|
|
Weird case
|
Logged in as: Guest
|
|
Users viewing this topic:
none
|
|
Login  | |
|
Weird case - February 6, 2007 2:04:00 AM
|
|
|
PTupdate.com
Posts: 1490
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
Just saw this gentleman last night, and very weird presentation:
40-something year old, progression of RLE weakness, especially foot/ankle. Bounced around various orthopods and neuro guys, often told "This can happen, we don't know why, and there is nothing we can do for you".
Presents to me showing:
1. Severe calf/lower leg atrophy, with no active contraction to any lower leg musculature. While definite foot drop, no plantarflexion contracture! Does not wear an AFO. No clonus, no ankle reflex, intact base sensation, no Charcot deformity
2. 4/5 quads with atrophy, 4-/5 hip abduction.
3. Could not elicit contraction to any lower leg muscle groups with NMES, using pads and probe, both AC and DC, so obvious denervation. Could elicit quad contraction with NMES, so performed that
4. Has had MRI done back and pelvis and brain, all negative. EMG/NCV done, confirming the nerve issue, but no explaination otherwise (I do not have full report). Pelvic CT with dye done, negative. Lumbar CT/myelogram to be done today.
He was an add-on patient, so I did not have all the time I wanted, and will finish up with other exam material next time. However, cannot figure out what could have caused such a multilevel neurological problem and still not be diagnosed.
Diet was discussed, as he has severe episodes of cramping in the calfs and upper legs, along with muscle fasciculations. Quinone prescribed and it does work. He does not take any multi-vitamin, and is very strict with a "healthy organic" diet.
Any ideas/suggestions?
John Duffy, PT OCS
www. PTupdate.com
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
|
|
|
|
|
Re: Weird case - February 6, 2007 2:56:00 AM
|
|
|
mcap56
Posts: 619
Joined: October 26, 2002
From: New York, NY
Status: offline
|
WOW. What a case. Poor guy. Considering he has seen several neuro people, I am not sure of what I can add to the equation. Are you friendly with the neuro professor at your school? If not, let me know. Perhaps I can find someone to ask.
There are some things that affect the NMS system that go unoticed at first. Is he taking any medications at all? Sometimes statins have severe side effects. What about undiagnosed lyme disease? What about a severe neurological entrapment (peripheral).
You may want to post this too med complexity or query Dr. Wagner. You may also want to speak with the EMG/NCV person. If you get the report, I can show it to the PT who does our EMG/NCV lectures.....
Marc
|
|
|
|
|
Re: Weird case - February 6, 2007 3:01:00 AM
|
|
|
Marc Bronson
Posts: 113
Joined: January 13, 2007
From: Toronto
Status: offline
|
John,
What has the temporal history been like? Was this progressive/spontaneous? Family Hx of any demyelinating conditions or anything other that might be contributory? Ethnic background? Any history of falls, unsteadiness, gait difficulties?
What is his proprioception like (big toe)? Imaging you said revealed nothing, what about a biopsy? Any atrophy in the hands, feet? Any skin lesions anywhere?
This sounds like an organic pathology case to me. Will get my thinking cap on and post later after work...
M.
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
|
|
|
|
|
Re: Weird case - February 6, 2007 3:37:00 AM
|
|
|
FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
Status: offline
|
unilateral...just distal LE
of course you think neuropathy of some sort or some infection that caused some degeneration...every now and again you'll see a weird presenting peripheral neuropathy, I had one I had not known existed, I don't even remember the name anymore, but same presentation but all proximal..hip and quads only...was like asymetric proximal neuropathy or something, I'd imagine there may be something similar for distal..also could be vascular...
I'd say though if you cannot ellicit a contraction, then I'd work on safety and adaptation. Treat the dysfunctions we can treat.
|
|
|
|
|
Re: Weird case - February 6, 2007 3:44:00 AM
|
|
|
PTupdate.com
Posts: 1490
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
Thanks guys. No, no biopsy done. Slump stretch and femoral nerve tension test actually revealed MORE motion than opposite limb...as if it was transected!?!
He did have an episode back when all this started of lower limb edema, doppler being negative, cause unknown, and edema showing on a LE MRI. I wondered if perhaps neural compression occurred due to this swelling of unknown cause.
Nothing in his health history that he reports, nothing else wrong with other limbs.
I have seen that statin problems, and while nothing noted in history, will double check. Going to suggest a dynamic AFO, and sure can't figure out why no PF contracture occurred. Will also get copy of EMG/NCV, which is going to be redone in the near future as well.
Duffy
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
|
|
|
|
|
Re: Weird case - February 6, 2007 11:59:00 AM
|
|
|
SJBird55
Posts: 2467
Joined: May 10, 2004
From: Michigan
Status: offline
|
Could be a virus.
|
|
|
|
|
Re: Weird case - February 6, 2007 12:04:00 PM
|
|
|
SJBird55
Posts: 2467
Joined: May 10, 2004
From: Michigan
Status: offline
|
Necrotizing vasculitis?
|
|
|
|
|
Re: Weird case - February 6, 2007 12:26:00 PM
|
|
|
Marc Bronson
Posts: 113
Joined: January 13, 2007
From: Toronto
Status: offline
|
SJ
I was thinking along the lines of something like inclusion body myositis, post-polio syndrome, ALS or something of the like.
Personally, if I were the MD managing this case I would go in for a biopsy as there is really nothing to lose by doing it at this point and the risk/benefit ratio is huge as it could lead to a definite Dx.
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
|
|
|
|
|
Re: Weird case - February 6, 2007 2:05:00 PM
|
|
|
dfjpt
Posts: 238
Joined: April 9, 2006
Status: offline
|
Infection(viral), some sort of poisoning, something systemic. Tumor or some other SOL pressing into the neural tunnel. Just some ideas. Does the individual walk with a slap footed gait? I hear syphilis is on the rise, but that usually causes neuropathy in both feet at once, doesn't it?
|
|
|
|
|
Re: Weird case - February 6, 2007 2:19:00 PM
|
|
|
jma
Posts: 2432
Joined: August 24, 2000
From: NY
Status: offline
|
Sounds like he was seen by specialists. I'm curious to know if he reported any past/recent illnesses that he had. Could there has been a past infection or virus involved. Has blood work been involved? Did the neurologist consider examining the spinal fluid? Just thoughts. Perhaps it was.
|
|
|
|
|
Re: Weird case - February 6, 2007 2:26:00 PM
|
|
|
Marc Bronson
Posts: 113
Joined: January 13, 2007
From: Toronto
Status: offline
|
D,
The syphillis would have to be in the tertiary stage (30 years + post initial infection leading to tabes dorsalis) for neurological symptoms to be present. So, that's unlikely that he caught syphillis at age 12 unless he was a real casanova. Didn't your ehjuhmucayshun teach you that?
I suppose it's worth checking the Med Hx, duffy, for any previous STD's and make sure that hasn;t been overlooked).
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
|
|
|
|
|
Re: Weird case - February 6, 2007 5:18:00 PM
|
|
|
xltherapy
Posts: 8
Joined: January 20, 2007
Status: offline
|
Intact sensation means it is either upper or lower motor neuron issue. No clonus or spasticity in the calf makes me think of it as lower motor neuron disorder. This means it is either individual nerve issue eg common peroneal nerve or higher up in sciatic nerve or multiple nerve roots or somewhere in lumbo sacral plexus after the nerve fibers exits from the spinal chord.
Sounds like the problem area is L4,5 S1,2 (?S 3,4,5)Does the patient have bladder control. How are hamstrings and Gluts?
Also , Keeping etiology on the back burner(don't ignore it though), what exactly is the patient here for?
|
|
|
|
|
Re: Weird case - February 6, 2007 5:19:00 PM
|
|
|
xltherapy
Posts: 8
Joined: January 20, 2007
Status: offline
|
Intact sensation means it is either upper or lower motor neuron issue. No clonus or spasticity in the calf makes me think of it as lower motor neuron disorder. This means it is either individual nerve issue eg common peroneal nerve or higher up in sciatic nerve or multiple nerve roots or somewhere in lumbo sacral plexus after the nerve fibers exits from the spinal chord.
Sounds like the problem area is L4,5 S1,2 (?S 3,4,5)Does the patient have bladder control. How are hamstrings and Gluts?
Also , Keeping etiology on the back burner(don't ignore it though), what exactly is the patient here for?
Dave Patel, BPT
|
|
|
|
|
Re: Weird case - February 7, 2007 1:15:00 AM
|
|
|
PTupdate.com
Posts: 1490
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
I have arranged to spend some more time with him tonight (depending on how he feels after yesterdays CT/myl)
He primarily presents to resolve the weakness and foot drop. Since I have not been overly impressed with his work-up to date, I feel the need to help dig deeper into the issue. Even the wife was surprised that PT has never been recommended until now.
I'll focus on improving deficits, as I always do, along with adaptation to those that I have no luck resolving, and of course use everybody's help here to make sure all bases are covered.
Marc: I understand your suggestion on STD's, but we all must be very very careful and tactful when going down that road!
John Duffy, PT OCS
[URL=http://www.PTUpdate.com]www.PTUpdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
|
|
|
|
|
Re: Weird case - February 7, 2007 4:49:00 AM
|
|
|
FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
Status: offline
|
Duff-
I had to go down this road recently, I used a novel approach may work for you if the situation is right. I explained to this guy that his reason for his problems aren't obvious, and therefore we can't look for an obvious explanation. So, I asked him, do you watch House? Luckily he said yes. I said, well, welcome to your own episode of house, I am going to be House. So, I need to rule out every possible cause no matter how bizarre or absurd or unlikely it is, so bear with me, because I may come across like House, but it is only to come up with the diagnosis in the end. That way it was sort of a game, and the pt didn't mind me asking os many questions about sex life etc..
Ben
|
|
|
|
|
Re: Weird case - February 7, 2007 5:13:00 AM
|
|
|
Shill
Posts: 1107
Joined: February 13, 2003
From: Madison WI USA
Status: offline
|
What diagnoses are the neurologists contemplating?
_____________________________
Steve Hill PT
|
|
|
|
|
Re: Weird case - March 26, 2007 2:01:00 AM
|
|
|
PTupdate.com
Posts: 1490
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
Figured I'd post an update on this gentleman:
Whole body EMG's done due to the physician(s) undressing him and noticing muscle fasciculations elsewhere. He indicates they found problems, but was not able to detail what. As with the other physicians, they indicated they just don't know.
Was tested for all STD's, heavy metal contamination, viruses, etc. with nothing found
I am now able to elicit some muscle contraction using NMES to calf, so am jumping on that one...hopefully will get something to anterior tib/peroneals in the future.
Calf is cold, with 50% hairloss compared to opposite side.
Duffy
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
|
|
|
|
|
Re: Weird case - March 26, 2007 6:36:00 AM
|
|
|
Shill
Posts: 1107
Joined: February 13, 2003
From: Madison WI USA
Status: offline
|
No hyperalgesia?
_____________________________
Steve Hill PT
|
|
|
|
|
Re: Weird case - March 28, 2007 4:21:00 PM
|
|
|
PTupdate.com
Posts: 1490
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
Nope, none. Handles a good workout, and NMES as well.
Duffy
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
|
|
|
|
|
Re: Weird case - March 29, 2007 3:55:00 AM
|
|
|
Shill
Posts: 1107
Joined: February 13, 2003
From: Madison WI USA
Status: offline
|
Vascular issue? The temperature (obviously) and hairloss (less obviously) can be suggestive of this. I see he had a doppler somewhere, but was it calf or inguinal? You are right, this is a challenging one. Any other PMH you didnt mention, (pulmonary) or any findings regarding the "problems" that he mentioned were found when the fasciculations were found?
I had heard one time, but not at band camp, rather at a presentation by one of our spine docs, that there can be venous "congestion" issues at the level of the central spinal canal that can impede circulatory flow to nerve roots, and yet not necessarily behave like a neurogenic claudication. Have you tried any spine flexion repeatedly, just to see what happens, or what he reports? At this point, I know I would be pulling out my hair, and I cant say that I could afford to do that too much before I run out.
Steve
_____________________________
Steve Hill PT
|
|
|
|
 New Messages |
 No New Messages |
 Hot Topic w/ New Messages |
 Hot Topic w/o New Messages |
 Locked w/ New Messages |
 Locked w/o New Messages |
|
 Post New Thread
Reply to Message
Post New Poll
Submit Vote
Delete My Own Post
Delete My Own Thread
Rate Posts |
|
0.453
|
Printable Version
