Moderator ventana Posted February 1, 2019 Moderator Share Posted February 1, 2019 a develping case 76 yr old white female mild htn and obesity, htn well controlled on meds 20-30 yr hx of being on pred low dose for presumptive PMR? Has some pain complaints, LS MRI shows moderate stenosis loosing mobility, EMG legs shows denervation of both quads Neuro is stumped (Attending and PA both are out of thoughts) CRP was elevated(mildly), ESR, RA w/u negative as was all labs and heavy metals lyme neg recent flair of pain responded well to pred burst has been referred to a tertiary neuro clinic Any thoughts??? Has been referred to a physiatry clinic specializing in neuromuscular Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 1, 2019 Share Posted February 1, 2019 What about distal upper extremities? Dorsal deformities of hand digits (similar to spooning appearance)? Grip weakness? Dysphagia? Polymyositis, or more specifically, Inclusion Body Myositis. Treatment, if this, is NOT to give steroids! Influenza vaccination can also exacerbate myositis episode. Distal LE weakness may appear initially but there will be loss of grip strength and fine motor movements due to digital deformities. Diagnosis is based on muscle bx. and pathologist needs to know what to look for. Link to comment Share on other sites More sharing options...
Cideous Posted February 1, 2019 Share Posted February 1, 2019 I would do a rapid strep test. If that is neg, send a strep culture. If that is neg, refer to the ER. This concludes your Urgent Care work-up moment. :D :D :D Link to comment Share on other sites More sharing options...
sk732 Posted February 1, 2019 Share Posted February 1, 2019 Interesting...LP for atypical GBS? Link to comment Share on other sites More sharing options...
Moderator ventana Posted February 1, 2019 Author Moderator Share Posted February 1, 2019 14 hours ago, GetMeOuttaThisMess said: What about distal upper extremities? Dorsal deformities of hand digits (similar to spooning appearance)? Grip weakness? Dysphagia? Polymyositis, or more specifically, Inclusion Body Myositis. Treatment, if this, is NOT to give steroids! Influenza vaccination can also exacerbate myositis episode. Distal LE weakness may appear initially but there will be loss of grip strength and fine motor movements due to digital deformities. Diagnosis is based on muscle bx. and pathologist needs to know what to look for. no UE issues grip stength grossly normal no inspection findigs on hands I am hoping for muscle and nerve Bx....... Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 1, 2019 Share Posted February 1, 2019 If it were such, the hand sx would be a late development, as would the GI sx. Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted February 1, 2019 Share Posted February 1, 2019 I'm sure neuro would have covered this base, but given the improvement with steroids, is MS in the differential? Link to comment Share on other sites More sharing options...
Moderator ventana Posted February 1, 2019 Author Moderator Share Posted February 1, 2019 29 minutes ago, ohiovolffemtp said: I'm sure neuro would have covered this base, but given the improvement with steroids, is MS in the differential? was, but ruled out Link to comment Share on other sites More sharing options...
Guest Samhain_Grim Posted February 1, 2019 Share Posted February 1, 2019 You mention EMG showing denervation; any myopathic potentials? Nerve conduction studies with CMAPs, SNAPs, conduction velocity? Any spasticity, changes to reflexes? Muscle wasting? CK level? You mention pain and response to steroids; is there muscle cramping specifically? Needs an LP if not done yet. Maybe muscle biopsy if has myopathic findings. Sounds myopathic because it's proximal, but if EMG is showing denervation specifically then perhaps not. If inflammatory myopathy, expect CK to be elevated. Possible GBS if EMG looks demyelinating. Depending on other findings, worst case would be the beginnings of motor neuron disease. If it was rheumatological, I think it would be odd to just involve motor, but I'm unsure.. Link to comment Share on other sites More sharing options...
cinntsp Posted February 1, 2019 Share Posted February 1, 2019 What is the timeline we're talking about here? What were the ESR and CRP results? Link to comment Share on other sites More sharing options...
Moderator ventana Posted February 1, 2019 Author Moderator Share Posted February 1, 2019 almost 30years on/off pred Link to comment Share on other sites More sharing options...
Guest ral Posted February 2, 2019 Share Posted February 2, 2019 He who knows syphilis knows medicine. - William Osler Link to comment Share on other sites More sharing options...
cinntsp Posted February 2, 2019 Share Posted February 2, 2019 6 hours ago, ventana said: almost 30years on/off pred I meant the loss of mobility. Has it been progressing slowly over 30 years or is this more acute? Link to comment Share on other sites More sharing options...
Moderator ventana Posted February 2, 2019 Author Moderator Share Posted February 2, 2019 mobilty has slowly decreased over the past 10+ years Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 2, 2019 Share Posted February 2, 2019 Trouble with steps/curbs or changes in floor surfacing? Drop episodes? Sent from my iPad using Tapatalk Link to comment Share on other sites More sharing options...
sk732 Posted February 3, 2019 Share Posted February 3, 2019 23 hours ago, ral said: He who knows syphilis knows medicine. - William Osler Two of Canada's greatest exports...syphilis (one of the highest prevalence rates in NA just down the road from me) and Bill Osler. Link to comment Share on other sites More sharing options...
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