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Neurology (Expert Forum)
Lots of symptoms - no clear answers... cont.
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Lots of symptoms - no clear answers... cont.
by stephz, Dec 19, 2005 12:00AM
I'm very sorry to cut short the previous post, but there's not a lot of room... here's the rest...
Bloodwork:
Everything is within normal ranges except:
Glucose = 114 (high - diabetic neuropathy?)
ALT = 46 (high - viral infection?)
MPV = 6 (low)
Lymph = 17 (low - )
Seg = 75 (high - )
Ca Channel Bind Ab, P/Q = 0
Ca Channel Bind Ab, N = TNP
ACh Resep Muscle Bind Ab = 0
Lyme Antibody Screen = Negative
ANA Screen = Negative
Paraneoplast CRMP5 IgG = Negative
TSH Hormone = 1.7 (normal)
PTH Hormone = 45.4 (normal)
Miscellaneous:
I don't have the facts, but he says that the following have been ruled out: Huntington's Disease, Kennedy's Disease, Lyme Disease, HIV
He has pain in lower back and in neck. When he sits with his legs crossed, they go numb.
When he pulls his chin to his chest and arches his back, the fasciculations in his arms go away.
Questions:
1. Could he have MMN or D-LMN instead? He doesn't appear to have any muscle weakness and his physical exam showed no upper motor neuron loss at this time.
2. How come he was told there is a strong possibility of ALS when everything I've read says it's not possible without upper motor neuron loss?
3. He was told by his doctor that there's a very small chance it could be a viral infection. How would we know?
4. His mild stenosis, bulging, and sciatica were promptly dismissed as being part of the problem.
Why - especially when EMG shows concern in the same areas where stenosis or bulging occurs?
5. Could this be a combination of other things and not necessarily ALS?
Thank you so much!
Bloodwork:
Everything is within normal ranges except:
Glucose = 114 (high - diabetic neuropathy?)
ALT = 46 (high - viral infection?)
MPV = 6 (low)
Lymph = 17 (low - )
Seg = 75 (high - )
Ca Channel Bind Ab, P/Q = 0
Ca Channel Bind Ab, N = TNP
ACh Resep Muscle Bind Ab = 0
Lyme Antibody Screen = Negative
ANA Screen = Negative
Paraneoplast CRMP5 IgG = Negative
TSH Hormone = 1.7 (normal)
PTH Hormone = 45.4 (normal)
Miscellaneous:
I don't have the facts, but he says that the following have been ruled out: Huntington's Disease, Kennedy's Disease, Lyme Disease, HIV
He has pain in lower back and in neck. When he sits with his legs crossed, they go numb.
When he pulls his chin to his chest and arches his back, the fasciculations in his arms go away.
Questions:
1. Could he have MMN or D-LMN instead? He doesn't appear to have any muscle weakness and his physical exam showed no upper motor neuron loss at this time.
2. How come he was told there is a strong possibility of ALS when everything I've read says it's not possible without upper motor neuron loss?
3. He was told by his doctor that there's a very small chance it could be a viral infection. How would we know?
4. His mild stenosis, bulging, and sciatica were promptly dismissed as being part of the problem.
Why - especially when EMG shows concern in the same areas where stenosis or bulging occurs?
5. Could this be a combination of other things and not necessarily ALS?
Thank you so much!
Doctor's Answer
by CCF-Neuro-M.D.-PW, Dec 21, 2005 12:00AM
1) MMN is characterised by weakness (of which there is apparently none) and conduction block on nerve conduction studies (which there is no documentation of either. I'm not sure what you mean by D-LMN.
2) classically ALS has a combination of upper and lower motor neuron signs (ie fasciculations and increased refelxes), but there are even rarer variants that can appear as a lower motor neuron (progressive muscular atrophy) or upper motor neuron (primary lateral sclerosis).
3) In many viral infections, isolation of teh exact virus/cause is not possible. Herpes viruses can sometimes attack nerve roots, but unless increases in viral antibodies at the time of the infection are found (which is rarely done) diagnosis is difficult. As your doctor said, its a very small chance.
4) The lower extremity findings could be consistent with a sciatic nerve or S1 root problem such as commpression by a disc.
5) ALS is rare, and unlikely in the absence of muscle weakness, wasting, fasciculation and/or bulbar symptoms. The upper extremity findings could also localize to the upper trunk or C6 nerve root in that arm, caused by possible cervical spine disease - have you had a neck MRI?
Please note that the interpretation of the EMG findings is extremely difficult without knowing objectively what the findings are, and the skill of the EMGer. Whereas your findigns could be consistent with radiculopathies, I cannot ruleout whatever true findings there are.
The glucose is uninterpretable without knowing if you were fasting, after a meal etc, if fasting you should get confirmatory tests for diabetes. Diabetes is a common cause of neuropathy and sometimes radiculopathy.
Please refrain from using more than one question slot a day, there is only two per day, and we should allow other people the opportunity to ask a question. Additional comments cna be added in the add comment section of the forum.
Thank you
2) classically ALS has a combination of upper and lower motor neuron signs (ie fasciculations and increased refelxes), but there are even rarer variants that can appear as a lower motor neuron (progressive muscular atrophy) or upper motor neuron (primary lateral sclerosis).
3) In many viral infections, isolation of teh exact virus/cause is not possible. Herpes viruses can sometimes attack nerve roots, but unless increases in viral antibodies at the time of the infection are found (which is rarely done) diagnosis is difficult. As your doctor said, its a very small chance.
4) The lower extremity findings could be consistent with a sciatic nerve or S1 root problem such as commpression by a disc.
5) ALS is rare, and unlikely in the absence of muscle weakness, wasting, fasciculation and/or bulbar symptoms. The upper extremity findings could also localize to the upper trunk or C6 nerve root in that arm, caused by possible cervical spine disease - have you had a neck MRI?
Please note that the interpretation of the EMG findings is extremely difficult without knowing objectively what the findings are, and the skill of the EMGer. Whereas your findigns could be consistent with radiculopathies, I cannot ruleout whatever true findings there are.
The glucose is uninterpretable without knowing if you were fasting, after a meal etc, if fasting you should get confirmatory tests for diabetes. Diabetes is a common cause of neuropathy and sometimes radiculopathy.
Please refrain from using more than one question slot a day, there is only two per day, and we should allow other people the opportunity to ask a question. Additional comments cna be added in the add comment section of the forum.
Thank you
Why did you go to a doctor if you have no weakness, no tripping, slurring, or coordination problems? Just because fasciculations?
What did your doctor say? Does he think it is ALS looking the results of EMG?
All the best for you.
He was, of course, concerned about ALS but did not know at the time that the lack of muscle weakness should cause no concern. After he went and had an EMG, doctors told him ALS was likely. I'm assuming they said this based on the EMG results alone. (Please see previous post for EMG info.)
I'm concerned because it seems like it came on all too sudden and he has no weakness at this time yet two doctors are telling him it's likely. Meanwhile, he'll have his second EMG on Jan 23 and it's torture for him to wait to see if he gets weak or if his second will be worse so I'm trying to do a lot of investigation for him to see what else it could be to give him hope, albeit somewhat guarded.
In may I began with fasciculations. They are widespread and they aren't constants, just sometimes.
I went in 2 doctors specialized in ALS and both of them said me the same: without muscle wasting and weakness, NO ALS.
Are the doctors of your bothers neurologists specialized in neuromuscular diseases? What were the results of clinical exames (reflexes, weakness,...)?
How about the fasciculations of your brother? Are they constant in his arms and legs, during whole day?
I hope (and I think) your brother don't have ALS.
All the best for you.