59 year old female with bilateral lower and upper limb weakness

This case has been taken by: https://dr-arefin.blogspot.com/2022/11/59f-with-als.html

CHIEF COMPLAINTS 

This is the case of a 59-year-old female, a company employee who expressed the following complaints:

- Weakness in both upper and lower limbs (involving fingers and waist) since 11 months 

- Inability to maintain balance and walk without support since 6 months 

HISTORY OF PRESENTING ILLNESS 

The patient was apparently asymptomatic 11 Months ago 

11 months ago, the patient developed left lower limb weakness, which was insidious in onset and progressive in nature. She describes that she was prone to frequent falls, she recollects three such episodes once on the bank of a well and twice in her yard. There were multiple injuries to her legs at this point.

The muscle weakness, initially present in her left lower limb gradually spread to her left upper limb. The patient could carry out her daily activities with discomfort for the following months. 

 

6 Months ago the muscle weakness spread bilaterally to the right upper and lower limb. The patient was unable to maintain her balance, due to weakness, thus was unable to walk without support. 

5 Months ago the patient was able to sit in her bed. She required assistance to visit the washroom and to bathe. There is no history of dysphagia or dysarthria. There are no deficits in her cognition or memory. 

5 months ago, the patient visited 3 doctors.

According to the medical records, the patient had Grade III Muscle weakness, Spastic paralysis of the lower limbs, and muscle wasting in all limbs. The patient also complained of neck pain radiating to bilateral upper limbs. Superficial and deep sensations were intact. 

Thus MRI of the cervical spine, NCV and EMG studies were done based on which the patient was diagnosed with Amyotrophic Lateral Sclerosis. 

The patient is currently consuming Tablets Rilozol and Vitamin E. 

PERSONAL HISTORY 

Diet – Mixed diet 

Appetite: Normal 

Bowel and bladder movements – Normal

Sleep: Adequate 

PREVIOUS CONSULTATIONS 

PREVIOUS INVESTIGATIONS 

GENERAL EXAMINATION 

The patient is moderately built and moderately nourished. 

CNS Examination : 

(Based on history, relevant to the case  )

Higher Mental Functions : 

- No Dysarthria 

- Memory - recent and remote: Normal 

Motor System Examination : 

- Bulk of muscle on inspection: Reduced bilaterally in both upper and lower limbs 

-Power: Inability to lift both lower limbs from bed while lying down. 

- Reflexes: -Brisk reflexes 

Sensations: intact 

Autonomic Nervous system: Bowel and bladder movements normal. 

DIAGNOSIS ; 

Amyotrophic Lateral Sclerosis 

Clinical case discussion on PaJR Group 

Patient 59F: Good Evening Doctor.

Arefin Sadat: Greetings!

Arefin Sadat: https://dr-arefin.blogspot.com/2022/11/59f-with-als.html- click here

Here is the updated case report with deep tendon reflex videos of the patient: 59F with ALS

Patient 59F: New symptom we found today, according to her it's very old, below video FYR

Patient 59F: ‎<attached: 00000013-VIDEO-2022-11-21-22-21-35.mp4>

 Dr. Rakesh Biswas sir: Looks like brachial artery pulsations.

 Patient 59F: is there any medical center to take her for treatment, please suggest

Dr. Rakesh Biswas sir: All medical centers will examine her and may offer some treatment but once they too clinically confirm the diagnosis of ALS there isn't much effective treatment medical science has been able to discover till now for this condition.

Most centers can try to find solutions to support her current activities using what are currently called neurorehab tech.

Please share her hourly activities here so that we can assess her current requirements

 Patient 59F: Sir , she dosen't have strength on her waist to Stand or walk, please advise if there is any treatment / surgery which can help her


 Dr. Rakesh Biswas sir: As per the data you have shared till now through  (AS) this could be ALS in which case surgery is not available but for any paraplegic one of the neurorehab solutions available in US is "exoskeleton" and other devices.

You can read more about them here https://link.springer.com/article/10.1007/s00415-022-10971-w

Some of our team members are researching on these technologies. @ may be able to put you in touch with our team member and robotics expert, Abhishek Choudhury who is also there in our PaJR volunteers group


Dr. Dinesh Datta: ‎<attached: 00000019-PHOTO-2022-11-23-00-22-13.jpg>


 For this case

- do they use well water for drinking or other household purpose?
- What filter they use for drinking water?
- please share her district and state name.
Well water is associated with sporadic ALS caused by probably fungal infection or inorganic toxins like selenium. Lead toxicity also one possibility due to sindur, so can we know if she is hindu?

What is his husband's age and how is his health?

 Dr. Rakesh Biswas sir: Share all the references too

Dr. Rakesh Biswas sir: 👆Please see if you can answer @9 questions

 Dr. Rakesh Biswas sir: Share clickable links too


‪+9: https://pubmed.ncbi.nlm.nih.gov/16909025/

The importance of questions is, if she consumes water from well, can stop that. If it's in a district where water toxicity with metals are common then we may look into research to find ALS scenario there as sometimes toxicity treatment may help symptoms. If filter at home then better if family members consume water from that and avoid from well if we find possible connection.

So whenever possible, you may find answers from patient or their family.


Patient 59F: we have RO machine , from there we are Drinking water


 Dr. Rakesh Biswas sir: Does she use a wheel chair?

Patient 59F: No sir

 Dr. Rakesh Biswas sir: Is she able to walk nowadays?


Patient 59F: No she is not able to walk, she need support to walk, once we hold her hand with that she is walking with very slow step


 Dr. Rakesh Biswas sir: Alright that means she can walk with support.

How long does she walk daily?
Is she able to walk from her bed to the bathroom and able to look after herself?

Any ayurvedic medication use by the patient now, recently/ recent past?

Please list all if used with duration used for.

They sometimes case lead toxicity.

Arefin Sadat:  can you please tell the current condition of the patient? Is there any visible progress?


Dr. Rakesh Biswas sir: Please ask them to share their daily energy input (food plates) and outputs (hourly activities).