Discussions By Condition: I cannot get a diagnosis.

Dr JCottleMD, will you please help me?

Posted In: I cannot get a diagnosis. 8 Replies
  • Posted By: frustratednurse
  • July 2, 2009
  • 05:59 AM

As you are a very experienced Neurologist I would be honored if you would look over my case and give me any suggestions.

37 y/o female, married with 2 children, work as a Home Health RN, No major stresses.

No smoking, alcohol or illicits

symptoms began 1 1/2 years ago with numbness and tingling in left arm, left face, severe fatique, mild tightening in chest. I got scared and went to ER after 12 hours. Had full cardiac work up all was grossly normal. they diagnosed me with anxiety attack, I spoke with my PCP and told him that my mother probably had depression in her 30s but never sought treatment, she slept alot, left my dad, was very moody. (she was killed in car accident at 47) He opted to put me on Lexapro. I became less moody and nicer to my husband but that was about it for me.

3-4 mos later began getting extremely sleepy during the day to the point I would have to pull my car over and rest before continueing to my next patient. It was almost like a pain med reaction without the med. I had some memory problems like forgetting appts, forgetting to run errands, turn things in etc..., words would get jumbled and my speach was slow at times (my friends tell me).

I saw my PCP when I had an episode of vertigo followed by weakness and altered sensation on my R side. I was admitted and work up was done for CVA including D-dimer, carotid u/s, MRI of brain w/ contrast, MRI of carotids, cardiac work up with stress test, and much blood work. All was normal. He said I had a beautifully normal appearing brain and had no evidence of stroke, tumor, MS or any injury. He also said it was stress related and sent me back to my PCP. My PCP was not convinced but increased my lexapro to "prove" it was not stress and referred me to neurolgy dept at Vanderbilt university. Another MRI of Brain done and ANA, CRP, and coag studies. again all is normal with the MRI but my coag was abnormal and my CRP was elevated to 14 (I think). They suggested an ASA daily. And I also had the DNA test for lupus which was normal. This was the stroke specialist, I don't know why I ended up seeing him but we both agreed I probably didn't need to.

since then my flare ups are more predictable, starting with a numb feeling in my R knee joint, jerky or double vision, floaters, words won't come, progresses to extreme weakness in R leg and knee "gives" out, more pronounced neuropathy in hands and feet which is migratory severe indescribable fatique and sleepiness, Also had vertigo very badly during this past flare up. Medrol dose pack always makes my symptoms go away. Most of the time symptoms are brought on by physical stress and heat.

I forgot to mention that he changed me to Cymbalta also to r/u fibromyalgia, I do not have the tender points but I did have major muscle aches every night that are gone now.

My PCP is now thinking possibly polymyocitosis or RA but my symptoms don't really fit. He did another CRP, CPk, and thyroid study this week, I don't have the results yet.

Is it possible that I have MS and don't have lesions? 2 neuros say it is unlikely with the severity and frequency of my symptoms, My PCP and a neurosurgeon friend tell me it is possible but I have to prove it.

Any suggestions for me??

Thanks for sharing your timeless wisdom and experience.

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8 Replies:

  • Well, I'll be glad to review your symptoms with you but don't feel too honored; my age constantly outpaces my experience by a good margin and attempts to close the gap have been unsuccessful. Contemplations of MS in the midst of symptoms such as those described is sort of compounding an already illusive game of hide-n-seek, so to speak. There are a good number of disorders capable of producing the symptomatology you describe and unless there is sound evidence of at least two areas of the spinal cord or brain that demonstrate plaque formation subsequent to demyelination, and, the evidence can demonstrate the temporal relationship of a relapsing/remitting pattern, then considerations of MS need to put on the shelf and out of the equation until such time that evidence supports it. The progressive form of the disease would naturally be absent from the equation because the timeframe of original onset of symptoms would have brought it to the level of detection by this point. Indeed, as already mentioned by your neurologist, there is a direct correlation between the lesion formation and characterization of symptoms at any given time. The absence of evidence on imaging in the presence of your symptoms would indeed suggest a cause otherwise. With regard to the double vision, please inform me whether when you alternate covering one eye the vision problem disappears. Always remember that in instances of actual double vision, if it's prior to the optic chiasm then covering one eye will make no difference. If it's beyond the chiasm, then the vision through an uncovered eye will be absent the double vision and would confirm the problem to be strictly visual in nature. When you say "jerky" vision, are you describing the awareness of a quivering effect in your vision when trying to focus on something in particular, or is there true horizontal or vertical nystagmus on direct examination? Also remember that a mild degree of horizontal nystagmus on extreme left or right gaze is entirely normal. Floaters are merely a separation between the retina and the vitreous humor and mostly represent an unremarkable finding. There are a few instances where greater concern may be warranted, but in this case the finding would be incidental only. Tell me more descriptively about the vertigo. Was there a sensation that either you or the room was spinning, or did it constitute a more sudden shift in balance as though the environment suddenly tilted to one side or the other? Alternatively, did the episode occur more as a descrease in steadiness or balance, causing you to feel light-headed? With regard to daytime somnelescence, please tell me whether your sleep patterns at night have been disturbed or altered to any extent, regardles of whether you feel the changes to be related. This is the first and foremost issue to examine in determining a cause for such complaints and it's extremely rare for patients to proclaim excellent sleep habits at night while simultaneously complaining of daytime somnelescence. When you say the corticosteroid treatment always makes your symptoms go away, please tell me the timeframe for abatement of symptoms to occur once the dose pack is started? Also tell me how long you remain symptom-free once steroid treatment has concluded? Prothrombin, partial prothrombin and CRP are among a number of tests that can be affected by various circumstances and, in of themselves, do not suggest pathology. You could likely have the PT and PPT performed again and find an entirely different result, most likely within the normal range. C reactive protein can be elevated due to inflammation in general and not necessarily as a consequence of a neurodegenerative disease. I would not put much emphasis on tests like this as supportive of any particular direction to proceed. They are incidental findings only at this point. Let me know the results of the pending tests and we'll talk further but for the time being, I think trying to settle on a diagnosis of MS at this point is far too premature and in general doesn't fit very neatly. Best regards, J Cottle, MD
    JCottleMD 580 Replies Flag this Response
  • I became lost over the duration of these flare ups. A couple of points I would add though. Firstly, if you do have the occurence of floaters and visual disturbances, then you must get your eyes examined. Floaters are common and usually harmless, but they can be an indicator of retinal problems. That said, I don't think you are describing floaters but rather an aura. If so, then you might be suffering from a type of eye migraine (you don't need a headache to qualify). This could explain your other symptoms also. However, you will need the views of a specialist in this field to determine how likely this is in your case (there are several different types of eye migraine) or at least you need to discuss it in detail with your doctor.
    Anonymous 42789 Replies Flag this Response
  • Regardless of the visual phenomenon that you are describing, I feel certain that at some point along the way your doctors performed an opthalmic exam as part of the workup to rule out MS. Optic neuritis is a very common clinical finding in the disease and if you had any type of retina or macular problem, it would have been identified at that time. You'll find a number of people specifically seeking out my postings and struggling to countermand my comments for the purpose of gaining attention, with the notion that their own opinions somehow represent the more prudent advice. Again, there is nothing to suggest that you need a full opthalmic exam at this point. If the clutter gets to be too much of a nusiance, I will provide you with a direct link to a restricted physician's forum that will exclude these individuals from participating. Best regards, J Cottle, MD
    JCottleMD 580 Replies Flag this Response
  • JCottle, you seem to be very defensive if not a little paranoid. The lady asked for suggestions and that is what I provided. I do not care about you or your opinions. In fact, I was not even contradicting you.I would urge you (frustratednurse) to look further into the visual disturbances you are suffering, to see if you can better describe these to your doctor. You should be able to get a full description of an aura from various sites on the internet by searching for migraine and aura. If this is what you are experiencing, then you should mention it to your doctor. If not, then dismiss it.
    Anonymous 42789 Replies Flag this Response
  • Eye migraine is something that the poster's neurologists would have already considered. To present it as a legitimate medical consideration, in this case, constitutes "medical trolling."
    m3dh31p 69 Replies Flag this Response
  • m3dh31p, whatever "medical trolling" is supposed to be. I know what internet trolling is though and I smell a hint of that in you and your fellow poster. If frustratednurse's neurologists have ruled out a migraine source, then all well and good. There is no basis for this assumption however, based on what frustratednurse has said, especially if she has been understandably confused over the symptoms. I assume that if you have anything constructive to say, then she would welcome that too, even if it is a condition that has been ruled out already.
    Anonymous 42789 Replies Flag this Response
  • To KNN First of all, the forum history shows that you've made no other posts except in response to my own. You've also made no effort to join the forum and merely appear to raise controversy, which speaks to a pathology all its own. Secondly, if you want to practice medicine, go to medical school and obtain a license to do so. Otherwise, your comments to any person making inquiry about medical problems is entirely speculative and unsubstantiated. Providing support is one thing, but giving medical direction or advice in the absence of the qualifications to do so is reckless at the very least. J Cottle, MD
    JCottleMD 580 Replies Flag this Response
  • To KNN First of all, the forum history shows that you've made no other posts except in response to my own. You've also made no effort to join the forum and merely appear to raise controversy, which speaks to a pathology all its own. Secondly, if you want to practice medicine, go to medical school and obtain a license to do so. Otherwise, your comments to any person making inquiry about medical problems is entirely speculative and unsubstantiated. Providing support is one thing, but giving medical direction or advice in the absence of the qualifications to do so is reckless at the very least. J Cottle, MDGiven that you know so little about me, then this is a bold statement indeed. An important point to make however, is that an internet forum is not the place to provide a medical diagnosis. That is the domain of the patient's doctor. You would do well to remember that. There is nothing wrong with suggesting alternatives that the doctor may not have considered and there is nothing wrong with the patient discussing these with his/her doctor. But ultimately, it is only the patient's doctor who can consider these in detail, as only they are aware of the patient's history. Going to medical school would be a major leap backwards for me.You are no newcomer to controversy yourself, are you? I am surprised that a man of your supposed experience seems to shy away from debating points and sharing his learning, but rather prefers to become defensive. Other than that, all I have to add is that I don't feed trolls.
    Anonymous 42789 Replies Flag this Response
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