neurological dilema

    
      Re: neurological dilema
    


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Posted by ccf neuro M.D. on May 25, 1997 at 20:43:08:

In Reply to: neurological dilema posted by KATHY SCHULZ on May 14, 1997 at 13:03:37:

: HELP NEEDED,
  MY MOM IS 66 YEARS OLD AND HAS ALWAYS ENJOYED GOOD GENERAL HEALTH. LATELY, HOWEVER, SHE IS DEFINITELY GOING DOWNHILL FAST AND NO ONE CAN GIVE US ANY ANSWERS. WE HAVE BEEN TO FOUR NEUROLOGISTS, HAD NUMEROUS TESTS AND STILL, NO ANSWERS.  THE FOLLOWING TESTS WERE COMPLETED; CHEM PANEL WAS NORMAL,CBC WAS NORMAL, B12, FOLIC ACID WERE NORMAL, NERVE CONDUCTION STUDY WHICH SHOWED SOME NERVE DEGENERATION, MUSCLE AND NERVE BIOPSY, WHICH SHOWED NO HISTOPATHOLOGICAL ABNORMALITY OTHER THAN FOCAL ATROPHY. AN M.R.I. OF HER BRAIN WHICH SHOWED NO M.S.,HER SED. RATE IS 7, ANA, CPK, THYROID, TSH PROTEIN ELECROPHORESIS, AND IMMUNOELECTROPHORESIS ALL NORMAL,BLOOD TESTS ARE ALL NORMAL, E.M.G. SHOWED SOME EVIDENCE OF DENERVATION BELOW THE KNEES BILATERALLY.  AN M.R.I. OF HER SPINE WAS NORMAL. PHYSICAL EXAM AS FOLLOWS; CRANIAL NERVE EXAM DOES NOT SHOW ANY ABNORMALITY WITH THE EXCEPTION OFA PATCHY LOSS OF PIN AND COTTON AROUND THE LIPS AND ON THE LEFT SIDE OF THE HEAD AND FACE. CRANIAL RELEASE REFLEXES ARE; A WEAKLY POSITIVE GLABELLAR, WEAKLY POSITIVE SNOUT, NEGATIVE PALMOMENTAL, AND TRACE POSITIVE JAW JERK.  MOTOR EXAM SHOWS AN ALMOST GIVEAWAY TYPE OF WEAKNESS AND SLOWNESS OF MOVEMENT, WHICH IS PRESENT IN THE HIP FLEXORS, AND TO A LESSER EXTENT, IN THE LEFT HAND INTRINSIC MUSCLES. MUSCLE TONE IS NORMAL,WITH THE EXCEPTION OF THE LEFT LEG, WHICH SHOWED A DEFINITE SPASTIC CATCH IN THE RECUMBANT POSITION.  REFLEXES SHOWED THAT THEY WERE IN THE 1+ RANGE IN THE UPPER EXTREMITIES WITH A PARTIAL HOFFMANN IN THE RIGHT HAND, 2+ at the knees, 2+ at the ankles, and toe signes were definitely downgoing.  SENSORY EXAM: SHE CANNOT FEEL MANY THINGS THROUGHOUT HER ARMS, LEGS AND CHEST AND ABDOMEN. SHE CANNOT SENSE ANY FOOT POSITION. THE FINGERTIPS HAD DECREASED POSITION SENSE.  VIBRATION SENSE ABSENT FINGERS AND TOES,CHEST OR FOREHEAD, BUT SAID SHE COULD HEAR IT.   COTTON SENSATION LIKEWISE ABSENT FROM LARGE PATCHES OF LEGS , ARMS, AND CHEST. HISTORY;  SHE WOKE UP ONE MORNING IN FEB.,1996, WITH A WEAK VOICE AND UNABLE TO RAISE HER LEFT LEG.  SINCE THEN, HER ABILITY TO WALK IS DEMINISHING, SHE CAN'T LIFT HER LEGS TO CLIMB STAIRS, HAS TROUBLE WITH INCLINES, AND NOTICES A GENERAL MUSCLE WEAKNESS AND FATIGUE. HER VOICE STILL HAS NOT RETURNED IN THE PAST YEAR, BUT SHE HAS NO DIFFICULTY SWALLOWING. SHE HAS PAIN IN THE HIP JOINT AND SHINS BILATERALLY. SHE HAS COMPLETE NUMBNESS OF FINGERS AND TOES.
  HOPE YOU CAN HELP GIVE US SOME CLUES. HER INSURANCE IS BECOMING SOMEWHAT UNCOOPERATIVE BECAUSE OF A LACK OF DIAGNOSIS.  THANKS, KATHY SCHULZ
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Giveway weakness and patchy sensory loss that does not conform to any known nerve distribution coupled with a lack of identifiable diagnosis despite extensive testing and evaluation by four neurologists is very strongly suggestive of a psychological rather than a neurological problem. Has your mother been seen by a psychiatrist to rule out the possibilities of depression or a chronic anxiety disorder with somatic (body/physical) symptoms? Other than what appears to be a mild peripheral neuropathy at the best (the preserved ankle jerks argue strongly against a significant neuropathy), I cannot think of any neurologic diagnosis that would present in the manner you describe and not be diagnosable with the evaluation that she has undergone. Even the abnormalities you describe on the EMG test of some denervation below the knees is typical for many otherwise normal elderly people. There are no additional tests, with the possible exception of an antiacetylcholine receptor antibody test to rule out myesthenia gravis (given her hoarseness and fatiguability) that would help at this point. If she does have a serious neurologic disease, this should become very clear in the next year or two. I would not seek a fifth neurology opinion, but would again strongly suggest a first psychiatric opinion, as depression can produce most or all of the symptoms you describe, especially the fatigue part. I hope this information is useful to you and not offensive--- what I am suggesting is both well intentioned and medically sound based on the highly detailed information you have provided. Good Luck!