Could all these symptoms be related? MS?

[Soccer Mom]

HI, I am a 44-year-old woman. I have been having problems lately with pins and needle sensation in my hands my feet, legs hands and arm daily for months, occosional shocks. My left arm felt like it was being squeezed for over a month.Sometimes my thigh feels that way too.My BP is usually low, sometimes very low.I had a head MRI done earlier this month, it came back showing 3 spots in the white matter that were @ 4mm, these were slightly visible 3 years ago on an MRI that was done to rule out optic tumors. The symptoms are much worse lately and more common. I  have advanced Normal Tension Glaucoma that has caused 50% blind spot in one eye, not so bad in other eye. I take travtan,alphagan and am in the Memantine drug study for NTG. I got back some unusual blood test results back when I donated blood in 1999, PK-TP positive, FTA-ABS positive,RPR negative,This sent alarms to the health dept, more tests MHA-TP non reactive, VDRL nonreative, Western Blot test nonreactive. The Western blot test results cleared me of the suspected syphilis. I had never had syphilis or been treated for it. Lyme tests were also negative,Streptozyme -High @200. B-12 normal,I am also very tired, I need to work  hard at staying awake for my drive to work and back. Caffine doesn't help.I often get to work and can't remember driving past checkpoints. Can you shed any light on what's happening to me? I suspect MS. Could all my health problems be related? I feel the DRs here are stumped, it has been suggested that I find a med student who needs a research project. I go to a Neurologist next week.

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

The numbness and tingling in your extremities could be a sign of a peripheral neuropathy. This can be evaluated with an EMG (nerve/muscle test). There is nothing in your history which says that this is MS. You should discuss this with your neurologist further. Regarding the excessive daytime sleepiness, things to be considered include your thyroid function, an inflammatory disorder (can be checked with a sedimentation rate), and a sleep disorder. The most common sleep disorder to cause this would be obstructive sleep apnea. This involves mutiple episodes per night when an individual stops breathing and wakes up for a brief period. If this happens enough, then patients can experience sleepiness, memory complaints, fatigue, and there is some evidence that these people are at higher risk for heart disease.

You should discuss these possibiities when you see the neurologist. Good luck.

[ontherecord]

If you aren't already doing so, you should see a glaucoma specialist at an academic health center (as compared to a general ophthalmologist) for the advanced normal-tension glaucoma.  Normal-tension glaucoma is more puzzling to clinicians than glaucoma which results from elevated intraocular pressure.  Travatan (a prostaglandin analog) is a safe and potent medication that increases the outflow of aqueous humor through the uveoscleral pathway (as compated to the trabecular meshwork).  Alphagan P, an alpha-agonist, increases both the outflow of aqueous humor and slightly inhibits the production of the ciliary body's production of aqueous humor.  I don't know whether this would be the best combination, and I think that travatan and timolol (a beta-blocker) may be a better combination since they have diametric mechanisms of action.  If you can tolerate beta-blockers (because they have a plethora of side effects) you may want to ask your ophthalmologist about that combination.  In addition, if the degneration of the optic nerve is progessing despite aggressive topical treatment, you may want to discuss laser  trabeculoplasty with your ophthalmologist.  In this procedure, they burn holes in the trabecular meshwork and this usually works well in keeping the pressure down.  However, in at least one-half of the cases, topical treatment is also necessary.  There are two types of laser trabeculoplasty -- Argon Laser and Selective Laser.  The benefit of the selective laser (which is relatively newer) is that it can be repeated more often than the argon laser, which can only be done twice or so.  The SLT can repeated as often as necessary, which makes it more likely to be used at an earlier stage in the battle against glaucoma.  From what I know, glaucoma is a pernicious, insidious disease and often the prognosis depends on treatment (in large part) which makes it imperative to see an experienced glaucoma specialist at an academic health center.  There, they will take pictures of your optic nerve, assess your corneal thickness, do advanced visual field testing, retinal imaging and perhaps optical coherence tomography.  At the very least, you'll be in the best hands in your battle against glaucoma.  I wish you well, and good luck with both your eyes and your other symptoms.

[Soccer Mom]

You seem pretty knowledgeable about Glaucoma. Do you have it too?I do see a very well respected Glaucoma Specialist every 3 months, he is involved with teaching and research at the University. I know I'm getting the best treatment for I can for my type of Glaucoma. Since I was not diagnosed early there is alot of optic nerve damage, My Dr. says that there is so much nerve damage and they are so fragile that odds are very high I might go blind when I get older. Knowing this makes me want to take all precauctions I can. MS can damage the eyes and if that is what I want it to be treated aggressivly. Memantine is a neuroprtector that has been approved for Parkinsons and Alzhimers, it is being tested to see if it will protect the optic nerves too. Alphagan is also rumered to have some neuroprotection properties also. I used to take betoptic, my Dr. thinks the neuroprotection properties of Alphagan-p may be of some benifit me.

[ontherecord]

Greetings once again.   When you see your neurologist next week, you will have a much better idea what exactly is happening and accurate diagnosis is essential for the treatment, and proper treatment often results in the best prognosis.  You may want to ask your neurologist whether a referral to a neuro-ophthalmologist is warranted depending on what transpires.  I don't know much about MS, but one of the key clinical features of MS is optic neuritis, the incidence of which is about 15% or higher in people with MS.  If you have never had optic neuritis, this is a good sign.  

I do not have glaucoma.  I am 26, but have ocular hypertension, which is elevated intraocular pressure with no glaucomatous damage to the optic nerves.  I have been told my optic nerves look excellent, and the cup-disc ratio is under .3 and the nerves are symmetrical and visual fields are clean.  My pressures, however, range from 22-24MM consistently.  My corneal thickness is 620 microns -- thicker than the average cornea of 580 -- which may explain why the readings are higher than what's actually happening inside the eyeball.  The Goldman tonometer measures how much resistance it takes to flatten the cornea, and that is what we know as IOP.  That's what that machine tells us.  

For the longest time, up until about a decade ago, elevated intraocular pressure was synonymous with glaucoma.  So much so, that glaucoma was defined as pressures greater than 21MM.  Today, however, glaucoma is defined as a disease of the optic nerve.  And surprisingly enough, over 90% of people with elevated IOP never go on to develop glaucoma.  On the other hand, 1/3 of all glaucoma patients have normal-tension, like you, and therefore, that explains why it was caught later than it should have been.  Elevated IOP is a red flag that warrants an immediate referral to an ophthalmologist. If the pressures are normal (as they were in your case), it often goes undiagnosed until some damage to the optic nerve actually occurs.  It's unfortunate, and I advocate that every optometrist should thoroughly examine the optic nerve notwithstanding normal pressures.  Today, with pressures such as mine -- elevated IOP with healthy optic nerves, some doctors take the wait-and-see approach while some treat.  One ophthalmologist decided to treat, and I too used Travatan for about a year-and-a-half before I went back in there and asked to be discontinued.  I took a proactive approach and he agreed that discontinuation was warranted, since I have no other risk factors besides elevated IOP.  Nevertheless, what complicates the issue even further is that there was the Ocular Hypertension Treatment Study which showed that prophylactic treatment delayed or preempted glaucomatous degeneration by 50% over a period of five years.  However, the conclusion I believe was derived using flawed logic and it failed to consider other risk factors as well.  It provides a good start but it doesn't convince me.  My policy: as long as my optic nerves are fine and the pressures are 25MM or under, I am not going to put a drop in my eye.  These drops have some side effects I wasn't to happy about, and since you used Travatan you certainly have an idea of what I mean.


Back to you, since your situation is emergent: There is one question I think is very important for you to ask your glaucoma specialist.  I have read one piece of literature that has indicated that the longer a person uses topical eyedrops the less likely that trabeculectomy (not to mistaken with laser trabeculoplasty) will be successful.  Whether this is true or not I do not know for sure but I am confident that your doctor will know the answer.

Besides that, I think follow ups with your glaucoma specialist every 3 months are a good idea.  Hopefully, given your situation, you are at a top-10 eye institute.  Wheter it is Bascom-Palmer in Miami or Wills Eye Institure in Philadelphia or Massachusetts Eye and Ear Infirmary in Boston or Wilmer Eye Institute in Maryland or UCLA-Jules Stein or USC-Doheny in California or Emory Eye Clinic in Atlanta, or wherever, your situation deserves the most experienced care.  

With aggressive treatment, and halting of further damage to the optic nerve, you could very well retain your sight for many, many years to come and I hope that this will be the case.  Best of luck to you once again.

[Soccer Mom]

I saw the neurologist yesterday. I had a positive Babkinski responce on both feet, and could not close my eyes and stand still with feet together, also could not do the heel to toe walking. I go in for a spinal MRI tomorrow. Are these symptoms all sure signs of MS?

[ontherecord]

A positive Babinski and a positive Romberg's Sign could signify a number of things.  You mentioned the heel-to-toe test, but what about other tests of cerebellar function? Did your neurologist ask you to tap your fingers together quickly or to take one heel and try to roll it down the alternate shin, or ask you hop on one foot? The MRI and spinal tap will help clarify what is going on, so try not to worry too much for now.  As well, what concerns did your neurologist express? I am sure that he or she discussed possibilities with you? Or maybe the doctor just wanted to get some tests done just to make sure? Either way, go in for those tests tomorrow and be sure to discuss these concerns in detail with your doctor.  In any event, MS is a clinical diagnosis and I don't think that there are "sure signs" of MS.  In addition, the initial onset of MS is usually between 20-40 years of age.  So don't worry yourself by jumping to conclusions without talking in depth with the neurologist.  I know it's easier said than done, but so far you are obviously receiving a thorough exam, so try to relax until the doctors find out for sure what is happening.  As always, best of luck.

As well, you will get an official response from the CCF Neurologist so hopefully the good doctor can shed some light on your situation.