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This is a case I'm struggling with. Any thoughts would be greatly appreciated:
Patient is a 60ish right-handed homeless male with a history of heavy labor on his hands. He also has a distant history of cervical fractures. He was hospitalized for septic meningitis about a month ago, suspected to be West Nile, but still don't have the titers back yet. He's not a great historian (still not even oriented x 3), but he claims he started having bilateral arm weakness, left greater than right, following the meningitis. On exam, he has significant wasting and weakness in basically both arms in every muscle group, as well as in the shoulder girdle, left much worse than right. Sensation is decreased to light touch in his left palm.
NCS showed severely slowed distal latency and reduced amplitude in both the ulnar and median nerves at the wrist, left worse than right. He also has a drop in velocity across the elbow for the ulnar nerve bilaterally. After those number, I expected not to get any sensory findings at all, but I did actually manage to get bilateral ulnar and median SNAPs which were slow peak latency and normal amplitude. Radial SNAP entirely normal (perfect, actually). MAC was normal on the left, couldn't obtain bilateral LACs.
EMG was a little limited by patient cooperation. First DI showed 3+ fibs/sharps, refused pronator teres, biceps/triceps both showed 2+ fibs/sharps with polyphasic motor units, deltoid didn't show much spont activity but a lot of polyphasic motor units, supraspinatus showed 1+ fibs/sharps. I did the cervical paraspinals and from the brief look I got, I didn't see any spontaneous activity, but at this point, the patient started yelling that I was assaulting him, so I stopped.
With this limited study, any thoughts? I have a few, but I'll wait to hear what people say.
Patient is a 60ish right-handed homeless male with a history of heavy labor on his hands. He also has a distant history of cervical fractures. He was hospitalized for septic meningitis about a month ago, suspected to be West Nile, but still don't have the titers back yet. He's not a great historian (still not even oriented x 3), but he claims he started having bilateral arm weakness, left greater than right, following the meningitis. On exam, he has significant wasting and weakness in basically both arms in every muscle group, as well as in the shoulder girdle, left much worse than right. Sensation is decreased to light touch in his left palm.
NCS showed severely slowed distal latency and reduced amplitude in both the ulnar and median nerves at the wrist, left worse than right. He also has a drop in velocity across the elbow for the ulnar nerve bilaterally. After those number, I expected not to get any sensory findings at all, but I did actually manage to get bilateral ulnar and median SNAPs which were slow peak latency and normal amplitude. Radial SNAP entirely normal (perfect, actually). MAC was normal on the left, couldn't obtain bilateral LACs.
EMG was a little limited by patient cooperation. First DI showed 3+ fibs/sharps, refused pronator teres, biceps/triceps both showed 2+ fibs/sharps with polyphasic motor units, deltoid didn't show much spont activity but a lot of polyphasic motor units, supraspinatus showed 1+ fibs/sharps. I did the cervical paraspinals and from the brief look I got, I didn't see any spontaneous activity, but at this point, the patient started yelling that I was assaulting him, so I stopped.
With this limited study, any thoughts? I have a few, but I'll wait to hear what people say.
