My father's strange case

[W222]

I am entering med school this fall so I have no real background to answer this puzzle, I was wondering who could help? My father is mid-50s and a carpenter/contractor/Big Dig inspector by trade. He noticed that last year he began to have a tremor in his right arm and that things were progressing quickly. He went to a neurologist who diagnosed him with early Parkinson's and he recommended Dopamine therapy to help stop the tremors. Well, Dopamine did nothing and the doctor said that this drug was a good diagnostic indicator that my father did not have Parkinson's. THEN my father relayed a strange story to me: He said he had been swimming in cold water and that when he got out and changed he was cold/shivering/goose bumped on one side of his body (only on the right side) and that he had no shiver on the left and no goose bumps on left either. I read somewhere (BRS I believe) that this sort of thing points to cranial nerve damage, ANYONE HAVE ANY SUGGESTIONS AS TO WHAT IS GOING ON? I am just curious and could use some info.

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[W222]

Why is Doc Mom such a Nazi when it comes to forum control? Lay off a little.


Anyone have any clues?

 

[MustafaMond]

My diagnosis....
Needs more HPI.


How long has he had a tremor, resting tremor or action tremor, any pain numbness, any h/o HT, HL, DM, CVA, CAD? DJD?

 

[W222]

Has had this a year. Resting tremor. No numbness.

 

[pikachu]

Any toxic exposures? Is the tremor episodic or always present? has he had any imaging studies done? What other medicines is he taking and does he have any other medical problems?

unilateral piloerection (goosebumps) most likely does not have anything to do with the cranial nerves. it could suggest a focal seizure or possibly pathology in the sympathetic chain.

 

[W222]

His neurologist said something about Bell's Palsy but I thought my dad was just confused because isnt Bell's a cause of facial paralysis. He takes no other medication and has no other medical problems. The shivering/goose bumps thing on one side of the body seemed strange, are you sure this doesnt suggest anything?

 

[pikachu]

Pubmed search reveals that (as I said above) unilateral goosebumps can be a presentation of a partial seizure. Goosebumps are mediated by the sympathetic nervous system so (as I said above) this could also be related to something going on in the sympathetic chain. Obviously I don't know your father's case and frankly these forums are not the optimal place to seek medical advice and diagnosis. If you are dissatisfied with the answers you are getting from his current neurologist (and yes, Bell's palsy is idiopathic unilateral facial nerve paralysis, nothing to do with the extremities) I would strongly suggest seeking a second opinion. If you are in Boston as I assume you are then there are excellent university centers there who would give your father's case the attention it deserves.

 

[neurodoc]

All that shakes is not Parkinson's Disease (PD). Consider Essential tremor (ET). Both PD and ET can present with a lateralized tremor. The main difference is that the PD tremor tends to occur during "rest." The ET tremor occurs at other times. A skilled neurologist can tell the difference.

 

[margaritaboy]

I'm no neurologist, but that seems like sound advice above.

For my education and enrichment, what do you neuro docs think about the possibility that the case above is related to a Parkinsons Plus syndrome that is resistant or refractory to dopaminergic therapy? The patient may have presented with Parkinson-like symptoms, and been given a trial of levadopa as part therapy and part diagnostic test. The Shivering experienced may have been unilateral tremor.

Viable theory? Or DOA?

 

[tofurious]

Margaritaboy is the first one to have said something intelligent (you really need to watch out who is giving you advice here). Consider one of the Parkinson Plus syndromes with an autonomic component such as multisystem atrophy (MSA). MSA with autonomic failure brings Shy Drager syndrome to mind. You should find a neurologist who can do a sweat test.

 

[dentite001]

Getting blood/glucose tests could also be a good idea. Shakiness can often be a sign of diabetes. Just my two cents.

 

[JRB]

W222,

Sorry to hear about your father's symptoms. Although there's not enough information here to go on, you might want to consider RSD (Reflex Sympathetic Dystrophy) in the diagnostic differential.

I hope you find out something soon.

JRB

 

[tofurious]

you might want to consider RSD (Reflex Sympathetic Dystrophy) in the diagnostic differential.

Highly unlikely, given there's no pain, the unilateral nature of such, and the autonomic failure rather than autonomic hyperactivity.

 

[pikachu]

Margaritaboy is the first one to have said something intelligent (you really need to watch out who is giving you advice here).

Yeah, advising someone (who couldn't get a diagnosis from a neurologist who didn't even know what Bell's palsy was) to seek a second opinion is really suspect advice...

So, W222, do you have any new info about what's been going on with your father?

 

[tofurious]

Yeah, advising someone to seek a second opinion is really suspect advice...

Well, that is hardly the only thing you said. You felt obliged to throw in some PubMed-based (mis)info knowing that inaccurate information is probably worse than no information at all. It is true that better to remain silent and be thought a fool than to speak out and remove all doubts.

 

[pikachu]

I was pointing out the fact that his father's symptoms could mean something serious and the family should seek a more informed opinion than what he was getting. I don't see what's so foolish about that, or what's so mis-informative about peer-reviewed articles on Pubmed. Is it something about Pubmed in particular, or do you not read journals at all, simply relying on your own brilliance for current medical information? If you're not concerned about new onset unilateral neurological symptoms/possible parkinsonism not responding to first-line treatment in a middle aged man with a smoking history and probable toxic exposures, I would suggest that it is you who plays the fool.

 

[MustafaMond]

Everyone is getting theirpanties ruffled over what sounds like ET.

 

[tofurious]

I don't see what's so foolish about that, or what's so mis-informative about peer-reviewed articles on Pubmed. Is it something about Pubmed in particular, or do you not read journals at all, simply relying on your own brilliance for current medical information?

Nobody is disputing the potential seriousness of the symptoms. PubMed has a wealth of information, but it is up to the reader/user to determine what is important and in particular what is relevant. You can tell us all about the latest studies on hangnails or any exotic syndrome of your choice, but that does not help the case nor the patient/family involved in the case if your original search is not even on the right course. You took useful information from PubMed and made it misinformation by using it in the wrong place. That is why becoming a physician involves more than knowing how to use PubMed. Accusing me of not reading is a detractor and a poor defense of the wrong path you had taken the OP down.

As for ET, ET is usually bilateral, but I am sure we'll hear all about the latest on ET from PubMed. Also, for those who are just following this thread, poor levodopa response is rather common in Shy Drager syndrome.

 

[pikachu]

That is why becoming a physician involves more than knowing how to use PubMed.

Thanks for the quotable profundity, Sir Doctor Osler. Again, I'm not sure what's so discreditable about PubMed. If you'd care to share your wisdom...we would ALL learn.

 

[jatadero]

don't know if you've figured it out yet but i had a patient who came in with unilateral piloerection.since i did not know where to start, i researched it and found the following article. you may need to consider that if the tremors and piloerection were related, whether these are ictal manifestations.

http://jnnp.bmjjournals.com/cgi/content/full/75/6/879