Dx challenging - anyone up to it?

QuestMasterX at webtv.net QuestMasterX at webtv.net
Sat Nov 4 15:53:46 EST 2000

This was a very challenging Dx:
35  yo WM  w/o significant medical history.  ht 180 ht 72in
S&S:  course intermittant but progressive with evolution from primarily
sensory (parasthesias and "crawling feeling in extremities" which where
far greater at night than Daytime.  Initially grade 2 bilateral reflexes
progresed to hyperreflexia in left lower extremity.  Pain presents
distally and radiating from plexi esp. brachial bilaterally but greater
on left. red rash which was similar to deratitis (drug reaction type)
appeared over cntral dorsal and ant thoracs with spread to bil ticeps
and delt areas (rash also intermittant),  fasciculations visible at rest
in extremities.  Pain continues to be increased nocturnally and symptoms
now include pain which increases after exercise, headach (L temporal
"burning") occassional, duodienitis, occassional nocturnal tremor also
increased after exercise.  2 episodes of reactive but unequal pupil over
past 3 yrs with nausea and dizziness at time, periods of wt loss (5-15#)
occur with increased neuro symptoms and increased GI problems (hx ulcer
and duodenitis ongoing), intermittant periods of extreme fatigue lasting
for up to a month and as little as several days.  
Cranial and Spinal MRI taken within last yr are normal
ANA, SED and RA are normal
CBC is slightly abnormal but not significantly suggestive (slight
elevation of gran and other  WBC with normal RBC)
Hepatic:  Previous panels non-suggestive but recent increases in last 4
AST, ALTs with normal  biliribin (both) and alk.phos.
No LP available
protein normal
CP,B12 ,T4 and T3 and all other labs unremarkable
Lyme titers including WB were normal (symptoms and isoty were otherwise
highty suggestiv of neuro-borreliosis due to significant tick exposures
in endemic areas)  Pt indicates that he never drinks nor uses OTCs other
than anti-oxidan and B-vit.
Care to attempt this neuro-diagnostic challenge?  

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