Quick progression- could it be something other than ALS?

Hello,
My father had absolutely no symptoms (except for fasciculations in upper arms for about a year), fell last December, and then developed drop foot and weakness in his arm on same side. Had the EMG in the spring at local hospital that produced diagnosis of ALS/spinal myelopathy- one doc ruled out ALS and pushed SM. He was healthy and strong in time leading up to spinal surgery, with exception of previously described symptoms and back pain, in June at Cleveland Clinic (went perfectly-follow-up MRI has also demonstrated that- and when I say healthy I mean cutting trees down with a saw healthy). Within the last three to four months he has negatively/quickly progressed with all cardinal ALS signs (weight loss, tongue fasciculations, occasional loss of fine motor skills, general weakness and muscle loss). Went to ER right before Thanksgiving because he woke up one morning with a slight slur, had brain mri, cat-scan, blood work- nothing came up. The neurosurgeon in ER told him it was physical therapy related- he's been going to PT since surgery but doc believed he needed more strength training. Not all symptoms are consistent, except muscle weakness in all limbs and fasciculations (which are not present everywhere) . He's a 66 year old man. Went to family doctor yesterday and he's concerned enough to send him back to Cleveland Clinic where spinal surgery took place. However, my dad can stand on the drop foot and balance himself, while lifting up his leg and I believe that his reflexes are within the normal range (all good, non-ALS right?). Can the disease progress from nothing to everything in a matter of months? Could the surgery have sped it up? Have you ever heard of someone being diagnosed with ALS and then having it changed to another final conclusion? I have read the literature on these two diagnoses, and I understand they mirror one another greatly. The surgeon in Cleveland has assured us that my dad needed the surgery no matter what, but that they would have looked into ALS had that diagnosis been forwarded to them as well. What are the chances he really did have both?!? He is going to have another EMG, but we are very scared about the quick progression of these symptoms and the initial "dirty" EMG, however, I do not know how intensive it was. He was also diagnosed with vitamin b deficiency and a lyme test came back negative (but I have heard that a more sophisticated test is truly needed). What are your thoughts concerning this and do you believe that the neurosurgeon was foolish to not send along the neurologist's original diagnosis to Cleveland? Thanks very much in advance for your advice- Lindsey

[Dr. Kokil Mathur]

Hi!
I am sorry to hear about your father and can understand your apprehensions. If he was diagnosed with vitamin B deficiency, and especially if it was vitamin  B12 deficiency, then this can cause worsening of symptoms and fasciculation. Low intrinsic factor in gut that hampers absorption of B12 and causes pernicious anemia is the commonest cause of low B12. If this is so then increasing intake of B12 will not help, and you will need to take Vitamin B12 injections at regular frequency as prescribed by your doctor. Other causes of low B 12 are parasites in the gut, diet poor in Vit B12, Crohn's disease, IBS, or poor metabolism by liver. Please consult a doctor to rule these out.
In fact vitamin B12 and vitamin B6 deficiency can cause tongue fasciculations and a slur due to swelling in the tongue. However, as you said it can also be due to ALS.
If the EMG is positive then he may have ALS. A positive EMG alone is not diagnostic of ALS. To confirm that a doctor has to find signs of both upper (muscle weakness, decreased motor control, inability to perform fine movements, increased spinal reflexes, and positive Babinski sign—great toe going up) and lower motor (muscle weakness, abnormal EMG etc) neuron signs in one limb. Symptoms of many of these diseases do mimic ALS. ALS like symptoms can be due to fibromyalgia, chronic fatigue syndrome, severe anemia, spinal nerve compression high up in the cervical spine, ankylosing spondylitis, osteoarthritic changes of the vertebrae, calcium deficiency, low Vit D, electrolyte disturbance, peripheral neuropathy due to diabetes or hypothyroidism or due to bad posture. Lyme and lupus are the other possibilities.
Electromyography (EMG), nerve conduction velocity (NCV), muscle biopsy, etc are done to confirm diagnosis or rule out ALS.  Please discuss with your father’s treating doctors. Take care!