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clinics, but her symptoms did not improve with the   Conflicts of interest
            use of the muscle-relaxants prescribed.           There are no conflicts of interest.
            DISCUSSION                                        REFERENCES


            ALS has many varied manifestations as first       1.   Logroscino G, Traynor BJ, Hardiman O, Chiò A, Mitchell D,
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                                                                  clinical practice and research. Muscle Nerve 2014;49:786-803.
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            electrodiagnostic (EMG/nerve conduction velocity)   5.   Chen L, Zhang B, Chen R, Tang L, Liu R, Yang Y, Yang Y, Liu
            evidence of denervation. Besides MNDs, other etiology   X, Ye S, Zhan S, Fan D. Natural history and clinical features of
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                                                    [14]
            electrolyte disturbances, medications,  etc.  Our   6.   Huynh  W,  Kiernan  MC.  A  unique  account  of  ALS  in  China:
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            examinations which support the other disease. As to   7.   2015;86:1051-2.
                                                                  Robberecht W, Philips T. The changing scene of amyotrophic lateral
            pathophysiology, the muscle cramps may arise from     sclerosis. Nat Rev Neurosci 2013;14:248-64.
            spontaneous discharges of the motor nerves, this may   8.   Shoesmith CL, Findlater K, Rowe A, Strong MJ. Prognosis of
            origin at neuronal level and then transferred through   amyotrophic lateral sclerosis with respiratory onset.  J Neurol
                                                                  Neurosurg Psychiatry 2007;78:629-31.
            the nerve trunks to the muscular fibers or it may   9.   Nalini A, Thennarasu K, Gourie-Devi M, Shenoy S, Kulshreshtha
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                                                                  India. J Neurol Sci 2008;272:60-70.
            The neurodegeration in ALS might be caused by a   10.  Caress JB, Ciarlone SL, Sullivan EA, Griffin LP, Cartwright MS.
            complicated interaction of glutamate excitotoxicity,   Natural history of muscle cramps in amyotrophic lateral sclerosis.
                                                                  Muscle Nerve 2015;53:513-7.
            generation of free radicals, superoxide dismutase 1   11.  Ioannides ZA, Henderson RD, Robertson T, Davis M, McCombe
            enzymes,  resulting  in  impaired  axonal  structure  or   PA. When does ALS start? A novel SOD-1 p.Gly142Arg mutation
            transport  defects. [2,14]   A  “dying-forward”  process  is   causing motor neurone disease with prominent premorbid cramps
                                                                  and spasms. J Neurol Neurosurg Psychiatry 2015; doi: 10.1136/
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                                                              12.  Brooks BR, Miller RG, Swash M, Munsat TL, World Federation of
            Hitherto,  there  is  no  disease-modifying  therapeutics   Neurology Research Group on Motor Neuron Diseases. El Escorial
            for ALS. The main managements for patients with ALS   revisited: revised criteria for the diagnosis of amyotrophic lateral
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            are the symptomatic treatments, including muscle      2000;1:293-9.
            relaxants, anticonvulsants for cramps, fasciculations   13.  Ringel SP, Murphy JR, Alderson MK, Bryan W, England JD, Miller
            and spasticity, physiotherapy for weakness or disability,   RG, Petajan JH, Smith SA, Roelofs RI, Ziter F. The natural history of
                                                                  amyotrophic lateral sclerosis. Neurology 1993;43:1316-22.
            and ventilator support for dyspnea, [2,14]  These treatments   14.  Kiernan MC, Vucic S, Cheah BC, Turner MR, Eisen A, Hardiman
            can alleviate symptoms, improve the quality of life and   O,  Burrell  JR,  Zoing  MC.  Amyotrophic  lateral  sclerosis.  Lancet
                                                                  2011;377:942-55.
            increase the life expectancy.                     15.  Ferguson TA, Elman LB. Clinical presentation and diagnosis of
                                                                  amyotrophic lateral sclerosis. NeuroRehabilitation 2007;22:409-16.
            In conclusion, our case presents a rare initial   16.  Moirangthem V, Ouseph MM. Atypical presentations of
            manifestation of progressive painful muscle cramps in   amyotrophic lateral sclerosis: a case report. J Neuropsychiatry Clin
                                                                  Neurosci 2011;23:362-4.
            the absence of muscle weakness. It helps to improve our   17.  Shemisa K, Kaelber D, Parikh SA, Mackall JA. Autonomic etiology
            early recognition of the atypical initial presentations of   of heart block in amyotrophic lateral sclerosis: a case report. J Med
                                                                  Case Rep 2014;8:224.
            ALS, and formulate effective symptomatic therapies to   18.  Miller TM,  Layzer RB. Muscle cramps.  Muscle Nerve
            improve the life quality and survival of the patients.  2005;32:431-42.
                                                              19.  Browne SE, Yang L, DiMauro JP, Fuller SW, Licata SC, Beal MF.
            Financial support and sponsorship                     Bioenergetic abnormalities in discrete cerebral motor pathways
                                                                  presage spinal cord pathology in the G93A SOD1 mouse model of
            Nil.                                                  ALS. Neurobiol Dis 2006;22:599-610.



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