What Causes Clumsiness, Anxiety, Loss Of Interest And Difficulty Talking?

Brief Answer:
Boxcarring= Vasculitis

Detailed Answer:
Dear Ms. Brooks- My name is Dr. Dariush Saghafi and I'm YET another NEUROLOGIST. You can't seem to get those people away from you, huh? :0

I would like to try and make sense out of what you've written. I'm a neurologist with both a private practice in the XXXXXXX OH area as well as having a position at an academic center (Director of the Headache Division at the XXXXXXX Stokes VA Medical Center).

Allow me to collect a bit more data which could be helpful.

8 years ago your family started noticing some subtle changes in you but nothing was done at that time. Is this correct? Can you elaborate on what some of the EARLIEST CHANGES noticed might've been? Also, thinking back to that time, what were you DOING? How were you FEELING? In general, how was your medical health? How was your mental health as well?

Do you have a history of any type of substance abuse of illicit or even prescription types of drugs such as painkillers, Alcohol, etc.? And please tell me your marital status? Do you have children and if so how is their overall health? How about that of your family? Any members with any rare or unusual diseases such as neurological problems, seizures, epilepsy, Lupus, Alzheimer's, etc.?

Now, let's summarize a bit first and hopefully things can be more organized.

Major symptoms have been clumsiness, difficulty with speech/language to the point where things are garbled or unintelligible by listeners. You mention protruding the tongue whenever you speak. Sometimes you will also keep talking. You have difficulty with completing tasks, concentrating and focusing. You feel anxious, moody, have trouble with falls, and can break things due to rough handling, and bump into objects. You've become incontinent more recently which is worsening. You've had a fall down stairs and suffered a concussion. It was determined that you'd suffered a grand mal seizure. You've stopped driving due to multiple accidents. Things seem to be accelerating yet visits to multiple doctors (neurologists for the most part) have not yielded results despite testing to include metabolic surveys in blood for rare diseases. You've had an MRI and CT of the head and lumbar puncture.

What has come from all this testing is the comment by a neurologist from another Province that you have caudate atrophy and "boxcarring" and that he would pass this information on to your treating neurologist with some recommendations.

I think those are the major points to this juncture, correct?

Obviously, without the advantage of seeing films or labs it is difficult to know for sure how many tests have been obtained that could help us but I think it's a safe assumption to say that if Huntington's, MS, and now seizures are/were on the table as possibilities that bloodwork would reflect at least those entities as well as more standard things. Again, it would be nice if you could upload some of the results of what you've been through to the system. I would especially be interested in seeing some notes from any of the neurologists who have seen you, ESPECIALLY the last one who seems to have more ideas thusfar than the others.

The term BOXCARRING is one that is typically used in conjunction with a condition known as VASCULITIS (inflammation of blood vessels). For the neurologist this entity is looked for (usually in the brain) and usually is detected after having done either an MRA or straight Angiogram (invasive with XXXXXXX placed in the artery of either the arm or neck). One of the most common neurological entities that would be related to the general disease category of VASCULITIS which I believe could have relationship with at least some of your symptoms such as the frontal lobe seizure, behavioral changes, and falls is LUPUS CEREBRITIS.

Blood work looking for that entity is fairly standard and I'd be surprised that within your current blood work that wouldn't've been thought of. Nonetheless, that is one diagnostic possibility as I see it. Another might be something such as TEMPORAL ARTERITIS (again thinking in terms of Vasculitides) which could also go along with your bumping into things if your visual acuity were being compromised. However, I've never heard of an untreated case of fulminant TA going 8 years without causing severe problems of blindness and of course, progression to more complicated neurological presentations.

You mentioned that you saw a doctor who specialized in epilepsy and seizures. I don't know exactly how your managed health care system works in Canada but my question to you is whether or not you have the ability to get to the nearest ACADEMIC TEACHING HOSPITAL? I would think that at such a facility the likelihood of obtaining a diagnosis is much higher than in the community due to their access of resources and sheer greater numbers of other specialists who may be able to chime in on some of what's going on.

If you would like to obtain some of the paperwork I mentioned as well as the MRI images of the study which showed this "boxcarring" you can load those items up for further review and analysis to see if we can suggest anything else. However, to sum it up with respect to what the last neurologist said I would say that VASCULITIS is the most likely entity that he is referring and you may find this to be the case if you can lay your hands on his reports.

Also, just for completeness sake since there was a search for MS done I always have the habit of asking for studies with GADOLINIUM CONTRAST XXXXXXX Was this injected into you? Or perhaps iodine was used in the CT scan? But GAD (as we call it) should be considered in any repeat study of the MR type in my opinion. Also, when I have a patient who I suspect may possibly be an MS or transverse myelitis patient of some sort (complaints of bowel/bladder incontinence and equilibrium issues with the falls) I always run an MRI of the CERVICAL SPINE to look for lesions. In MS and other entities sometimes it is the case that people have completely pristine head imaging but then, you may find lesions farther south in the spinal cord but it gets missed because most people don't image at least the Cervical spine. I think it's probably a long shot but in your case since nothing else has panned out to this point if this study has not been done I would consider including it on the next round of testing.

And just one other thing that I'm thinking should be checked with the symptom list you've mentioned....HEAVY METAL SCREENING in both BLOOD as well as URINE. I don't know if that could possibly be a problem where you live but again, it's kind of one of those standard entities we think about getting when symptoms are many but other standard diagnostic tests don't seem to be yielding anything.

I will stop at this point with the hope that you might be able to answer just a few more questions or get the information uploaded to this system that I've mentioned.

If any of this information has been useful to you could you include a brief written comment so that I will know if I answered some of your questions although I realize that you're really in search of a diagnosis which I hope you get soon.

Also, if there are no further questions or commentaries could you CLOSE THIS QUERY so that the network will credit for the time spent? I would greatly appreciate that.

All the very best!

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