature was 38.5℃ and the highest level reached 38.9℃. Each time her parents lowered the high fever by cold application, and sometimes her mother gave her one to two febrifugal tablets. After two weeks’ intermittent high fever, the patient’ motor and verbal function began to degenerate. Gradually, she lost the ability to walk, to creep, to turn over, or to articulate “pa-pa” “ma-ma”. Then her parents took her to the most advanced hospital in Saudi Arabia, where the doctor diagnosed her as leukodystrophy through “MRI” but they gave her no treatment. At present, the patient’ spirit is poor, appetite normal, urination and bowel movement normal, finger marks are slightly reddish, and the tongue coating is thin and whitish.

Body Development History: She became able to lift her head at 4 months old, to sit without support at 6 months old, to walk under support and to call “pa-pa” and “ma-ma” at 8 months.

Past history: She was generally healthy before she was 8 months old. No history of other disease. She had preventive vaccination at home.

Family history: Her parents were close relatives. It is known as intermarriage. They had 5 children who were all healthy except Alali. Several of their close relatives in her family had intermarriage, and some of them had hypothrenia, dyskinesia and logopathy.

Physical examination

T 36.3℃，P 108bpm, R 34bpm, W: 7.5kg

She was quiet and poorly nourished. She was unable to speak, to walk or to sit without support. The head circumference is 44cm. Retard closure of her sunken fontanel. Bilateral pupils were round and equal in size. Her both eyes are sensitive to light reflection. Red lips and no nasal dent or suppuration. Hearing was normal. No discharges were found in external auditory canals. No tenderness in the mastoid process. No abnormal odor in the mouth. Teeth regularly aligned. No gingival reddening, swelling or pyorrhea. Tongue coating was thin and white. Neck was soft and trachea in midline. No swelling in the thyroid gland. No pharyngeal congestion. No thoracic deformity. Respiratory movements were normal. Chest percussion noted resonance. Sound of breath was bilaterally normal on auscultation. Heart beat 108 times/min. The rhythm is regular. No pathological murmurs on auscultation. Abdomen was flat and soft without tenderness or rebound tenderness. Liver, spleen and hypochondriac region were untouched. Intestinal gurgling sound was normal. The spine had physiological curvature but no deformity. The development of the anus and pudendum was normal. 

The flexion of left elbow and wrist were both 20°. She was always making a fist with the adduction of thumb. The adduction degree of her left shoulder joint was 15° and that of her left leg was 20°. Her two legs were crossed. Her feet were flat. The flexion of hip joint was 25°. She also had tendon hyperreflexia and ankle clonus. Foersters(+); Babinsni(+); Hoffmann(+).

Diagnostic examination: MRI showed leukodystrophy.

Essentials for diagnosis:

1. The patient suffered dyskinesia and logopathy for 9 months and her condition became worse for three  months.

2. The syndrome differentiation for this disease mainly focuses on differentiating whether the disease is congenital or postnatal, and whether it is asthenia or sthenia. The patients with disease caused by congenital factors mostly belong to asthenia of the liver and kidney as well as deficiency of renal essence and blood. Main symptoms and signs include retarded development, hypophrenia, delayed closure of fontanel, as well as weak and thready pulse. While postnatal insufficiency largely pertains to the weakness of the spleen and stomach as well as deficiency of qi and blood. Asthenia mostly pertains to deficiency of renal essence, yin deficiency of the liver and kidney, as well as deficiency of qi and blood. Main symptoms and signs include cry and restlessness, sleeplessness, red tongue, fine and rapid pulse. Sthenia is always caused by blood stasis cerebral collaterals and internal stagnation of phlegm and dampness. Main symptoms and signs include dizziness, throat gurgling with sputum, and epigastric fullness.

3. Difficulty in supporting the head, creeping, sitting, standing, walking, or turning over. Hypomyotonia. Tendon hyperreflexia. The flexion of left elbow and wrist were both 20°. She was always making a fist with the adduction of thumb. The adduction degree of her left shoulder joint was 15° and that of her left leg was 20°. Her two legs were crossed. Her feet were flat. The flexion of hip joint was 25°. Foersters(+); Babinsni(+); Hoffmann(+). She was unable to articulate “pap-pa” and “ma-ma”. She was timid, and had much saliva dripping all the time.

4. MRI showed leukodystrophy.

Diagnosis:

TCM: Flaccidity syndrome and “wuchi” (spleen deficiency and weak stomach, deficiency of qi and blood, kidney essence deficiency, liver and kidney yin deficiency )

Western medicine: Cerebral palsy

Principle of TCM treatment

1. Replenishing renal essence and bone marrow

2. Tonifying the liver and kidney

3. Strengthening the spleen and supplementing qi

Plan of treatment and care

1. On general routine

2. On grade II care

3. High-protein diet

4. Herbal tea: one dosage a day and drink by twice

5. Daily acupuncture and massage

6. Have more medical examinations if necessary

8^th of August 2006

The child has been brought to No. One People’s Hospital for MRI and IQ tests. The result of MRI showed leukodystrophy, while the IQ test indicated mental retardation. Her sleep and appetite are good. She had a bowel movement at 8:30a.m, which is soft and normal. Tongue coating is thin and whitish.

9^th of August 2006

Dr. Yan, Dr. Ming, and Dr. Qiu held a consultation to prepare a treatment plan for Wujdan, such as acupuncture once a day, massage twice a day, hyperbaric oxygenation (one treatment a day for ten days), and also asking her parents to teach Wujdan verbal articulation everyday as well as some functional exercises for motor ability.

11^th of August 2006

The child has no hyperbaric oxygenation treatment due to sudden swellings on her head. She has been brought to the Chinese Medicine Hospital of Huaihua to do EMG, and the result is that kinesic conduction velocity of nervus peroneus communis, posterior tibial nerve, median nerve, and ulnar nervus is bilaterally normal, but esthesiodic conduction velocity of nervus suralis is slow. Her sleep and appetite are good, and urination and defecation are normal. Tongue coating is thin and white. As for the swellings, the doctor has given her an anti-inflammatory ointment called “Fuyangshuang”.

13^th of August 2006

Today the child’s swellings on her head are greatly reduced after applying the anti-inflammatory ointment. Salivate basically disappeared. Her fingers can move more flexibly, as evidenced by her ability to pick up a key ring. She is able to sit up for a moment with her legs crossed. Further treatment is including herbal tea, acupuncture, massage, and hyperbaric oxygenation, is recommended. Her spirit and appetite are good. Her urination and bowel movement are normal. Tongue coating is thin and whitish.

16^th of August 2006

Wujdan presents with a good spirit today and a smiling face. No salivation. Her appetite and sleep are very good. Her fingers are more flexible, for she is able to hold a pen. She is able to sit up with her legs crossed and nearly able to turn over while lying on stomach. Further treatment, including herbal tea, acupuncture, massage, and hyperbaric oxygenation, is recommended by Dr. Yan, who has also asked Wujdan’s parents to instruct her to do verbal articulation as well as some functional exercises for motor ability more frequently.

21^st of August 2006

Wujdan presents with a good spirit today and a smiling face. Her spirit and appetite are pretty good. Her urination and bowel movement are normal. Her fingers are more flexible, for she is able to catch some small things such as a key ring, or a pen. She shows a better ability to do some fine movements. She is able to sit up with her legs crossed. She is unable to turn over. Her legs are crossed like scissors, but the angle is smaller (about 15°). She is still unable to speak, but her voice is louder than before. Dr. Yan points out that drinking herbal tea should be continued for nourishing yin and tonifying kidney, fortying the spleen and boosting qi. And acupuncture, massage, and hyperbaric oxygenation should also be continued. Meanwhile, Wujdan’s parents should lead her to do verbal articulation as well as functional exercises for fine movement of the fingers or ability to step and walk regularly.

24^th of August 2006

Wujdan presents with a good spirit today and a more expressive face. Her sleep and appetite are good. Her urination and bowel movement are normal. Her fingers are more flexible. Muscular strength of her hands is increased. She shows a better ability to do some fine movements. She is able to sit up with her legs crossed. She is sill unable to turn over. Her legs are still crossed like scissors when her body is erect. She is still unable to speak. Dr. Yan has asked Wujdan’s parents to lead her to do verbal articulation as well as some functional exercises for motor ability everyday.

27^th of August 2006

Wujdan presents with a good spirit today and an expressive face. Her sleep and appetite are good. Her urination and bowel movement are normal. The flexibility of her fingers remains the same. Muscular strength of her hands is increased. She is able to sit up with her legs crossed. She is sill unable to turn over. Her legs are still crossed like scissors when her body is erect. She is still unable to speak. Wujdan’s parents should continue helping her do verbal articulation as well as some functional exercises for motor ability everyday.

30^th of August 2006

Wujdan presents with a good spirit today and an expressive face. The tongue coating is thin and white. Her sleep and appetite are good. Her urination and bowel movement are normal. The flexibility of her fingers remains the same. Muscular strength of her hands is a little increased. She is able to sit up with her legs crossed. She is sill unable to turn over, but she is able to creep for a short distance. Her legs are still crossed like scissors when her body is erect. She is still unable to speak. Wujdan’s parents should continue helping her do verbal articulation as well as some functional exercises for motor ability everyday.

2^nd of September 2006

Wujdan presents with a good spirit today and an expressive face. Her sleep and appetite are good. Her urination and bowel movement are normal. The flexibility of her fingers increased a little evidenced by her ability to hold her nursing bottle. Muscular strength of her hands is a little increased. She is able to sit up with her legs crossed. She is sill unable to turn over, but she is able to creep for a short distance. Her legs are still crossed like scissors when her body is erect. She is still unable to speak. Wujdan’s parents should continue helping her do verbal articulation as well as some functional exercises for motor ability everyday.

5^th of September 2006

Wujdan presents with a good spirit today and an expressive face. The tongue coating is thin and white. Her sleep and appetite are good. Her urination and defecation are normal. The flexibility of her fingers remains the same. Muscular strength of her hands is the same. She is able to sit up for about 5 seconds with her legs crossed. She is sill unable to turn over, but she is able to creep for a longer distance. Her legs are still crossed like scissors when her body is erect but the angle that her legs form is bout 10°. She is still unable to speak. Wujdan’s parents should continue helping her do verbal articulation as well as some functional exercises for motor ability everyday.

8^th of September 2006

Wujdan presents with a good spirit today and an expressive face. The tongue coating is thin and white. Her sleep and appetite are good. Her urination and defecation are normal. The flexibility of her fingers increases a little. Muscular strength of her hands is the same. She is able to sit up for more than 5 seconds with her legs crossed. She is sill unable to turn over, but she is able to creep for a longer distance. Her legs are still crossed like scissors when her body is erect but the angle that her legs form is about 10°. And she can move several steps under support.

Summary

Wujdan Alali, female, 1 year and 11 months old, was admitted into the Huaihua Red Cross Hospital on August 5, 2006 due to dyskinesia and logopathy for 9 months with a worse condition for 3 months.

Original condition

She had MRI in Saudi Arabia, which noted leukodystrophy. She didn’t have the ability to perform such actions as straightening her neck, sitting, standing or walking as well as to move her fingers flexibly due to dyskinesia. She also had hypomyotonia and tendon hyperreflexia. And, she was unable to articulate any words, including “pa-pa” and “ma-ma”, because of logopathy. She was timid and had ptyalism. Her sunken fontanel was not closed. EMG showed that the esthesiodic conduction velocity of nervus suralis was slow.

After the patient was admitted, she has been drinking herbal tea for replenishing renal essence and bone marrow, tonifying the liver and kidney, strengthening the spleen and supplementing qi—300ml a day for twice as well as having acupuncture once a day, massage twice a day, and hyperbaric oxygenation (one treatment a day for ten days).

Current condition

The patient is much better. Her fontanel is closed. No salivation. Her neck can support her head now. She is able to sit with her legs crossed, though still unable to stand or walk without support.

The flexibility of her fingers increased admirably evidenced by her ability to hold a pen or several pieces of paper, or catch a key ring with one finger. Muscular tension is increased. Foerster(－). Her language ability is improved a little evidenced by her occasional articulation of “pa”. Two teeth in her upper jaw grow larger. Her urination and defecation are normal. Her tongue coating is thin and white. Her legs are still crossed like scissors when her body is erect but the angle that her legs form is bout 15° less than before. Sometimes, she is able to move several steps automatically under support.

12^th of September 2006

Wujdan presents with a good spirit today and an expressive face. The tongue coating is thin and white. No fever. Her sleep and appetite are good. Her urination and defecation are normal. The flexibility of her fingers remains the same. Her legs are still crossed like scissors when her body is erect but the angle that her legs form is about 15° reduced. And she can move several steps under support. Wujdan’s parents should continue helping her do verbal articulation as well as some functional exercises for motor ability everyday.

15^th of September 2006

Wujdan presents with a good spirit today and an expressive face. Her sleep and appetite are good. Her urination and defecation are normal. Her finger mark is light red. Her tongue coating is thin and white. The flexibility of her fingers remains the same. Her legs are still crossed like scissors when her body is erect but the angle that her legs form is about 15°,  much less than before. She is going to leave the hospital today.

The updated condition：

The patient is much better. Her fontanel is closed. Two new teeth grow in her upper jaw. No salivation. Her neck can support her head now. She is able to sit with her legs crossed, though still unable to stand or walk without support.

The flexibility of her fingers increased admirably evidenced by her ability to hold a pen or several pieces of paper, or catch a key ring with one finger. Muscular tension is normal. Her language ability is improved a lot evidenced by her occasional articulation of “pa”.. Her legs are still crossed like scissors when her body is erect but the angle that her legs form is bout 15° less than before. Sometimes, she is able to move several steps automatically under support. Her tongue coating is thin and white.

Doctor’s advice：

1.Continue with the herbal tea for replenishing renal essence and bone marrow, tonifying the liver and kidney, fortifying the spleen and supplementing qi.

2. Hyperbaric oxygenation (for ten days treatment and one time a day).   

3. Wujdan should do more exercises for verbal functions as and motor functions frequently.