need help with a case...

[gardilimo]

hey guys, im an ms4 with a complicated patient. can you help out?

61 yo Caucasian male c a PMH of DM2 and HTN presents with worsening 'foot drop' in RLE over past 5 months, pain on movement of neck and RUE, severe pain radiating from R cervical region radiating down to R shoulder, pain in the lower back feeling as if radiating down the vertebrae, R eye drooping periodically, R 'droopy lip' ie periodically unable to keep food in mouth, salivating x 2 wk. Pt also states that he is unable to form some words with his mouth and when he wears a hood he becomes dizzy and gets a severe headache. Denies headaches, changes in vision, numbness, tingling, N/V/D/C, fever, muscle weakness, etc. Pt goes to see FP who tells him it is arthritis and refers him to Neurologist. Neurologist orders a series of blood tests and MRI but does not feel this is emergent.

Meds: Byetta (incretin mimetic), baby asa
PMH: HTN, Cholelithiasis, DM2, Psoriasis, Restless Leg
Surg: Cholecystectomy

On physical (quickly in ER): Vitals WNL, BP 140/90
Well nourished, mildly overweight man who appears his stated age
CN2-12 grossly intact, R reflexes absent completely, L sided 1+ throughout. Pt does not have full ROM in neck, stopping when moving toward R side in pain, unable to raise RUE past 90 degrees. Both LE 3/5 in strength throughout. ROmberg Positive, Unable to tandem walk.

Diagnostics: Awaiting lab and MRI results

I know this is not very thorough and you guys are thoroughly annoyed with the physical listed.

But what DDX would you consider?
CVA (ischemic- SCA, PICA, AICA, hemmorhagic-basilar artery-less likely) with subsequent TIA's?
TIA
Lymes??
MS
West Nile Virus

I would assume if CVA, that the MD would have pursued this and gotten an emergent MRI. We were kept in the dark about his reasonings.
THANKSSS!

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[Nerdoscience]

If he's got 3/5 LE strength, how did you test a Romberg? He should not be able to support his own weight. If he has right eye drooping, he has 1. something affecting the sympathetics on the right (Horner's), 2. something affecting CN III, or 3. You lied, and he's Asian, and he's got a CNVII lesion, which would also explain the droopy lip.

There is nothing emergent about a 5 month old problem, and it doesn't sound like one brain lesion could cause all this.

This guy might have something bad going on in his spinal cord affecting the sympathetics somewhere. But, not really enough details.

By the way, are you using this forum as a way out of looking stuff up yourself?

 

[gardilimo]

thanks for the reply! no, i did try to look all this up, i am just having a hard time explaining all his issues. i havent found any good neuro texts really to reference and neuro at my school, like many others, is lacking in a large way!

 

[Phantom Spike]

When confronted with a neurological problem, I often find it useful to start out by deciding whether we're dealing with a central (brain or spinal cord) or peripheral (muscle, junction, nerve, plexus or root) problem. If it's been five months and you have hyporeflexia and (presumably) diminished tone, it's very unlikely to be central. Also, when there are multiple complaints, as in this case, I find it easier to try and localize each one and then see if they "overlap" anywhere.

To start with the right foot drop, it could be secondary to a peroneal neuropathy, a sciatic neuropathy, a lumbosacral plexopathy or an L5 radiculopathy. It would be helpful to have a detailed sensory exam, as that may prove useful in localizing among these possibilities, but you mentioned that he was areflexic in the entire RLE, so multiple roots or significant portions of the plexus must be involved. You mentioned 3/5 strength, but is that in every muscle tested, or was the strength weaker in muscles supplied by specific nerves or roots? And how much is pain a factor in the weakness? Involvement of the other leg is also suggestive of a diffuse process, with the same localization again. Low back pain does tend to favor a radiculopathy, but a description of the radiation would be helpful.

In the RUE, there is weakness in abduction of the shoulder beyond 90 degrees. I would try to localize the same way we approached the right foot drop. Again, the lesion appears to be peripheral. The deltoid performs this function, but is there evidence of weakness in other muscles supplied by the posterior cord of the brachial plexus (e.g, triceps or wrist extensors) or the C5 root (e.g., biceps)? Is the scapula displaced, and does it wing with attempted abduction (suggesting a spinal accessory involvement due to trapezius weakness)? What is the sensory exam like? There is diffuse areflexia in the right arm too, again implicating several nerve roots or large portions of the brachial plexus, and neck pain radiating into the arm and worsened with movement, suggesting a multilevel radiculopathy.

Also, the patient complains of a history of ptosis, but you found none on your exam. That means it's either resolved or intermittent. Is it fatiguable, suggesting a neuromuscular junction disease? If it was due to a structural lesion, it would be unlikely to come and go, although the localization that Nerdoscience mentioned still holds true. Episodic facial weakness could also possibly be a neuromuscular junctional disorder, but you're right, you can't completely rule out a TIA with the history we have. Does difficulty forming words with his mouth refer to an aphasia (with a cortical localization) or dysarthria (with a less specific localization)? It seems to me that these cranial nerve complaints are unlikely to be related to his limb complaints. And while inablility to perform tandem gait suggests cerebellar dysfunction and possibly sensory ataxia, and a positive Romberg's suggests sensory ataxia (that could localize to the peripheral nervous system or the posterior columns of the spinal cord), I agree with Nerdoscience that we really can't comment on these symptoms with such profound weakness.

I would say that CVA and MS are unlikely, since I think this is a peripheral problem and pain is not a major feature of either. Multilevel radiculopathy is possible with Lyme's (as well as HIV and sarcoid) but again, pain is not a prominent feature. The same argument holds true for West Nile, which can give you a polio-like picture and affects the anterior horn cells, but not much pain. Pain also argues against ALS, which could be a consideration as it might explain some of the cranial nerve signs, but I would expect some hyperreflexia and ptosis is generally not a feature. Diabetes itself can cause painful multilevel radiculoplexopathies (diabetic amyotrophies) but they tend, I beleive, to mainly involve the proximal thigh muscles.

I guess what I would do with the information we have available, is image the cervical and lumbosacral spines (MRI with contrast) and perform an EMG/NCV study of the right upper and lower extremities. The latter would include a repetitive nerve stimulation study for NMJ disease. If no structural lesions are present and the EMG confirms a multilevel radiculopathy, I would order bloodwork and might do an LP to rule out an autoimmune/vasculitic or infectuous etiology.

 

[exgatr]

How about a malignant process:

1. Spinal mets from prostate cancer

2. Pancoast Tumor

3. Lambert-Eaton myasthenic syndrome (but that doesnt come with pain usually)

 

[neurodoc]

Physical Exam contradicts Symptoms: e.g., right lid droop and R facial weakness (and apparent bulbar dysarthria) don't jibe with the report that CN exam is normal. Shoulder/neck pain suggests a cervical cord/root problem, and I was thinking of a cervical myeloradiculopathy. That could give LMN weakness in the RUE and UMN weakness in the LE's (R>L for a R sided C-cord compression). But you say the R sided DTRs are hypoactive.... A C-cord lesion on the R could give a R Horner's syndrome (R lid droop), but shouldn't affect the facial or bulbar musculature. In short, the whole picture doesn't fit together.

Nick

 

[neurodoc]

I suppose some sort of patchy pathology affecting CN and spinal roots could explain the symptoms, but it would be REALLY odd that all of these lesions affected only the R side... Examples of patchy pathologies are: inflammatory and infectious polyradiculoneuritis, granulomatous and carcinomatous meningitis, and neurofibromatosis. MS can be patchy, but it will result in central and UMN findings.

Nick

 

[gardilimo]

thanks so much for the replies and helping me make sense of all this. i obviously a,m new to all of this and i appreciate the detailed approach of how you would diagnose such a patient. im sorry for such a s%#@tty H+P but that was all i had. i have been corrected: his proximal thigh muscle strength was 4/5 b/l. he also complained of his nose running profusely on his left side periodically and not being aware of it until he saw mucus running out of it. this was not accompanied by any lacrimation, salivation, etc on either side. he also noted that at times, his facial weakness is worse in the morning altho he has experienced the eyelid drooping in the middle of the day! he has been a reliable historian in the past and he has no family history of any illness except emphysema and asthma, neither of which he suffers from. No FH of any autoimmune, vasculitic, neuromuscular, cancer related diseases. The only thing that seems to contribute is his diabetes.

 

[neglect]

As is usual and all too typical, this patient needs a neurologist to take a history and do an exam. There are many disconnects on exam and frankly I don't trust it.

Not your fault though. You need to see about 10 of these patients before you get your game on.