weello Posted April 13, 2011 Share Posted April 13, 2011 I know this is probably wrong but possibly a unique case of guillain-barre syndrome, fits with the progressive SOB, dysphagia, and muscle weakness. Just a guess off the top of my head. Link to comment Share on other sites More sharing options...
weello Posted April 13, 2011 Share Posted April 13, 2011 or even ALS?!? Link to comment Share on other sites More sharing options...
acozadd Posted April 13, 2011 Share Posted April 13, 2011 ALS is usually a younger and would have uncontrollable movements, etc. Guillian-Barre is generally bilateral and starts at the feet and moves upward. Possible, but his symptoms are primarily right sided, and she didn't mention a recent GI infection, etc. Link to comment Share on other sites More sharing options...
Annika Posted April 13, 2011 Share Posted April 13, 2011 Did something spread to the CNS? Pressure? Tumor? The first thing that jumped out at me was something pressing on something, and it being secondary to the possible mass? But then if it's neuro...What is in that lower lung area? I'd think the CT would be essential...I keep thinking some sort of primary CA with mets.... So appreciate these! Link to comment Share on other sites More sharing options...
acozadd Posted April 13, 2011 Share Posted April 13, 2011 So far we've imaged the brain, c-spine, and t-spine and found nothing. There could either be something in the L-spine, or it could be something that simply cannot be seen on imaging. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted April 13, 2011 Administrator Share Posted April 13, 2011 ... I'm not so sure we've found no tumors. Reread the stated CT results and see if you agree that they're pretty narrowly worded to what we were specifically looking for. I don't see any reason this can't be an occult cancer somewhere with mets to the CNS. Link to comment Share on other sites More sharing options...
boomersooner34 Posted April 13, 2011 Share Posted April 13, 2011 Do the DTRs increase after patients contract several times? How about calcium channel antibodies? DDx: possibly Myasthenic syndrome (Lambert-Eaton syndrome) Link to comment Share on other sites More sharing options...
deborah212 Posted April 14, 2011 Author Share Posted April 14, 2011 ANCAs negative, ANA negative, RF nl, Lyme Ab negative, RPR negative, ESR 15, copper/cerulopasmin nl, viral work-up included HIV neg ... Patient had TLS MRI which was negative for everything except DJD. ... PFTs with severely reduced FVC and FEVI (% predicted in the 30s) consistent with restrictive lung disease. Patient unable to inspire/exhale deep enough for DLCO. ... EMG with active denervation and chronic reinnervation changes most severe on right but also present on left with preserved SNAP amplitudes consistent with motor neuron disease. ... Swallow eval with aspiration on thin liquids Final Diagnosis: Amyotrophic Lateral Sclerosis Treatment: Prescribed Rilutek (riluzole) and set up with pulmonary as would need tracheostomy in near future This was a sad case, but a good teaching point nonetheless. Average age of onset of ALS is ~65 with slight male predominance. This was a zebra... but again illustrates that history is essential. Link to comment Share on other sites More sharing options...
Guest guthriesm Posted April 14, 2011 Share Posted April 14, 2011 Yay for history - of course I am only saying that because it is the only part I really know (finishing up my first semester in a couple of weeks). Link to comment Share on other sites More sharing options...
acozadd Posted April 14, 2011 Share Posted April 14, 2011 For some reason when I read ALS before I was thinking of Huntingtons... woops! Interesting case, definitely a head scratcher. Link to comment Share on other sites More sharing options...
chiaroscuro27 Posted April 14, 2011 Share Posted April 14, 2011 Great case! Please keep them coming. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted April 14, 2011 Administrator Share Posted April 14, 2011 Indeed, thank you very much for putting us through our paces! Link to comment Share on other sites More sharing options...
andersenpa Posted April 14, 2011 Share Posted April 14, 2011 deborah212 if this comes up on my next PANRE I'm sending you a coffee card. Link to comment Share on other sites More sharing options...
dcrowell Posted April 17, 2011 Share Posted April 17, 2011 I'm starting PA school in the fall, but have been reading theses cases. They are great. I realize that there is no definitive test for AlS. So was the diagnosis primarily based on the presence of UMN and LMN deficits? Obviously along with the absence of other neurologic pathologies? Link to comment Share on other sites More sharing options...
deborah212 Posted April 18, 2011 Author Share Posted April 18, 2011 ALS is a diagnosis based on the progression of upper and lower motor neuron findings. EMG (electromyography) is helpful for confirmation. However, because the disease is so devastating, a thorough work-up of alternative causes should be pursued. Emedicine is a fantastic resource (comparable to UptoDate and FREE). Just google "emedicine" and whichever disease process you are interested in reading about. You can read more about ALS and its diagnosis here: http://emedicine.medscape.com/article/1170097-overview Link to comment Share on other sites More sharing options...
dcrowell Posted April 18, 2011 Share Posted April 18, 2011 Great thanks Link to comment Share on other sites More sharing options...
Davo Posted April 20, 2011 Share Posted April 20, 2011 Very cool! Link to comment Share on other sites More sharing options...
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