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Subject: Re: possible ms ... maybe/maybe not
Forum: The Neurology and Neurosurgery Forum
Topic Area:
Posted by CCF MD mdf on March 19, 1998 at 09:51:05:
In Reply to: possible ms ... maybe/maybe not posted by Stacey on March 16, 1998 at 14:50:13:
: Hello. I'm a 27 year old woman living with my husband and 28-month old son in northwestern Vermont. Last year on 2/20/97, I had an emergency neuro. exam at which time I was rxed oral steroids after a rapid onset of symptoms that worsened over a 1 -2 week period. My symptoms were "acute vertigo", an inability to turn my right eye out, total right side facial paralysis, double vision and intermittent foggy vision in my right eye, right side tinnitus, difficulties with speech, progressively weakening legs (right leg worse), right-side weakness which made it impossible for me to walk. The dr. was "99% certain" I have MS. I began having bladder incontinence and was choking on liquids. I was hospitalized on 2/24/97.
I was treated at the hospital with 8 days of IV Prednisone. I had a CT Scan, brain and cervical MRI, a LP and several blood tests - all normal. I was discharged to a rehab. center where I did 3 weeks of intensive inpatient rehab. I had a 14 day taper of oral Prednisone. Also while at rehab I was examined by a psychiatrist and had tests to rule out Conversion Reaction - also negative.
I have yet to have what my neuro would classify as a full remission. My condition improved very gradually with hard work in both land-based and aquatic physical therapy. I am currently taking 100 mg of Amantadine 1x each a.m.. A urologist rxed Ditropan tablet a.m. and early p.m. and 1 tab. at bedtime for urge and hesitancy incontinence "caused by a spastic bladder".
In 11/97 I had another brain and cervical MRI. We discussed the possibility of having tests for Conversion Reaction if my MRI was again found negative.
The radiology report findings are quoted below:
". . . There is noted to be one focus of high signal adjacent to the left lateral ventricle, which is not definitely seen on the prior study and may be new. There is a very questionable second lesion seen on proton density image 14 just medial to the atria of the left lateral ventricle, but I suspect this is just a vein. . . ."
The neuro. decided against the psych. testing as he could not rule out a neuro. problem with the presence of an abnormal MRI, although unconcerned about "UBO".
I've recently reviewed my medical records from the time I was hospitalized. Although I was told that all my tests at the hospital were normal, I discovered as I looked at the lab results that there were abnormalities listed. My neuro. has not seen these results, and is not interested in looking at them. He is certain that if they are of importance they would have been brought to my attending neuro.'s attention at that time. It appears by the date on the lab report that the results did not return to the hospital until after I was discharged and after my attending neuro. had finished his rotation. The results in question were reported as follows:
Hemagram and Differential - ABS Neutro. - high - 9.17
R1343 Fluid Differential - Lymphocyte - high - 93
- Mono/Macro - low - 4
R1259 Protime=11.8 I.N.R. =0.9 PTT = 25-low
Could you please interpret these for me?
Since 2/2/98 I've had an onset of new symptoms and worsening of old symptoms. The symptoms include dizziness and fatigue which is improved with extended sleep, my left arm and left leg are weak, my left cheek feels heavy and appears a bit droopy. At times I feel like my eyes are not moving together. I have blurred vision in both eyes. My right side is weak, though the left is definitely worse. Following any amount of physical exertion, I have tremors in my hands and legs. I'm having difficulty swallowing food. My worst and latest symptom is difficulty breathing, as though someone is sitting on my chest or stomach. It is most apparent when I'm eating, after I've talked a while and worsens if I am at all tired. I've been forced to dis-continue physical therapy and now I feel I've lost all the strength and balance I had gain.
***I tried posting the above info. about 2 weeks ago and had some trouble with my post. I have recently upgraded my computer and so I'm going to try to post once again. Sorry for any trouble ...
Presently, after about 7 weeks of "being down", I have begun to feel stronger and have better endurance. My coordination has suddenly improved as well and I am now able to walk with forearm crutches, for four or five steps at a time. I am still having considerable difficulty with my swallowing and breathing. I can swallow, but it feels inefficient - the food gets stuck and occasionally I choke on liquids. My breathing is improved, as well, although it is still very bad when I am eating or when my son sits on my lap and lays his head against my chest, also after physical exertion. My neuro is not willing to treat these symptoms as I do not have a positive dx and he says that labored breathing is not a ms symptom. I saw my g.p. for this, and pulmonary problems as well as anxiety were ruled out with several tests. My g.p. believes that my breathing difficulty is muscular and has referred me back to my neuro for the possibility of a neuromuscular disorder. I had a blood test for Myasthenia Gravis which was negative. My neuro. has now referred me back to my g.p. as he has run out of ideas for causes.
It might be helpful for you to know that I have a history of unexplained symptoms, such as intermittent blurred vision, fatigue, "clumsiness", and bladder incontinence, that go back about seven years.
I know that something is very wrong with me. Can you suggest other dx/tx? Is breathing difficulty really not a symptom of ms? Any enlightenment would be very much appreciated. = Wow, you've really had some hard times. I'm glad you reported you're getting better. When neurologists try to fit symptoms and physical exam findings into a diagnosis, the first order of business is to localize the part of the nervous system from which the problem arises. The second task is to try to figure out what the actual process is. The original symptoms from 02-97 appear to be related to malfunction of parts of the brain stem, particularly the regions around cranial nerves 6, 7, 8, 9, and 10 on the right. The bladder incontinence doesn't fit with that - it may reflect a spinal cord problem. The question is, what's the lesion? If it's MS, your problems are due to damage to myelin coating of fibers passing through the region. But there are potentially other causes which must be ascertained in a careful interview, physical exam, and thoughtfully selected tests. Of particular importance is an imaging study of the brainstem. A typical brain MRI usually is good enough for that, though a CT scan of the brain would be inadequate. Interpretation of the MRI finding is difficult without seeing the film itself. Even then, it is often unclear what a UBO really means. Be aware that the location you reported does not correlate with symptoms. However, if it is a demyelinating lesion in that location, it lends support to the diagnosis of MS even if the lesion in the brainstem is not documented. The lab tests you mentioned must be taken in context. An absolute neutrophil count (part of the CBC) will fluctuate from day to day, and may mean nothing at all or it might have significance. Likewise, without the whole report of your CSF examination, the lymphocyte and mono/macro count can't be interpreted. The PT/PTT/INR looks OK, but again caveat emptor: it must be taken in context. I can't say from the data at hand what your diagnosis is, but would advise you to seek a second neurologic opinion. For complex cases like yours, your best bet is an academic center such as a university neurology department. Of course, if you live close to Cleveland, you are welcome to call 800 223 2273 and request an appointment with the neurology department. Hope this helps. Of course, this is general information for your education only. Any specific medical advice regarding your diagnosis, treatment options, and prognosis MUST come from your physician. CCF MD mdf.
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