Is this disease functional or organic?

Dr C P HO cpho at hkma.org
Mon Jul 28 19:21:22 EST 1997


Hi all,

I have a friend whose wife got some stange symptoms.  She had been
investigated by nearly all the tests available in Hong Kong and had been
seen by many doctors.  I am still not sure what the disease is and not even
whether it is functional or organic.

I shall be obliged if any of you can shed any light on this case. (sorry
the case presentation is long)

"
	An case of bilateral, progressive numbness and pin-pricking sensation of
the tongue, lips, gum, palates and pharynx.

To:		All medical colleagues in the world.
		Any bright ideas or suggestions on diagnosis or
		management are welcome.

A 45 year old house wife noted  progressive numbness and pin-pricking
sensation over 			the tongue, gum, lips, palates and then the pharynx for
one year.

	The symptoms started one year ago when she noticed soreness 			of the tip
of the tongue.  She was seen by a dentist and was 				diagnosed to have
repeated minor injury due to an ill-fitting 				dental filling between the
lower incisors.  The dental filling was 			removed but symptoms persisted. 
The soreness and then pin-				pricking sensation became more severe and
these feelings 				spread to the gum, lips and posterior part of the
tongue.  Taste				was said to have diminished, though present.  The patient
				also noticed more frequent injury by fine fish-bone and she 			
attributed it to the diminished sensation of her tongue and buccal 		
cavity.  Injury to	the buccal mucosa was said to cause less pain 			than
before.  In the past 3 - 4 months, she noticed discomfort of the 		pharynx
( a numbness feeling which was similar to that due to local 		anaesthetic
spray ).  She also felt that her speech was a bit more 			clumsy than
before.  No difficulty in swallowing was noticed.

		Examination 6 months ago showed that her teeth and mucosal 			surfaces of
the gum, tongue, palates, floor of the mouth and cheek			were normal.	There
was bilateral diminished pain and tactile 				sensation over the gum,
tongue and palates and lips.  Salty and 			sweet taste was intact over
anterior two third and posterior one third 		of the tongue.  No objective
speech defect was noticed.  Other 			cranial nerves were normal.  No other
neruological deficit was 				detected.  

		She was seen by a neurologist and M.R.I. of the brain stem with 		
angiogram was done which showed  no evidence of brain stem or 			focal
intracerebral abnormality.  EMG and light evoked potentials 			were normal.
 EB virus antibodies were negative.  Detailed report 			please refer to
appendix. She was also seen by a dental surgeon who discovered nothing 
abnormal in her gums, tongue and buccal cavity.
		
		She was treated with anxiolytic medications for 2-3 weeks but no 		
improvement was noticed.
	
		The patient said she had experienced similar numbness and 			
pin-pricking sensation of her lips and tongue 3 years ago 					immediately
after she had bilateral myringotomy for her 					Eustachian tube syndrome. 
The feeling was so distressing that 			she requested to have the
myringotomy tubes removed.  The 				symptoms subsided 2 - 3 weeks after the
tubes were removed.


Past Health
                                                                           
                                                                           
                                                                           
                          		1).	Right hemithyroidectomy in Feb. 1995
because of a thyroid 				adenoma
		2).	One episode of chronic cough from Mar. 96 to Aug. 96 with 			
enlarged mediastinal lymph nodes.  Cough and lymph node 				enlargement
subsided later.
		3).	Hypercholesterolaemia on dietary control

Physical Examination

		Examination recently showed the same neurological signs as 6 			months
ago.  The external appearance of the tongue, gum lips 			palates and buccal
mucosa was normal.  Pain and tactile sensation 		was diminished over these
areas. Salty and sweet sensation was 			intact in the whole tongue.  Other
cranial nerves were normal.  No 			other neurological deficit was noticed.


M.R.I. of brain in June 94

No focal areas of abnormal signal intensity is noted in the cerebral and
the cerebellar hemispheres as well as in the brain stem and the
cerebello-pontine angles.  The internal auditory nerves are unremarkable. 
The ventricular system is normal.  The sulci and the cisterns are
unremarkable.

The pituitary and the other visible cranial nerves are also normal.  The
nasopharynx and the paranasal sinuses are clear.  No lesion is seen in the
region of the cavernous sinus.  The 5th cranial nerves are unremarkable.

CONCLUSION:

No focal intracerebral lesion is seen.
M.R.I. of brain on 4th Oct 96

Clinical Information:

Chronic cough with hilar L.N. enlargement.  Perioral numbness including
tongue.  To rule out hilar lymphadenopathy?  brain stem lesion.


FINDINGS:

No focal area of abnormal signal intensity is seen in the brain stem, the
cerebral and the cerebellar hemispheres.  The temporal lobes are
symmetrical and are normal.  The ventricular system is normal.  The sulci
and the cisterns are within normal limits.  The visible cranial nerves and
the pituitary are also normal.   No abnormality is seen in the nasopharynx.
 The paranasal sinurses and the mastoids are clear.  No abnormal enhancing
structure is seen after gadolinium injection.

Satisfactory flow signal is seen in the anterior, middle and the posterior
cerebral arteries.  The internal carotid artery and the basilar artery are
normal.  Both vertebral arteries are patent in the neck and are of similar
calibre.  The carotid bifurcations are also normal.

COMMENTS:

No evidence of any brain stem lesions or other focal intracerebral
abnormality.  The MR cerebral antiogram is also normal.

M.R.I. Thorax with gadolinium on 4th Oct 94

FINDINGS:

A tiny nodular soft tissue thickening is seen in the mediastinal fat behind
the ascending thoracic aorta, anterior to the trachea and above the right
main pulmonary artery.  This is isointense on the T1 weighted images
outlined by the hyperintense mediastinal fat.  It is under 1cm size.  It
may represent a small lymph node.  There is no enhancement after gudolinium
injection.  The rest of the mediastinum is unremarkable.  There is no
suspicion of any hilar lymphadenopathy.  No focal areas of abnormal signal
intensity is seen in the lungs.  There is no pleural fluid or mass lesion.

The rest of the thorax is unremarkable.

COMMENTS:

The appearance could be due to the presence of a tiny lymph node in the
mediastinum but this is probably unchange in size from the previous CT. 
There is no enhancement after gadolinium injection.  Active pathology is
therefore probably unlikely."


Thank you,
Dr C P Ho, FRCP (Edin)





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