Posters
Presentation Type
Poster
Discipline Track
Patient Care
Abstract Type
Case Report
Abstract
Background: Muscle weakness and numbness are prevalent complaints amongst patients and can have a varying range of diagnoses from benign inconsequential to life-threatening causes. The pattern and intensity of weakness, accompanying symptoms, medication use, and family history assist the physician in determining if a patient's presentation is caused by infectious, neurologic, metabolic, inflammatory, psychiatric, or drug-induced condition.
Case Presentation: Our patient is a 37-year-old female who presents to the clinic for a follow-up. The patient has a past medical history of Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), and an undiagnosed neuromuscular weakness for approximately 10 years. The weakness can affect a limb or at times an arm and leg and can last days to weeks. She does not note any precipitating symptoms. She had a complaint of a recent onset of numbness in the outer side of the foot that began a week ago and frequent headaches.
On physical examination, there was normal muscle tone and strength testing was 5/5 on all extremities except ankle flexion and extension were 4/5 bilaterally. She had bilateral decreased sensation to pinprick on the lateral sole of the feet. Cranial nerves I-XII were intact.
Antinuclear antibody testing screen was negative. Thyroid stimulating hormone testing was normal. White blood cell count mildly elevated at 12.4 with an absolute neutrophil count elevated. She reports over the years she’s had extensive work-up including MRI of the head, muscle biopsy, nerve conduction testing and multiple specialist visits with no formal diagnosis.
Her previous history of relapsing and remitting weakness and numbness raises concern for various neuromuscular disorders further discussed in this article. Our differential includes multiple sclerosis, guillan-barre, systemic lupus, fibromyalgia, or other etiology.
Conclusion: We are faced with a young woman with nonspecific symptoms of intermittent muscle weakness and numbness that have been present for years. We must not miss certain diagnoses such as Multiple Sclerosis while also keeping in mind a high-value approach to care. It is important to note which features are suggestive of MS such as the relapsing/remitting nature, the onset of age 15-50, optic neuritis, Lhermitte sign (shock-like sensation with flexion of the neck), ophthalmoplegia, fatigue and heat sensitivity. There is also a risk of bias impacting our diagnosis as she has MDD and GAD, we may be quick to jump to Fibromyalgia. There is a reported bidirectional association between fibromyalgia and depression where each disease may increase the likelihood of developing the other. Recent studies on post-COVID had brought more understanding to the pathology and treatment of Fibromyalgia which may help our patient. Comprehensive rehabilitation programs with aerobic exercise have demonstrated improvement in post-COVID symptoms attributed to mental and physical fatigue.
Though our search continues for an etiology for our patient’s intermittent muscle weakness, we also are reassured that we have kept the differential broad, we do not see a diagnosis of multiple sclerosis, and we are focusing on continuing her function and activity.
Academic/Professional Position
Medical Student
Academic/Professional Position (Other)
MS3
Recommended Citation
Campos, Pamela; Selva, Sidney; Bialaszewski, Ryan; Althaus, Elizabeth; Arab, Shuaibahmed M.; and Chang, Chelsea, "Mystery Case: an effort to diagnose a patient with a decade of relapsing and remitting neurologic symptoms with a comprehensive medical approach" (2024). Research Symposium. 32.
https://scholarworks.utrgv.edu/somrs/2023/posters/32
Included in
Mystery Case: an effort to diagnose a patient with a decade of relapsing and remitting neurologic symptoms with a comprehensive medical approach
Background: Muscle weakness and numbness are prevalent complaints amongst patients and can have a varying range of diagnoses from benign inconsequential to life-threatening causes. The pattern and intensity of weakness, accompanying symptoms, medication use, and family history assist the physician in determining if a patient's presentation is caused by infectious, neurologic, metabolic, inflammatory, psychiatric, or drug-induced condition.
Case Presentation: Our patient is a 37-year-old female who presents to the clinic for a follow-up. The patient has a past medical history of Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), and an undiagnosed neuromuscular weakness for approximately 10 years. The weakness can affect a limb or at times an arm and leg and can last days to weeks. She does not note any precipitating symptoms. She had a complaint of a recent onset of numbness in the outer side of the foot that began a week ago and frequent headaches.
On physical examination, there was normal muscle tone and strength testing was 5/5 on all extremities except ankle flexion and extension were 4/5 bilaterally. She had bilateral decreased sensation to pinprick on the lateral sole of the feet. Cranial nerves I-XII were intact.
Antinuclear antibody testing screen was negative. Thyroid stimulating hormone testing was normal. White blood cell count mildly elevated at 12.4 with an absolute neutrophil count elevated. She reports over the years she’s had extensive work-up including MRI of the head, muscle biopsy, nerve conduction testing and multiple specialist visits with no formal diagnosis.
Her previous history of relapsing and remitting weakness and numbness raises concern for various neuromuscular disorders further discussed in this article. Our differential includes multiple sclerosis, guillan-barre, systemic lupus, fibromyalgia, or other etiology.
Conclusion: We are faced with a young woman with nonspecific symptoms of intermittent muscle weakness and numbness that have been present for years. We must not miss certain diagnoses such as Multiple Sclerosis while also keeping in mind a high-value approach to care. It is important to note which features are suggestive of MS such as the relapsing/remitting nature, the onset of age 15-50, optic neuritis, Lhermitte sign (shock-like sensation with flexion of the neck), ophthalmoplegia, fatigue and heat sensitivity. There is also a risk of bias impacting our diagnosis as she has MDD and GAD, we may be quick to jump to Fibromyalgia. There is a reported bidirectional association between fibromyalgia and depression where each disease may increase the likelihood of developing the other. Recent studies on post-COVID had brought more understanding to the pathology and treatment of Fibromyalgia which may help our patient. Comprehensive rehabilitation programs with aerobic exercise have demonstrated improvement in post-COVID symptoms attributed to mental and physical fatigue.
Though our search continues for an etiology for our patient’s intermittent muscle weakness, we also are reassured that we have kept the differential broad, we do not see a diagnosis of multiple sclerosis, and we are focusing on continuing her function and activity.