Monday, May 4, 2009

Leg numbness and loss of balance

A 60 something year old gentleman consulted me for complaints of progressive leg numbness and loss of balance. He lives in a rural, wooded area and was concerned about the possibility of Lyme disease. He was accompanied by his wife who had heard of my interest in tick borne illness. The patient had visited his primary care physician and a neurologist without a diagnosis. His symptoms had been progressive over a period of years. He claimed that he could no longer feel his legs and that he was falling over at times. Perhaps he was a bit weaker as well. He denied any changes in memory or cognitive functioning. He denied any pains. He denied any unusual fatigue.

He looked generally well and high spirited.
His physical exam- neurologically, was quite abnormal.
His mental status was basically normal although at times he struggled to find words.
His cranial nerves were normal. The motor exam was normal. Deep tendon reflexes were diminished. Finger to nose testing was slow and imprecise. His sensory exam was highly abnormal. He had a complete absence of the ability to feel vibration in his feet, knees and hands. He had minimal ability to detect vibration on his elbows. He had a loss of hot and cold discrimination in his lower extremities. He had absent position sense in his feet- he could not discriminate if his big toe was up or down. He passed the Romberg test, but was a bit wobbly. His gait was abnormal- it was broad based with a "bowlegged" appearance.

His exam was not consistent with what I have seen in scores of Lyme patients. I have never seen diminished vibratory sense to that extent. I have never seen a loss of position sense and hot and cold discrimination in my Lyme patients. And his gait was not typical of what I had seen in Lyme patients.

He was not suffering from Lyme disease. In fact I immediately suspected the correct diagnosis. A key to making the diagnosis was a piece of standard medical history which I have omitted until now. I asked him if he drank alcohol- if so how much.
He reported that he drank 6 beers daily along with 6 little cigars. In medical school I was taught, somewhat facetiously, to triple patient reported alcohol consumption. This is a bit of an exaggeration. Nonetheless, it was clear to me that the extensive neurological abnormalities were entirely consistent with long term alcohol abuse. Alcohol can cause injury to the cerebellum causing a loss of balance with a broad based gait. It can cause the severe sensory deficits described due to injury to specific posterior column nerve tracts. There are other causes of these abnormalities but I did not think he had Lyme disease.

A complete neurological workup was ordered, including EMG and NCV. Brain MRI and PET scans were ordered to evaluate brain function and anatomy. Routine lab tests included a test for syphilis and vitamin B1- thiamine- low in alcoholism. The patient reported that he did not know that he was an alcoholic and that previous physicians had not made this diagnosis.

Not everything neurological is Lyme: clearly not. In this case the diagnosis was fairly straightforward. Interestingly, some studies have shown that these neurological deficits can improve with abstinence. We shall see.

2 comments:

Lyme report: Montgomery County, MD said...

Patient tested positive for Lyme.
I do my best to diagnose something else. I still believe alcohol is primary issue. I need to work on this before Lyme becomes the focus.

Narnia707 said...

his positive result just highlights your tricky position in terms of when to test or not! I agree with general position of not routinely testing though if patients asymptomatic

I have pins and needles in feet, muscle twitching/jerking and waking up occasionally with totally numb hand /arm. Also slightly numb cheek. Did have some balance issues too. Some other constitutional symtpoms too - shoulder pain, upper back pains between shoulders, stiff big toes and thumbs, very painful soles of feet every day. Symptoms started radiating from a spot/bite? on my leg last May 31st. Both sons definitely bitten by ticks same day as we removed them - they also, one in particular, have had neuro symptoms pins and needles mainly (but not space to give full story here)

My Igenex result IgG and IgM show positive bands 41 & 58. (blood PCR negative). This result was described as "indeterminate" by Igenex yet 60-70% specific for Borrelia with just these 2 bands. Also a very weak band 34 on IgM. I live in the UK - band 58 is considered a highly specific Borrelia band for European strains according to the German interpretation Guidelines
(CD57 lowish at 60)

Tests for MS done on State health - MRI scan normal, lumbar puncture oligoclonal bands normal. No Lyme antibodies found in CSF, PCR negative too

Last Summer I had 3 weeks doxy at 200mmg /day
There are VERY few LLMDs in the UK. I have recently weighed up all the evidence (I am scientist Biologist by background) and started long term abx. Done 3 months doxy at 400mg / day. Coming to end of this now. This week symptoms particularly bad - a herx?? But Symptoms not resolved yet - little noticable improvement which makes my husband increasinly sceptical. What next? Continue with doxy or switch to something ele? My LLMD did initially suggest after 3 months to switch to amoxy + azithromycin + tinidazole.....