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Neurology (Expert Forum)
ALS, MS or something Else?
This forum is for questions and support regarding neurology issues such as: Alzheimer's Disease, ALS, Autism, Brain Cancer, Cerebral Palsy, Chronic Pain, Epilepsy, Fibromyalgia, Headaches, MS, Neuralgia, Neuropathy, Parkinson's Disease, RSD, Sleep Disorders, Stroke, Traumatic Brain Injury
ALS, MS or something Else?
by seeking_help, Apr 03, 2005 12:00AM
I am sorry for this being so long. I have waited several months to post hoping this would go away.
44 y/o male. Thought I was generally healthy. Worked out at gym & jogged regularly. Was taking Acyclovir for gential herpes for 45 days then stopped prior to symptoms.
Problems started in 10/04. Felt like I had a bug . Had strange sensation in face in corner & under right eye & felt poorly all over. Right hand had some pain in 4th & 5th finger felt numb by wasn’t really. PCP gave me Z-Pack for sinus. Symptoms continued & also had little burning feelings under my skin all over. Went to ER. Did a CT scan okay except for inflammatory in ethmoid sinus, heavy metal screen- normal. Prescribed 1 week of steroids. Made Neuro appt.
Mid Oct/04 - Neuro did full office exam – normal. Ordered a MRI w/wo contrast. MRI results – 1)Mild generalized volume loss of undetermined etiology 2)several predominantly subcortical white matter changes left greater than right – probably nonspecific but most consistent with ischemic small vessel changes – not felt likely to represent focal demyelinization due to distribution. 3)Skull is unremarkable. 4)Repeat in 3-6 months.
Neuro followed up with blood work CBC, Glucose, CPK, ESR, ANA, Sjogren, B12,RPR, TSH, Lyme – all normal except B12 was 276 (range 211-911)
PLEASE SEE CONTINUED in COMMENTS THANKS!
44 y/o male. Thought I was generally healthy. Worked out at gym & jogged regularly. Was taking Acyclovir for gential herpes for 45 days then stopped prior to symptoms.
Problems started in 10/04. Felt like I had a bug . Had strange sensation in face in corner & under right eye & felt poorly all over. Right hand had some pain in 4th & 5th finger felt numb by wasn’t really. PCP gave me Z-Pack for sinus. Symptoms continued & also had little burning feelings under my skin all over. Went to ER. Did a CT scan okay except for inflammatory in ethmoid sinus, heavy metal screen- normal. Prescribed 1 week of steroids. Made Neuro appt.
Mid Oct/04 - Neuro did full office exam – normal. Ordered a MRI w/wo contrast. MRI results – 1)Mild generalized volume loss of undetermined etiology 2)several predominantly subcortical white matter changes left greater than right – probably nonspecific but most consistent with ischemic small vessel changes – not felt likely to represent focal demyelinization due to distribution. 3)Skull is unremarkable. 4)Repeat in 3-6 months.
Neuro followed up with blood work CBC, Glucose, CPK, ESR, ANA, Sjogren, B12,RPR, TSH, Lyme – all normal except B12 was 276 (range 211-911)
PLEASE SEE CONTINUED in COMMENTS THANKS!
Doctor's Answer
by CCF-Neuro-M.D.-PW, Apr 07, 2005 12:00AM
1) while ALS can cause a certain type of 'twitching' called 'fasciculations' I do not know of you really have fasciculation as opposed to other types of 'twitching'. Fasciculations are more continuous relatively slow irregular multifocal (in the same area). Other types of twitches occur that are more focal, faster, and more regular, that are not associated with ALS. A neurologist should be able to rcognise this if seen, and an EMG with active twitching can also differentiate this
Real fasciculations in the absence of muscle weakness and wasting (including the tongue, pharynx etc if that area is involved) is unlikely to be ALS.
2) strenght testing within the foot is difficult to judge. A better objective test of nerve damage in the foot is the EMG. Many other things than ALS can cause twitching in the foot including just for instance local trauma to the foot nerves from eg tight shoes. Again without EMG or clinical evidence of wasting it is unlikely to be ALS. Wasting would appear as a 'guttered' appearance between the tendons
3) see 1
4) see 2
5) that area is in the distribution of the trigeminal nerve which goes from the brainstem to the face skin areas. Anything in this path can cause irritation of the nerve and intermittent or constant symptoms. Sometimes a abnormal blood vessel loop can compress the nerve at the brainstem, and surgery is available if this is diagbnosed and symptoms are intolerable. An MRI concentrating on the trigeminal nerve may reveal this, other reasons like a tumor or growth would be seen on a regular MRI
6) I'm not sure why you are taking B12 if you have not been diagnosed with deficiency or a cause for the deficiency
7) Stress and anxiety can cause any neurological symptom, but this is a diagnosis of exclusion (other things need to be excluded)
8) what is elevating your arms? if it is the sides to an armchair or similar, you could be compressing a nerve in the arm
the resolution is to avoid the situation if possible with your arms elevated during sleep
I cannot give you a clinical diagnosis over the internet, but you should be at least encouraged that nothing serious has turned up at this point. Other potential causes include a type of postviral sensory neuropathy, Lyme, sarcoid, exclude a mass or blood vessel loop, or local trauma. The mildly elevated CSF protein is non-specific but could be consistent with a postviral neuropathy.
Good luck
Real fasciculations in the absence of muscle weakness and wasting (including the tongue, pharynx etc if that area is involved) is unlikely to be ALS.
2) strenght testing within the foot is difficult to judge. A better objective test of nerve damage in the foot is the EMG. Many other things than ALS can cause twitching in the foot including just for instance local trauma to the foot nerves from eg tight shoes. Again without EMG or clinical evidence of wasting it is unlikely to be ALS. Wasting would appear as a 'guttered' appearance between the tendons
3) see 1
4) see 2
5) that area is in the distribution of the trigeminal nerve which goes from the brainstem to the face skin areas. Anything in this path can cause irritation of the nerve and intermittent or constant symptoms. Sometimes a abnormal blood vessel loop can compress the nerve at the brainstem, and surgery is available if this is diagbnosed and symptoms are intolerable. An MRI concentrating on the trigeminal nerve may reveal this, other reasons like a tumor or growth would be seen on a regular MRI
6) I'm not sure why you are taking B12 if you have not been diagnosed with deficiency or a cause for the deficiency
7) Stress and anxiety can cause any neurological symptom, but this is a diagnosis of exclusion (other things need to be excluded)
8) what is elevating your arms? if it is the sides to an armchair or similar, you could be compressing a nerve in the arm
the resolution is to avoid the situation if possible with your arms elevated during sleep
I cannot give you a clinical diagnosis over the internet, but you should be at least encouraged that nothing serious has turned up at this point. Other potential causes include a type of postviral sensory neuropathy, Lyme, sarcoid, exclude a mass or blood vessel loop, or local trauma. The mildly elevated CSF protein is non-specific but could be consistent with a postviral neuropathy.
Good luck
Late Oct/05 - Ordered LP –Chemistry - CSF Glucose, Protein, Oligoclonal Bands, CSF Inflammation Panel, Microbiology – India Ink, VDRL, Fungal Culture, ADB Culture, Hematology – cell count, Differential, Miscellaneous - Mylen Basic Protein, Viral Culture, Cytology - all in range except RBC was 2 & CSF Protein was 52 (range was 15-45).
Ordered VERS – normal.
Neuro thought it was aniexty.
Nov 04 – Had same symptoms as before plus started having twitching in lower abdomen & over left ear, left inner thigh and a few places here & there. Neuro ordered spine MRI w/wo contrast– blood work of RA & Anti DNA DS – blood work normal.
MRI Spine results:
Cervical – 1)Mild degenerative changes without any central canal stenosis. 2)the neural foramen show very minimal narrowing on the left at c6-7.
Lumbar – 1)Very minimal degenerative changes of the lumbar spine without any central canal or neural foraminal stenosis.
Thoracic – Unremarable.
Neuro did EMG 11/10/04 of RU & LL extremities. Results revealed R ulnar neuropathy which is related to previous injury to R ulnar nerve otherwise normal. Neuro said see someone for anxiety.
Mid Dec/04 Symptoms persist with occasional pain in right hand but numb feeling gone, more twitching moving around some and face sensations causing my R eye to feel watery and the R corner of my lips to feel numb although they are not. Most twitching comes and goes except for R foot along the arch to my big toe & on the outside from my little toe down. Also have Right foot pain from time to time. Scheduled 2nd opinion with new Neuro for Jan /05.
Neuro appt consist of in office exam –seemed normal. Twitching in R foot now for over 1 month. Tried to show him but it didn’t do it then. Neuro ordered blood work, evoked potential of upper and lower extremities and EEG and repeat of Brain MRI.
Neuro Appt 03/05.
Brain MRI – no change from first MRI, EEG – Normal. Evoked Potentials normal. Blood Work RPR normal, positive for Epstein Barr and HSV 1 & 2. Neuro thinks EB virus has been in system for a long time and doesn’t seem worried. I showed him R foot again & it was twitching! He looked right at it as my concerns for ALS are high & said “that doesn’t look like ALS.” He looked at my calf muscle and asked me to walk across the room and back. I should have made him give me an EMG!. He said he thought my brain MRI was just normal aging and didn’t seem concerned with the weird sensation that goes from the corner of my R eye down to the corner of my right lips