Burning Pain and Aching

31 yo F in med field.  Hx of depression/anxiety after 9/11 and then serious panic/anxiety up until 2003.  Cognitive Tx last 5 yrs and meds really helped.  Aug. 06 - had some stress.  Began getting tingling big toe.  In few months, it spread to other toes and foot, up foot to calves. Dec '06 - couldn't walk up stairs w/o great effort, lost control of bowels for 4 days, no fever, but extreme fatigue, mild red rashes, fasciculations & aching joints.  Shaking limbs.  Jan 06 - MRI w/contrast brain & spinal cord - one small lesion on cc (Hx of migraines).  MS workup norm (lumbar puncture, VEP).  EMG norm.  ANA norm, SED rate norm, all bloodwork norm EXCEPT elevated IgM - "apparent monoclonal gammopathy".  Neuro sent me to a pain clinic with a Dx of Fibro.  I do not want to be labeled incorrectly.  Fam Hx of rheumatoid arthritis. The two rheumatologists in town won't see me down b/c they "do not accept Fibro patients."  Had a "chronic fatigue panel" and found my IgM levels for HSV-1, CMV and HHV-6 to be elevated as if I had active infection, however, I have never had a cold sore in my life.  Neuro put me on Neurontin, Famvir, Pamelor and Cymbalta.  My symptoms SLOWLY got better until this August.  I  have had a "flair up" of the same symptoms again.  My feet are burning (especially when in heat/sun), joints aching, fatigue, fasciculations, weak calves, cold extremities and feeling hot, but no fever.  My neuro ordered another panel, but I am wondering if I should see a rheumatologist or immunologist.  I don't seem to get sick with URIs, or any other infections easily??  I just had a physical with labwork and HIV test, all numbers looked great to my family doc, but I am experiencing these horrible symptoms that nobody can see.  Pain clinic said it looks like "classic" idiopathic peripheral neuropathy.  Where do I go from here? I want pain relief & an accurate diagnosis may be helpful before my nerves are completely destroyed.

[Kevin Pho, MD]

This is certainly a difficult case, and I agree with the comprehensive workup thus far.

I can't think of any other tests to be considered, as you pretty much have had everything done.  Many of the major neurologic and rheumatologic diseases would have been ruled out already.  

At this time, obtaining further opinions can be considered.  Another neurologist and/or rheumatologist referral can be obtained, preferably at a major academic medical center.  Monoclonal gammopathy can be evaluated by an immunologist - but it is less likely to lead to the symptoms you describe.  

If the consults continue to be non-revealing, obtaining care at a pain clinic to manage the symptoms is reasonable.

These options can be discussed with your personal physician.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
kevinmd_

[Hope75]

[Hope75]

Thanks.  I realize it is complex, and agree with your advice about a major academic medical center.

[Gangster58]

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