follow up re. neuropathy

[stephenpd69]

I am a 42 year old healthy male. In the fall of 2011 i had significant GI issues (parasites, amoebas). Jan 2012 i had an episode of Shingles (Dr thinks it was due to post gall bladder surgery). In early Feb 2012 i began to have muscle twitches and tingling/burning in hands and feet.  Periodically my hands would fall asleep while sleeping.

I had a neuro eval in mid March.  He did a physical exam (tilting my neck, tapping different parts of my body).  He then did a nerve conductivity study.  All came back normal (w/ the exception of some tapping on my left shoulder that he thought has an odd response).  He noted no concerns about MS.  I then had blood work done (lyme disease, some sort of immune testing, thyroid, SED rate, HIV).  All labs normal.  He had no explanation for my symptoms

Since then:  i was on Cymbalta, but stopped in March 2012 (the twitching calmed down).  I continue to have on/off tingling and burning in my hands and feet (some days not too bad, other days it is bad).  It seems that heat and pressure make it worse.

Questions:
1. I have learned that the nerve conduct. test addresses large nerve issues. If this was normal, does that mean no peripheral neuropathy
2. he did not do an EMG needle test (which looks at small nerve issues).  should i have this done?
3. he saw no need for MRI, but i wonder if it would be helpful to have one to rule MS out (he worries that at my age some "stuff" would show that would not be MS related)?
4. Should i accept "I don't know what this is" and not worry about it?
5. are there other things that should be looked at?
6. I do experience anxiety (made worse by a year of significant GI problems).  Could the tingling/pain be anxiety?
7. Ideas re managing pain?  i have started using Capsaicin.  What about other meds (possibly looking at one that addresses pain and anxiety)?  My PCP has talked about Lexapro and Celexa.

Thanks for your help

stephen

[stephenpd69]

I am a 42 yr old, generally healthy male.  have had the following symptoms since Feb 2012:  symmetrical tingling in hands and feet, on/off burning in feet, all-over body muscle twitches, on/off patches of skin that are sensitive to touch, and most recently bruising in left calve for past 6 weeks. I did have gi issues for past year (better now) and shingles in Jan 2012.
I saw a neurologist in March 2012 he need a physical exam, nerve conductivity test, and had labs done, all of which were normal.  He did not do a needle emg. I saw him again in May 2012, again physical exam normal. He ordered a neck mri, came back normal.  He said nothing else to do, see you in 6 months.
I have been getting depressed about not being able to find answers to what this is.  if it is nothing serious, then it will help me move on to some extent.  It is hard for my mind not to wonder if there is something serious going on.
Questions:
1. the nerve conduct. test should rule out large nerve issues, but could this be a small nerve issue?
2. small nerve issues seem to be limited in cause?
3. should i expect this to improve or not?
4. should i get another opinion (getting into another neuro means a referral from my dr...hard to get)
5. any recommendation on how i should go forward?
thanks for your help and thoughts,

stephen

[stephenpd69]

Thanks for the reply.
I should clarify, i did have a nerve conductivity test, just not the needle part of the EMG (my understanding is that they are two different tests).  The nerve conduct test was normal.  I saw my neurologist last week.  the second physical exam was normal.  again, since my symptoms are bi-lateral and symmetrical (both hands and feet) along with twitching, he sees no need for brain mri.  He is ordering an mri of my neck though.  
all blood work (including diabetes, lyme, b12, hiv, SED) has been done and all has been normal.

If it were to be benign fasiculation syndrome, would that present with twitching as well as tingling and burning in hands and feet.

[Christopher R Newey, DO]

Thanks for using the forum. I am happy to address your questions, and my answer will be based on the information you provided here. Please make sure you recognize that this forum is for educational purposes only, and it does not substitute for a formal office visit with a doctor.

Without the ability to examine and obtain a history, I can not tell you what the exact cause of the symptoms is. However I will try to provide you with some useful information.

There are two types of sensory neuropathies in the body – large and small fibers. With small fiber neuropathies, symptoms include burning or buzzing or other vague symptoms starting in the feet and hands then in some cases spreading to other parts of the body. The EMG/nerve conduction studies (NCS) (tests done to check for neuropathy) will not show an abnormality, and a definitive diagnosis can only be made with a skin biopsy so that the number of nerve endings can literally be counted. There are other tests of the function of small nerves that can be ordered, such as QSART testing which looks at how much sweat the skin makes, since sweating is in a sense of function of these small nerves. There are several causes of small fiber neuropathy, including diabetes, vitamin deficiencies, and autoimmune problems.

The other type of sensory neuropathy is called a large fiber neuropathy. There are several categories of this type of neuropathy, and there are many many causes. Sensory neuropathies can involve just one nerve or several nerves in the body. The symptoms are sensory loss and if motor nerves are involved weakness may occur. Some types of sensory neuropathies occur and progress very slowly, others sort of wax and wane (with flare-ups) and some are progressive. One of the most common causes of neuropathy is diabetes, and sometimes only glucose intolerances, or abnormal rises in blood sugar after a glucose load can be the only indication (this is called a oral glucose tolerance test. Other causes include but are not limited to hereditary/genetic causes (such as in a disease called Charcot-Marie-Tooth, in which there is a family history of sensory neuropathy usually from an early age associated with other clinical features such as high-arched feet), autoimmune problems (such as lupus (SLE), Sjogren's, Churg-Strauss (in which asthma also occurs), polyarteritis nodosa, which affects blood vessels), and demyelinating diseases (such as CIDP). Vitamin B12 and B6 deficiency, as well as excess vitamin B6, can also cause neuropathy. Some toxins, such as lead, arsenic, and thalium can cause large fiber sensory neuropathy. Other causes include abnormalities of protein metabolism, as in a type called amyloidosis or monoclonal proteinemia. In many neuropathies, both the sensory and motor nerves (the nerves that supply the muscles) are involved, leading to sensory symptoms as well as weakness.

I am surprised that an EMG was not performed. Sometimes EMG will not be performed if the patient refuses. As mentioned though, small fiber neuropathies will not show up on an EMG/NCS. An MRI of the brain may or may not be helpful. If your symptoms are one-sided, it would be worth obtaining. Other workup (as indicated above) may be necessary to determine the cause. However, in a large number of cases, the cause may not be readily identified. It is worthwhile to test for the more common causes such as diabetes.

Treatment for neuropathic pain (pain coming from nerves) includes neurontin and lyrica, and medications such as elavil (which is an antidepressant but has actually been found to be helpful with neuropathic pain as well). There are other medications such as those used for depression that have some pain relieving effects.

Thank you for this opportunity to answer your questions, I hope you find the information I have provided useful, good luck.