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Having Pns And Cns Symptoms. Negative For MRI Of Brain And Spine Contrast , Myasenthia Gravis. What Could It Be?
Question: For 11 months I have been having pns and cns symptoms. My muscles fasciculate frequently every day. I have instances of numbness and tingling. I have severe headache daily which is electric like in the back of my head as well as behind my eyes. I have had mri of my brain and spine w contrast negative. Thyroid normal, metabolic panel normal. Negative testing for myasenthia gravis. I feel dizzy and disoriented most of the time. I don't have any loss of sensation and if any weakness has occurred it is not clinically detectable. I am an ex smoker of 5 pack years over 8 years. I have also had negative chest ct w contrast 8 months ago and one negative chest x XXXXXXX 1 month ago. Additionally I have chest pain that reoccurs daily. I am specifically concerned of paraneoplastic syndrome from sclc. Such as neuromyotonia or neuro encephalomyelitis with motor sensory neuropathy. I have had two normal neuro exams in the past 8 months. Should I try and get a paraneoplastic antibody panel? Any additional advice would be greatly appreciated.
Hi,
Thank you for getting back.
As discussed earlier, there are very little chances of your symptoms being due to paraneoplastic causes. However, let us assume that in view of your relatively long history of smoking, you have a higher risk of acquiring various types of cancers, especially the small cell lung cancer, so, theoretically, you can get paraneoplastic diseases.
Based on your symptoms, a few types of paraneoplastic neurological syndromes that could be considered are encepahlomyelitis, limbic encephalitis, and sensory neuropathy.
In the first two conditions, memory loss is prominent, along with changes in behaviour and personality. In addition, symptoms worsen rapidly and may lead to dementia in a few months, I see about 3-4 such cases per year.
In sensory neuronopathy, there is tingling, numbness and burning. On examination, we can demonstrate numbness over feet and hands and ankle jerks are sluggish or absent. This is more common and I see about 10 cases per year, usually with lymphoma (a malignancy of lymph glands).
So, I do not think there is a possibility of you having paraneoplastic neurological disease. However, if you want to be 100% sure, you can go for paraneoplastic auto antibody panel, especially you can check for anti-Hu auto antibody in the serum.
I hope it helps.
Best wishes,
Dr Sudhir Kumar MD DM (Neurology) XXXXXXX Consultant Neurologist
Thank you for getting back.
As discussed earlier, there are very little chances of your symptoms being due to paraneoplastic causes. However, let us assume that in view of your relatively long history of smoking, you have a higher risk of acquiring various types of cancers, especially the small cell lung cancer, so, theoretically, you can get paraneoplastic diseases.
Based on your symptoms, a few types of paraneoplastic neurological syndromes that could be considered are encepahlomyelitis, limbic encephalitis, and sensory neuropathy.
In the first two conditions, memory loss is prominent, along with changes in behaviour and personality. In addition, symptoms worsen rapidly and may lead to dementia in a few months, I see about 3-4 such cases per year.
In sensory neuronopathy, there is tingling, numbness and burning. On examination, we can demonstrate numbness over feet and hands and ankle jerks are sluggish or absent. This is more common and I see about 10 cases per year, usually with lymphoma (a malignancy of lymph glands).
So, I do not think there is a possibility of you having paraneoplastic neurological disease. However, if you want to be 100% sure, you can go for paraneoplastic auto antibody panel, especially you can check for anti-Hu auto antibody in the serum.
I hope it helps.
Best wishes,
Dr Sudhir Kumar MD DM (Neurology) XXXXXXX Consultant Neurologist
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dr. XXXXXXX
I have found your advice very useful. I understand how you came to the conclusion that these symptoms do not point toward paraneoplastic syndrome as I do not have memory problems. I do not show weakness or loss of sensation, and don't have loss of reflexes. My question becomes as you pointed out these symptoms seem to direct towards b12 deficiency or thyroid etc. As I have had these test normal twice. Can you think of alternative problems that could cause neurologic involvement in the CNS and PNS. My muscles are very tight and crampy which alone is concerning, however the cns symptoms of visual disturbance with flashing lights and floaters but no color vision or acuity lost and pain in back of head around occipital region as well as chest pain in my sternum between the lower portion of my pectorals on and off every day as well as fatigue upon waking that I have never previously experienced are enough to make me think something is seriously wrong. These symptoms have progressed over a period of 10 to 11 months with now slowing in sight.
I truly hope that your conclusions about paraneoplastic disease are correct and they seem very logical. I cannot seem to find any explanations upon numerous dr. visits as well as nearly all the testing that exists except antibody tests for numerous things to find an answer. I have been told this is anxiety and I do believe it is not helping the situation that due to my symptoms I am extremely anxious as I never feel well and basically am disabled to the point of just able to function. I am hoping that you have some alternate ideas upon what may be causing the problem.
I have been told by numerous people that they think I have lyme disease. I do live in MN which is an endemic area for this but never had a rash so my gp thinks it is unlikely. Do you think any other test might shed light on my predicament?
thanks in advance
XXXX
I have found your advice very useful. I understand how you came to the conclusion that these symptoms do not point toward paraneoplastic syndrome as I do not have memory problems. I do not show weakness or loss of sensation, and don't have loss of reflexes. My question becomes as you pointed out these symptoms seem to direct towards b12 deficiency or thyroid etc. As I have had these test normal twice. Can you think of alternative problems that could cause neurologic involvement in the CNS and PNS. My muscles are very tight and crampy which alone is concerning, however the cns symptoms of visual disturbance with flashing lights and floaters but no color vision or acuity lost and pain in back of head around occipital region as well as chest pain in my sternum between the lower portion of my pectorals on and off every day as well as fatigue upon waking that I have never previously experienced are enough to make me think something is seriously wrong. These symptoms have progressed over a period of 10 to 11 months with now slowing in sight.
I truly hope that your conclusions about paraneoplastic disease are correct and they seem very logical. I cannot seem to find any explanations upon numerous dr. visits as well as nearly all the testing that exists except antibody tests for numerous things to find an answer. I have been told this is anxiety and I do believe it is not helping the situation that due to my symptoms I am extremely anxious as I never feel well and basically am disabled to the point of just able to function. I am hoping that you have some alternate ideas upon what may be causing the problem.
I have been told by numerous people that they think I have lyme disease. I do live in MN which is an endemic area for this but never had a rash so my gp thinks it is unlikely. Do you think any other test might shed light on my predicament?
thanks in advance
XXXX
Hi XXXX
Thank you for getting back with more details.
I wish I had the chance to examine you so as to come to a better conclusion. However, coming to your question, the combination of CNS and PNS involvement can occur in the following diseases:
1. Demyelinating diseases, such as acute disseminated encephalomyelitis (ADEM), but your presentation is not like this. In ADEM, people have acute onset symptoms, which rapidly worsen, if left untreated.
2. Infections, such as tuberculosis, etc. Presence of fever and headache would be more suggestive. If in doubt, CSF analysis (lumbar puncture) would help.
3. Vasculitis- due to inflammation of blood vessels.
4. Collagen vascular diseases, such as systemic lupus erythematosus,
5. Malignancies, which is unlikely in your case.
I suggest you discuss these with your doctor, especially regarding vasculitis and collagen vascular diseases, whether they can be considered in your case. Then, the vasculitis work up would be useful.
Best wishes,
Dr Sudhir Kumar MD DM (Neurology)
Thank you for getting back with more details.
I wish I had the chance to examine you so as to come to a better conclusion. However, coming to your question, the combination of CNS and PNS involvement can occur in the following diseases:
1. Demyelinating diseases, such as acute disseminated encephalomyelitis (ADEM), but your presentation is not like this. In ADEM, people have acute onset symptoms, which rapidly worsen, if left untreated.
2. Infections, such as tuberculosis, etc. Presence of fever and headache would be more suggestive. If in doubt, CSF analysis (lumbar puncture) would help.
3. Vasculitis- due to inflammation of blood vessels.
4. Collagen vascular diseases, such as systemic lupus erythematosus,
5. Malignancies, which is unlikely in your case.
I suggest you discuss these with your doctor, especially regarding vasculitis and collagen vascular diseases, whether they can be considered in your case. Then, the vasculitis work up would be useful.
Best wishes,
Dr Sudhir Kumar MD DM (Neurology)
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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