Re: Twitching, fatigue, etc.

Posted By Tom Shipley on June 24, 1999 at 09:01:10
I have developed fasiculations across the past 3 months in both arms, legs, some in the trunk, and a few in the facial
muscle complexes (although not many in the facial area).  In addition, I have developed some perceived muscle weakness
in the arms and legs (more felt as moderate to extreme fatigue and muscle stiffness/pain), although there have been no
objective signs of weakness or wasting. I have not been in any accidents or traumas, either recently or in years past.  
Gait and balance are normal and I still walk outside frequently. Bladder and bowel control function are normal.  No trouble
swallowing or performing other motor functions (like typing, etc.).  No vision problems. No numbness anywhere, but some
tingling sometimes in the left foot or left hand that seem to clear with re-positioning.  I do use a computer and mouse most
of the day.
Coincidently, I had laproscopic gallbladder surgery (about six weeks before the neurologic symptoms developed-Feb 1999).
Loose bowel movements - about 3 per day - (for which Questran was prescrbed).  Just as a follow up to the loose movements, a colonscopy,
upper endoscopy, middle bowel, and CT of the chest abdomen and pelvis were all normal.  Also multiple chest/abdominal
flat X-Rays were done prior to CTs, with no abnormal findings.  This diagnosis was post gallbladder diarreaha.
Before neurologic symptoms, family internist had started by running electrolytes, aterial blood gases, thyroid panel,
and H5IIA for carcinoma symdrome. All results normal. In addition, Potasium, Calcium, and Magnesium were all results normal.
When neurologic symptoms initially developed (fasiculaitons and perceived weakness), I have had a reviews by
two different neurologists.  The first had run extensive physical examination shorly after onset of symptoms
(including an EMG which was completely normal).  After assurances about this NOT being a neurologic nerve disease
(ALS, MS, etc.), I returned a few weeks later (due to increased worry), and had a repeat EMG, which was
also normal.  This neurologist is at a large hospital and was previously one of the senior guys in an east coast Muscular
Distrophy center (20 yrs experience, and does his own EMGs - just to be sure they are right).  His diagnosis was benign
fasiculations, and anxiety/stress might be inducing the perceived weakness.
About 3 weeks later, a second neurologic review done by neurologic nerve disease disorders specialist at Johns Hopkins.
Once again, extensive physical exam was unremarkable, and more bloodwork was run for thyroid, PTH,  serum CK, ANA,
which were are normal (except TSH was low borderline, but T3 and T4 were normal).  End result was recommendation that
no diagnosis for any neurologic disease was found.  Both neurologists were in agreement to get MRIs done -results below -
however, diagnosis from Hopkins (after reveiwing first EMGs and exams) was also benign fasiculations and stress/anxiety.
They indicated for a person of 42, some narrowing of the c-spine area might exist that could cause this, but stress and
anxiety and concern/worry over health concerns could amplify these. However, MRIs were performed.
MRI of the Brain:
The appearance of the brain is normal. No infarctions or hemorrhages seen.   The gray and white matter appear normal.
After administration of 15cc of gadolinium, there is no evidence of abnormal enhancement of the brain or meninges.  
The posterior fossa and brainstem appear normal.
Cervical Spine:
The vertebral bodies are intact with no evidence of compression fracture. The visualized bone marrow appear normal.  
The spinal cord is unremarkable.
C3/C4:  Mild left sided foraminal narrowing is noted secondary to disc bulging and spondylosis.  No evidence of disc
herniation or spinal stenosis.
C4/C5:  Mild bilateral foraminal narrowing is noted secondary to spondylosis.  A mild degree of spial stenosis is seen,
again secondary to spondylosis.
C5/C6: Moderate right sided disc herniation is seen causing a mild mass effect on the right side of the cord and mildly narrowing
the proximal portion of the right C5/C6 neural foramen.
C6/C7:  Mild left sided foraminal norrowing secondary to spondylosis.  The spinal canal is minimally narrowed.  No evidence
of disc herniation.
No evidence of MS plaques found.
Lumbar Spine:
Alignment, vertebral body height, the visualized bone marrow signal intensity and the corius medullaris are normal.  There
is a small focus of fatty metamorphosis witin the T12 vertebral body.  The remainder of the bone marrow signal intensity is
normal.
The is a minimal annular bulge at L3/L4.  No disc protrusion, disc extrusion or central spinal stenosis is identified.  The
neural foramen are patent.
At this point, the familty internist and both neurologists seem to feel that these MRI results are unremarkable, and with
no nerve root compression, and no significant cord impingement/compression, MRIs don't indicate anything abnormal in
a person my age. They have started me in some PT, but do not think at this point that surgery is warranted, and think
that it might cause more problems that it would fix.
In the meanwhile (about 4 months into the process now), this perceived weakness/fatigue and significant muscle
stiffness/pain in the legs along with the fasiculations has made it very difficult to sleep and maintain normal routines
(like working full days, etc. - due to worry over will my legs continue to hold me, etc - although they always have).
Lower back also seems tender at this point (in the lumbar region, although as mentioned above, nothing on the MRI).
I am a smoker, and I guess that is one reason why all of the checking for cancers were done in the first place.
Subsequent review last week (about 4-5 months into this process), has another EMG/conduction study done and neuro eval done by one of the best
Neuro's at the other major university hospital in Baltimore.  This guy also says he sees the twitches, but does not see indications of
any degenerative disease (ie ALS, MS, etc.).  His final diagnosis was polymyalgia with twitching, but did not have any other
ideas for etilogy..
1. Should a t-spine MRI done? I have heard that problems typically do not occur there (like in the neck and lumbar
region).
2. Would MRI findings cause these symptoms or should I just try and continue to focus on the anxiety issues they point out?
    Should a second neurosurgeon be consulted?
3. Can anxiety/stress really cause widespead fasiculations, and perceived muscle weakness associated with stiff muscles/pain or
is it more related to the herniated disc?
4. Also, is it too early in the process to rule out things like ALS, MS, encephalitis (4 months) as well as other disorders (no family histories)
- although both parents do have some problems with arthritis? Wife ended up disabled 5 years ago(nursing home bound)
after finally being diagnosed with post viral encephalitis. Should I press to get CSF analysis done?
5. Is there really such a things a fibromyalgia and does this also cause twitching? I Do have a fair amount of joint aching(ankles, knees,
elbows, and wrists), but not necessarily all the points..
6. Since this seemed to crop up about two months after the gallbladder operation, is it possible that a malabsorption disorder is
now in play causing a vitamin or mineral deficiency and causing these symptoms that mimic neurologic disorders?
7. Any other reasons that you can think of?
Should I feel comfortable at this point after 4-5 months of this, since three neuros (all from different major university hospitals - Hopkins, University of Maryland, and the
Maryland Muscular Distrophy center) are saying things are benign?  
Thanks for you time and patience reading this,  but I wanted to get you as much information as possible.

[CCF Neuro[P] MD RPS]

Posted By CCF Neuro[P] MD, RPS on June 24, 1999 at 17:06:00
Dear Tom:
Sorry to hear about your fasciculations.  They can be really bothersome, (I can relate to your because I have them also).  It is always easy to come to the conclusion that you have the worse possible disease and you better get your house in order.  However, since your EMG, MRI, along with your physical exam were basically all normal, I would believe the conclusions by the other neurologists.  However, as you are fasciculating away it is difficult to do.  Yes, one's mindset can make things worse.  
Question 1: I don't think I would get a MRI of the thoracic spine.  The other images only show minor problems so I wouldn't think that the thoracic spine would be much different.
Question 2:  We did a study at the Cleveland Clinic and found that on routine MRIs approximately 20% of patients had mild/moderate disc bulging or minor neural foramen changes without any neurological problem.  It is difficult to correlate minor changes that you describe with the MRI.  It really doesn't sound like you are having spinal root problems or spinal cord compression problems so I wouldn't worry.
Question 3:  There is not consensus on the etiology of benign fasciculations.  The vast majority of people with disc buldges do not experience muscle fasciculations.  So, I don't think that buldges are causing your fasciculations.  Yes, as previous stated, anxiety can make your fasciculations worse.
Question 4:  I think that at this point in time you do not have MS, ALS etc.  However, there is nothing and there is never a point in time where a disease cannot pop up.  
Question 5:  I wouldn't worry about fibromyalgia.  If you do not have the trigger points, by definition you don't have fibromyalgia.
Question 6:  If all your tests are normal (as you say) then you have no malabsorption disorder.
Question 7:  Hug your wife, kiss the dog, etc.  You shouldn't worry about ALS or MS.  I know this is easy for me to say, but try as best you can.  
Sincerely,
CCF Neuro MD










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