Miopatia por propoxifeno: relato de 2 casos com histoquimica de músculos

Werneck, Lineu Cesar; Rachid, Acir; Lozovey, João Carlos A.

doi:10.1590/S0004-282X1981000100008

Resumos

São relatados os casos de dois pacientes sofredores de dores crônicas (um com gota e outro com lombalgia), que desenvolveram o vício pelo dextro-propo-xifeno, administrado por via intramuscular. Isto determinou alterações importantes na musculatura onde eram aplicado as injeções, com endurecimento da pele, edema e diminuição da mobilidade do membro afetado. A investigação revelou miopatia crônica, com intensa fibrose do tecido conjuntivo perimisial e endomisial, com infiltração por células linfomonocitárias; havia também atrofia de fibras musculares nas regiões próximas e fibrose com atividade muito aumentada para a fosfatase alcalina no local das lesões. Eletromiografia em um dos casos sugeria denervação e, no outro, envolvimento muscular primário. A retirada da medicação determinou regressão dos sintomas e sinais, mas o retorno de ambos os pacientes ao hábito, fêz recrudescer o processo. São discutidos os achados clínico-patológicos comparando com outras medicação e agressões físicas que acometendo o tecido muscular, acabam levando o musculo à fibrose. Possivelmente as injeções intramusculares repetidas, a irritação pelo cloridrato de dextro-propoxifeno e a redução da drenagem linfática sejam as causas dos sintomas e alterações patológicas.

The cases of a 43 years old-man with gout and a 24 years-old woman with severe back pain who developed dextro-propoxyphene addiction during pain treatment are reported. They had severe edema and fibrosis of skin, subcutaneous tissue and muscle involving the upper and lower limbs. ESR was elevated, CPK and LDH were normal. EMG in proximal muscles showed decreased duration and voltage of potentials, excess of short polyphasics and increased recruitmente (BSAP), with positive waves and fibrilations; distal muscles had fasciculations, fibrilations, positive waves, normal voluntary potentials, decreased recruitment. Limphography indicate delayed progression of contrst media and obstruction in the thighs. Muscle biopsy on fresh-frozen section and histochemistry showed extensive connective tissue proliferation with intense acid and alkaline phosphatase activity in the perimisial and endomisial area, infiltration of limphocytes near and around small vessels and capilaries. There was perifascicular and type II fiber atrophy. After discharge the patients returned to propoxyphene addiction and the symptons who subsided during drug withdrawl como back again. New admission, new drug withdrawl and they were discharged free of symptoms. Possibly the repeated needles trauma, irritation by the propoxyphene and impairment of lymphatics drainage were the cause of symptoms and pathologic changes.

Miopatia por propoxifeno: relato de 2 casos com histoquimica de músculos

Propoxyphene myopathy: report of two cases with muscle histochemistry

Lineu Cesar Werneck^I; Acir Rachid^II; João Carlos A. Lozovey^III

^IProfessor Assistente de Neurologia. Departamento de Clínica Médica da Universidade Federal do Paraná

^IIProfessor Titular de Reumatologia. Departamento de Clínica Médica da Universidade Federal do Paraná

^IIIResidente de Clinica Médica. Departamento de Clínica Médica da Universidade Federal do Paraná

RESUMO

São relatados os casos de dois pacientes sofredores de dores crônicas (um com gota e outro com lombalgia), que desenvolveram o vício pelo dextro-propo-xifeno, administrado por via intramuscular. Isto determinou alterações importantes na musculatura onde eram aplicado as injeções, com endurecimento da pele, edema e diminuição da mobilidade do membro afetado. A investigação revelou miopatia crônica, com intensa fibrose do tecido conjuntivo perimisial e endomisial, com infiltração por células linfomonocitárias; havia também atrofia de fibras musculares nas regiões próximas e fibrose com atividade muito aumentada para a fosfatase alcalina no local das lesões. Eletromiografia em um dos casos sugeria denervação e, no outro, envolvimento muscular primário. A retirada da medicação determinou regressão dos sintomas e sinais, mas o retorno de ambos os pacientes ao hábito, fêz recrudescer o processo. São discutidos os achados clínico-patológicos comparando com outras medicação e agressões físicas que acometendo o tecido muscular, acabam levando o musculo à fibrose. Possivelmente as injeções intramusculares repetidas, a irritação pelo cloridrato de dextro-propoxifeno e a redução da drenagem linfática sejam as causas dos sintomas e alterações patológicas.

SUMMARY

The cases of a 43 years old-man with gout and a 24 years-old woman with severe back pain who developed dextro-propoxyphene addiction during pain treatment are reported. They had severe edema and fibrosis of skin, subcutaneous tissue and muscle involving the upper and lower limbs. ESR was elevated, CPK and LDH were normal. EMG in proximal muscles showed decreased duration and voltage of potentials, excess of short polyphasics and increased recruitmente (BSAP), with positive waves and fibrilations; distal muscles had fasciculations, fibrilations, positive waves, normal voluntary potentials, decreased recruitment. Limphography indicate delayed progression of contrst media and obstruction in the thighs. Muscle biopsy on fresh-frozen section and histochemistry showed extensive connective tissue proliferation with intense acid and alkaline phosphatase activity in the perimisial and endomisial area, infiltration of limphocytes near and around small vessels and capilaries. There was perifascicular and type II fiber atrophy. After discharge the patients returned to propoxyphene addiction and the symptons who subsided during drug withdrawl como back again. New admission, new drug withdrawl and they were discharged free of symptoms. Possibly the repeated needles trauma, irritation by the propoxyphene and impairment of lymphatics drainage were the cause of symptoms and pathologic changes.

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Full text available only in PDF format.

Trabalho realizado nas Disciplinas de Neurologia e Reumatologia do Departamento de Clínica Médica da Universidade Federal do Paraná.

Disciplina de Neurologia, Deparatamento de Clínica Médica Universidade Federal do Paraná - Hospital de Clínicas - Rua General Carneiro 180, 13º andar - 80000 Curitiba, PR. - Brasil.

1. ABERFELD, D. C; BIENESTOCK, II.; SHAPIRO, M. S.; NAMBA, T. & GROB, D. - Diffuse myopathy related to meperidine addiction in a mother and daughter. Arch. Neurol. (Chicago) 19:384, 1968.
2.ASKARI, A.; VIGNOS, P. J. & MODKOWITZ, R. W. - Steroid myopathy in connective tissue disease. Am. J. Med. 61:485, 1976.
3. BENNET, J. - Myopathy from E-aminocaproic acid: a second case, Postgrad. Med. J. 48:440, 1972.
4. BOGARTS, L. J. & MILLER, W. C. - Pulmonary edema associated with propoxyphene intoxication. J.A.M.A. 215:259, 1971.
5. BOWDEN, D. H. & GOYER, R. A. - Drug-induced muscle necrosis with massive taurinuria. Arch. Pathol. 74:137, 1962.
6. BOWKER, C. H. & TURMER, P. - Myopathy after allopurinol. Lancet 1:365, 1977.
7. BURNHAM, H. A. - Pentazocine-induced fibrous myopathy. J.A.M.A. 234:913, 1975.
8. CAMPBELL, E. D. R. & MONTUSCHI, E. - Muscle weakness caused by bretilium tosylate. Lancet 2:789, 1960.
9. CHIU, S. S.; FURUYA. K.: ARAT, T.; NAKAGAWA, M. IIDA, M. - Congenital contracture of the quadriceps muscle. J. Bone Joint Surg. 56-A :1054, 1974.
10. CLAGHORN, J. L. & SCHOOLAR, J. C. - Propoxyphene hydrochloride: a drug of abuse. J.A.M.A. 196:1089, 1966.
11. CZLONKOWSKA, A. - Myasthenia syndrome during penicillamine treatment. Britsih Med. J. 1:726, 1975.
12. DAIKOS, E. K. & KOSMIDIS, J. C. - Propoxyphene Jaundice. J.A.M.A. 238:835, 1975.
13. DAM. M.; KRISTENSEN, C. B.; HANSEN, B. S. & CHRISTIANSEN, J. - Interaction between carbamazepine and propoxyphene in man. Acta Neurol. Scandinav. 56:603, 1977.
14. DUBOWITZ, V. Allopurinol in Duchenne muscular distrophy. Lancet 1:248, 1977.
15. DUBOWITZ, V. & BROOKE, M. - Muscle Biopsy: A Modern Approach, W. R. Saunders Co. Ltd., Philadelphia, 1973.
16. ENGEL, W. K. - Focal myopathic changes produced by eletromyographic and hypodermic needles: "Needle myopathy". Arch Neurol. (Chicago) 16:509. 1967.
17. ENGEL, W. K. & ZEE, D. S. - Acupuncture myopathy: remembrance of things passed. N. Engl. J. Med. 291:801, 1974.
18. FENICHEL, G. M.; DETTBARN, W. D. & NEWMAN, T. M. - An experimental myopathy secondary to excessive acetylcholine release. Neurology (Minneapolis) 24:41, 1974.
19. FENICHEL, G. M.; KLIBER, W. B.; OLSON, W. H. & DETTBARN, W. D. - Chronic inhibition of cholinesterase as a cause of myopathy. Neurology (Minneapolis) 22:1026, 1972.
20. GISCH, H. P.; WANDS, J.; YEUNG, J. & DAVIS, P. J. - Pulmonary edema and disseminated intravascular coagulation after intravenors abuse os d-propoxyphene. South. Med. J. 65:493, 1972.
21. GRAY, J. E. - Local histologic changes following long-term intramuscular injections. Arch. Path. 84:522, 1967.
22. GUSTAFSON, A. & GUSTAFSON, B. - Acute poisoning with dextropropoxyphene. Acta Med. Scand. 200:241, 1976.
23. HATAWAY, P. W.; DHAL, D. S. & ENGEL, W. K. - Myopathic changes produced by local trauma. Arch. Neurol (Chicago) 21:355, 1969.
24. HOLTZMAN, J. L. - Gentamicin and neuromuscular blockade. Ann. Int. Med. 84:55, 1976.
25. JEANMET, A.; GU!YONNADU, C; DUWOOS, H.; NOUVEAU, L.; GOULLE, J. P. & LAINE, G. - Souffrance myocardique et musculaire au cours d'une intoxication médicamenteuse. Coeur et-medicine Interne (Paris) 17:151, 1978.
26. JENSEN, O. B.; MOSDAL, C. & RESKE-NIELSEN, S. - Hypokalemic myopathy during treatment with diuretics. Acta Neurol. Scand. 55:465, 1977.
27. JOONG, S.; ROLLINS, J. L. & LEWIS, I. Pentazocine-induced fibrous myopathy. J.A.M.A. 231:271, 1975.
28. KIPLINGER, G. F. & NICKANDER, R. - Pharmacologic basis for use of propoxyphene. J,A.M.A., 216:289, 1971.
29. KLEIN, N. C. & MAGIDA, M. E. - Propoxyphene hepatotoxicity. Dig. Dis. 16: 467, 1971.
30. KONTOS, H. A. - Myopathy associated with chronic colchicine toxicity. N. Engl. J. Med. 266:38, 1962.
31. LANGER, T. & LEVY, R. I. - Acute muscular syndrome associated with administration of clorofibrate. N. Engl. J. Med. 279:856, 1968.
32. LANE, R. J. M. & MASTAGLIA, F. L. - Drug-induced myopathies in man. Lancet 2:562, 1978.
33. LATEUR, B. J. & HALLIDAY, W. R. - Pentazocine fibrous myopathy: report of two cases and literature review. Phys. Med. Rehabil. 59:394, 1578.
34. LEVIN, B. E. & ENGEL, W. K. - Iatrogenic muscle fibrosis: arm levitation as an initial sign. J.A.M.A. 234:621, 1975.
35. LHERMITE, F.; MARTEAU, R.; CHEDRU, F.; MALLECOURT, J.; ESTRADE, G.; GODET-GUILLAIN, J. & CHEVALLAY, M. - Neuromyopathie à la chloroqutne. Nouvelle Presse médicale 6:3205, 1977.
36. LIPPMANN, S.L. - Lithium: potassium gradient, muscle weakness and the EKG. Nerv. Syst. 38:53, 1977.
37. LINN, K. L. - Acute rhabdomyolysis and acute renal failure after intravenous self-administration of peanut oil. British Med. J. 2:385, 1975.
38. MacKAY, A. R.; SANG, U. H. & WEINSTEIN, P. R. - Myopathy associated with epsilon-aminocaproic acid therapy. J. Neurosurg. 49:597, 1978.
39. MARSDEN, C. D.; REYNOLDS, E. H.; PARSON, V.; HARRIS, R. & DUCHEN, L. Myopathy associated with anticonvulsant osteomalacia. Br. Med. J. 2:526. 1973.
40. MASTAGLIA, F. L.; GARDNER-MEDWIN, D. & HUDGSON, P. - Muscle fibrosis and contracture in a pethidine addict. British Med. J. 2:532, 1971.
41. MILLER, R. R.; FEINGOLD, A. & PAXINOS, J. - Propoxyphene hydrochloride: a critical review. J.A.M.A. 213:996, 1970.
42. MUNK, Z. M. & MANTEL, A. - Acute lindane poisoning with development of muscle necrosis. Can. Med. Assoc. J. 117:1050, 1977.
43. NISHIKAI, M.; FUNATSU, Y. & HOMMA, M. - Monoclonal gammopathy penicil-lamine-induced polymiositis and systemic sclerosis. Arch. Dermatol. 110:253, 1974.
44. OWNBY, C. L.; CAMERON, D. & TU, A. T. - Isolation of myotoxic component from rattlesnake (Crotalus viridis viridis) venom. Am. J. Path. 85:149, 1976.
45. PASTAN, R. S.; SILVERMAN, S. L. & GOLDEMBERG, D. L. - A musculoskeletal syndrome in intravenous heroin users. Ann. Int. Med. 87:22, 1977.
46. PEARLMAN, H. S.; WOLLOWICK, B. S. & ALVAREZ, E. V. - Intra-arterial injection of propoxyphene into brachial artery. J.A.M.A. 214:2055, 1970.
47. PIEDIRES, A. M.; ALVAREZ-UDE, F. & KERR, D. N. S. - Cloribrate-induced muscle damage in patients with chronic renal failure. Lancet 2:1279, 1975.
48. ROSMAN, N. P.; SCHAPIRO, M. B. & HADDOW, J. E. - Muscle weakness caused by and iodine-deficient diet: investigation of a nutritional myopathy. J. Neuro-pathol. Exp. Neurol. 37:192, 1978.
49. RUBIN, E.; KATZ, A. M. LIEBER, C.S.; STEIN, E. P. & PUSKIN. S. - Muscle damage produced by chronic alcohol consumption. Am. J. Pathol. 83:499, 1976.
50. SAUNDERS, F. P.; HOEFNAGEL, D. & STAPLES, O. S. - Progressive fibrosis of the quadriceps muscles. J. Bone Joint Surg. 47-A :380, 1965.
51. SERRANO, E. E. & WILDER, B. J. - Intramuscular administration of diphenylhydantoin. Arch. Neurol. (Chicago) 31:276, 1974.
52. STEINER, J. C; WINKELMAN, A. C. & dc JESUS, P. V. - Pentazocine induced myopathy. Neurol. (Chicago) 28:408, 1973.
53. TENNANT, F. S. - Complications of propoxyphene abuse. Arch. Intern. Med 123:191. 1973.
54. VANHAEVERBEEK, M.; ECTORS, M.; VANHAELST, L. & FRANKEN, L. - Myopatliy caused by polymyxin E: functional disorders of the cell membrane. J. Neurol. Neurosurg. Psychiat. 37:1343, 1974.
55. WECKER, L. & DETBARN. W. D. - Paraoxon-induced myopathy: muscle specificity and acetylcholine involvement. Exp. Neurol. 51:291, 1976.
56. WINFIELD, J. B.; GREER, K. - Cutaneous complications of parenteral pentazocine. South Med. J. 67:292, 1974.
57. WISLICKI, L. - Myasthenic syndrome during treatment with practolol. British Med. J. 2:237, 1976.

Datas de Publicação

Publicação nesta coleção
20 Ago 2012
Data do Fascículo
Mar 1981

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. ABERFELD, D. C; BIENESTOCK, II.; SHAPIRO, M. S.; NAMBA, T. & GROB, D. - Diffuse myopathy related to meperidine addiction in a mother and daughter. Arch. Neurol. (Chicago) 19:384, 1968.

[2] 2.ASKARI, A.; VIGNOS, P. J. & MODKOWITZ, R. W. - Steroid myopathy in connective tissue disease. Am. J. Med. 61:485, 1976.

[3] 3. BENNET, J. - Myopathy from E-aminocaproic acid: a second case, Postgrad. Med. J. 48:440, 1972.

[4] 4. BOGARTS, L. J. & MILLER, W. C. - Pulmonary edema associated with propoxyphene intoxication. J.A.M.A. 215:259, 1971.

[5] 5. BOWDEN, D. H. & GOYER, R. A. - Drug-induced muscle necrosis with massive taurinuria. Arch. Pathol. 74:137, 1962.

[6] 6. BOWKER, C. H. & TURMER, P. - Myopathy after allopurinol. Lancet 1:365, 1977.

[7] 7. BURNHAM, H. A. - Pentazocine-induced fibrous myopathy. J.A.M.A. 234:913, 1975.

[8] 8. CAMPBELL, E. D. R. & MONTUSCHI, E. - Muscle weakness caused by bretilium tosylate. Lancet 2:789, 1960.

[9] 9. CHIU, S. S.; FURUYA. K.: ARAT, T.; NAKAGAWA, M. IIDA, M. - Congenital contracture of the quadriceps muscle. J. Bone Joint Surg. 56-A :1054, 1974.

[10] 10. CLAGHORN, J. L. & SCHOOLAR, J. C. - Propoxyphene hydrochloride: a drug of abuse. J.A.M.A. 196:1089, 1966.

[11] 11. CZLONKOWSKA, A. - Myasthenia syndrome during penicillamine treatment. Britsih Med. J. 1:726, 1975.

[12] 12. DAIKOS, E. K. & KOSMIDIS, J. C. - Propoxyphene Jaundice. J.A.M.A. 238:835, 1975.

[13] 13. DAM. M.; KRISTENSEN, C. B.; HANSEN, B. S. & CHRISTIANSEN, J. - Interaction between carbamazepine and propoxyphene in man. Acta Neurol. Scandinav. 56:603, 1977.

[14] 14. DUBOWITZ, V. Allopurinol in Duchenne muscular distrophy. Lancet 1:248, 1977.

[15] 15. DUBOWITZ, V. & BROOKE, M. - Muscle Biopsy: A Modern Approach, W. R. Saunders Co. Ltd., Philadelphia, 1973.

[16] 16. ENGEL, W. K. - Focal myopathic changes produced by eletromyographic and hypodermic needles: "Needle myopathy". Arch Neurol. (Chicago) 16:509. 1967.

[17] 17. ENGEL, W. K. & ZEE, D. S. - Acupuncture myopathy: remembrance of things passed. N. Engl. J. Med. 291:801, 1974.

[18] 18. FENICHEL, G. M.; DETTBARN, W. D. & NEWMAN, T. M. - An experimental myopathy secondary to excessive acetylcholine release. Neurology (Minneapolis) 24:41, 1974.

[19] 19. FENICHEL, G. M.; KLIBER, W. B.; OLSON, W. H. & DETTBARN, W. D. - Chronic inhibition of cholinesterase as a cause of myopathy. Neurology (Minneapolis) 22:1026, 1972.

[20] 20. GISCH, H. P.; WANDS, J.; YEUNG, J. & DAVIS, P. J. - Pulmonary edema and disseminated intravascular coagulation after intravenors abuse os d-propoxyphene. South. Med. J. 65:493, 1972.

[21] 21. GRAY, J. E. - Local histologic changes following long-term intramuscular injections. Arch. Path. 84:522, 1967.

[22] 22. GUSTAFSON, A. & GUSTAFSON, B. - Acute poisoning with dextropropoxyphene. Acta Med. Scand. 200:241, 1976.

[23] 23. HATAWAY, P. W.; DHAL, D. S. & ENGEL, W. K. - Myopathic changes produced by local trauma. Arch. Neurol (Chicago) 21:355, 1969.

[24] 24. HOLTZMAN, J. L. - Gentamicin and neuromuscular blockade. Ann. Int. Med. 84:55, 1976.

[25] 25. JEANMET, A.; GU!YONNADU, C; DUWOOS, H.; NOUVEAU, L.; GOULLE, J. P. & LAINE, G. - Souffrance myocardique et musculaire au cours d'une intoxication médicamenteuse. Coeur et-medicine Interne (Paris) 17:151, 1978.

[26] 26. JENSEN, O. B.; MOSDAL, C. & RESKE-NIELSEN, S. - Hypokalemic myopathy during treatment with diuretics. Acta Neurol. Scand. 55:465, 1977.

[27] 27. JOONG, S.; ROLLINS, J. L. & LEWIS, I. Pentazocine-induced fibrous myopathy. J.A.M.A. 231:271, 1975.

[28] 28. KIPLINGER, G. F. & NICKANDER, R. - Pharmacologic basis for use of propoxyphene. J,A.M.A., 216:289, 1971.

[29] 29. KLEIN, N. C. & MAGIDA, M. E. - Propoxyphene hepatotoxicity. Dig. Dis. 16: 467, 1971.

[30] 30. KONTOS, H. A. - Myopathy associated with chronic colchicine toxicity. N. Engl. J. Med. 266:38, 1962.

[31] 31. LANGER, T. & LEVY, R. I. - Acute muscular syndrome associated with administration of clorofibrate. N. Engl. J. Med. 279:856, 1968.

[32] 32. LANE, R. J. M. & MASTAGLIA, F. L. - Drug-induced myopathies in man. Lancet 2:562, 1978.

[33] 33. LATEUR, B. J. & HALLIDAY, W. R. - Pentazocine fibrous myopathy: report of two cases and literature review. Phys. Med. Rehabil. 59:394, 1578.

[34] 34. LEVIN, B. E. & ENGEL, W. K. - Iatrogenic muscle fibrosis: arm levitation as an initial sign. J.A.M.A. 234:621, 1975.

[35] 35. LHERMITE, F.; MARTEAU, R.; CHEDRU, F.; MALLECOURT, J.; ESTRADE, G.; GODET-GUILLAIN, J. & CHEVALLAY, M. - Neuromyopathie à la chloroqutne. Nouvelle Presse médicale 6:3205, 1977.

[36] 36. LIPPMANN, S.L. - Lithium: potassium gradient, muscle weakness and the EKG. Nerv. Syst. 38:53, 1977.

[37] 37. LINN, K. L. - Acute rhabdomyolysis and acute renal failure after intravenous self-administration of peanut oil. British Med. J. 2:385, 1975.

[38] 38. MacKAY, A. R.; SANG, U. H. & WEINSTEIN, P. R. - Myopathy associated with epsilon-aminocaproic acid therapy. J. Neurosurg. 49:597, 1978.

[39] 39. MARSDEN, C. D.; REYNOLDS, E. H.; PARSON, V.; HARRIS, R. & DUCHEN, L. Myopathy associated with anticonvulsant osteomalacia. Br. Med. J. 2:526. 1973.

[40] 40. MASTAGLIA, F. L.; GARDNER-MEDWIN, D. & HUDGSON, P. - Muscle fibrosis and contracture in a pethidine addict. British Med. J. 2:532, 1971.

[41] 41. MILLER, R. R.; FEINGOLD, A. & PAXINOS, J. - Propoxyphene hydrochloride: a critical review. J.A.M.A. 213:996, 1970.

[42] 42. MUNK, Z. M. & MANTEL, A. - Acute lindane poisoning with development of muscle necrosis. Can. Med. Assoc. J. 117:1050, 1977.

[43] 43. NISHIKAI, M.; FUNATSU, Y. & HOMMA, M. - Monoclonal gammopathy penicil-lamine-induced polymiositis and systemic sclerosis. Arch. Dermatol. 110:253, 1974.

[44] 44. OWNBY, C. L.; CAMERON, D. & TU, A. T. - Isolation of myotoxic component from rattlesnake (Crotalus viridis viridis) venom. Am. J. Path. 85:149, 1976.

[45] 45. PASTAN, R. S.; SILVERMAN, S. L. & GOLDEMBERG, D. L. - A musculoskeletal syndrome in intravenous heroin users. Ann. Int. Med. 87:22, 1977.

[46] 46. PEARLMAN, H. S.; WOLLOWICK, B. S. & ALVAREZ, E. V. - Intra-arterial injection of propoxyphene into brachial artery. J.A.M.A. 214:2055, 1970.

[47] 47. PIEDIRES, A. M.; ALVAREZ-UDE, F. & KERR, D. N. S. - Cloribrate-induced muscle damage in patients with chronic renal failure. Lancet 2:1279, 1975.

[48] 48. ROSMAN, N. P.; SCHAPIRO, M. B. & HADDOW, J. E. - Muscle weakness caused by and iodine-deficient diet: investigation of a nutritional myopathy. J. Neuro-pathol. Exp. Neurol. 37:192, 1978.

[49] 49. RUBIN, E.; KATZ, A. M. LIEBER, C.S.; STEIN, E. P. & PUSKIN. S. - Muscle damage produced by chronic alcohol consumption. Am. J. Pathol. 83:499, 1976.

[50] 50. SAUNDERS, F. P.; HOEFNAGEL, D. & STAPLES, O. S. - Progressive fibrosis of the quadriceps muscles. J. Bone Joint Surg. 47-A :380, 1965.

[51] 51. SERRANO, E. E. & WILDER, B. J. - Intramuscular administration of diphenylhydantoin. Arch. Neurol. (Chicago) 31:276, 1974.

[52] 52. STEINER, J. C; WINKELMAN, A. C. & dc JESUS, P. V. - Pentazocine induced myopathy. Neurol. (Chicago) 28:408, 1973.

[53] 53. TENNANT, F. S. - Complications of propoxyphene abuse. Arch. Intern. Med 123:191. 1973.

[54] 54. VANHAEVERBEEK, M.; ECTORS, M.; VANHAELST, L. & FRANKEN, L. - Myopatliy caused by polymyxin E: functional disorders of the cell membrane. J. Neurol. Neurosurg. Psychiat. 37:1343, 1974.

[55] 55. WECKER, L. & DETBARN. W. D. - Paraoxon-induced myopathy: muscle specificity and acetylcholine involvement. Exp. Neurol. 51:291, 1976.

[56] 56. WINFIELD, J. B.; GREER, K. - Cutaneous complications of parenteral pentazocine. South Med. J. 67:292, 1974.

[57] 57. WISLICKI, L. - Myasthenic syndrome during treatment with practolol. British Med. J. 2:237, 1976.