ALS or other Progressive Neuropathy?

[Cindy]

My boyfriend is 22 yo and previously healthy; only complaint of lower back pain, which was attributed to spending too much time driving and lifting heavy equipment. 2 months ago he went to the ER for arrhythmia.  They did a CXR, EKG, thyroid check, all negative. A few wks. later he experienced headaches, which did not go away w/ aspirin/Tylenol. 1 week later he had left sided weakness and muscle twitches all over his body.  Recently he went to the ER again for SOB and they prescribed Xanax (0.25 mg).  Now, he is experiencing generalized weakness, especially on his left side.  He also has the sensation of not being able to move his hands/feet in the mornings (during the day his hands and feet feel fine) along w/ “painless cramping”.  The twitches are not as often now.   There is a measured difference btwn. his left calf and left arm, which are smaller than his right. (3 cm in his calf).  His neuro exams  have been normal and no weakness has been found.  His blood work including CK, ESR, C-reactive protein, ANA are all normal.  He also had an EMG, MRI, and Barium swallow (upper GI) that were normal.  Could this be ALS or any other progressive neuropathy or myopathy?  How many muscles do they usually test on an EMG? Should we still be worrying about ALS or any other progressive neuropathy or myopathy?  Should we be worrying about ALS or any other progressive neuropathy or myopathy?  How many muscles do they usually test on an EMG? Is there any way this could all be due to anxiety? What other tests should he have?

[CCF-Neuro-M.D.-JT]

Keep in mind I have never personally examined your friend nor have I reviewed his clinical history in its entirety.  But it would be very unlikely that he has ALS with a completely normal EMG and neurological exam. EMG studies vary from place to place with no set number of muscles to examine, but here at the cleveland clinic we do an extensive EMG workup for patients with suspected ALS including several in the hands, arms, legs, and back. Myopathies are also seen with the needle studies and many (not all) peripheral neuropathies can be picked up on the nerve conduction part of the EMG. So if everything looked ok, then it's not likely that these are the cause of his problems. Anxiety and panic attacks can certainly play a role in his symptoms, but someone should look at his thyroid to make sure that's not the problem. Talk to his primary care doc to see what his clinical suspicion for something medical going on such as a cardiac rhythm problem. He may need ongoing monitoring for this. Finally if his symptoms persist or get worse, consider a second opinion at a major academic or clinical center nearby. Good luck.