What is the likely diagnosis for a 6-week-old infant with normal eye fixation, weak anti-gravity (against gravity) movement, normal Creatine Kinase (CK) levels, and decreased reflexes?

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Diagnosis: Spinal Muscular Atrophy (SMA) Type 1

The most likely diagnosis is Spinal Muscular Atrophy (SMA) Type 1, given the combination of decreased reflexes with hypotonia at 6 weeks of age, which is pathognomonic for lower motor neuron disease. 1

Key Diagnostic Features Supporting SMA

The clinical presentation is classic for SMA Type 1:

  • Decreased or absent reflexes with hypotonia in early infancy is pathognomonic for lower motor neuron disease, specifically SMA 1
  • Weak anti-gravity movements at 6 weeks with decreased reflexes represents the hallmark presentation of early-onset SMA 1
  • Normal eye fixation is characteristic of SMA, as extraocular muscles are typically spared 1
  • Normal CK essentially excludes muscular dystrophies, which characteristically show CK elevations often >1000 U/L 1

Why Other Diagnoses Are Excluded

Congenital Myopathy (Option A) is ruled out:

  • Congenital myopathies typically preserve or show normal to slightly decreased reflexes, not the markedly decreased reflexes seen in this patient 1, 2
  • Hypotonia with preserved reflexes is the classic presentation of congenital myopathy, whereas SMA has decreased reflexes 1, 2
  • The absence of preserved reflexes argues strongly against a primary muscle disorder 3

Duchenne Muscular Dystrophy (Option C) is excluded:

  • DMD does not present at 6 weeks of age; symptoms typically begin between 2-5 years 1
  • Normal CK rules out DMD, which shows markedly elevated CK levels (>1000 U/L) 1, 3

The term "Muscular Atrophy" (Option D) is non-specific and does not represent a distinct diagnosis

Clinical Context for SMA Type 1

SMA Type 1 (Werdnig-Hoffmann disease) presents before 6 months of age with:

  • Profound weakness and hypotonia 1, 4
  • Absent or markedly diminished reflexes 1, 4
  • Normal cognitive development with expressive gaze contrasting with paralytic posture 4
  • Respiratory involvement predominantly affecting intercostal muscles 4

The onset at 6 weeks places this patient in the Type IB category (onset before 3 months), which implies no head control 4

Immediate Management Steps

Urgent genetic testing for SMN1 gene deletion is the definitive diagnostic test and should be ordered immediately 1

Early diagnosis is critical because disease-modifying therapies (nusinersen, onasemnogene abeparvovec, risdiplam) are most effective when initiated early in the disease course 1

Common Pitfall to Avoid

Do not be misled by normal CK levels into considering muscular dystrophy. While mild to moderately elevated CK can occur in SMA (particularly Type III), normal CK is common in SMA Type I and does not exclude the diagnosis 5. The key distinguishing feature is the combination of decreased reflexes with hypotonia, which points definitively to lower motor neuron disease rather than primary muscle disease 1.

References

Guideline

Diagnosis and Management of Spinal Muscular Atrophy (SMA)

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Guideline

Congenital Myopathy Diagnosis and Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Guideline

Congenital Myopathy Diagnosis and Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Research

Spinal muscular atrophy (SMA) type I (Werdnig-Hoffmann disease).

Archives de pediatrie : organe officiel de la Societe francaise de pediatrie, 2020

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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