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What Causes Severe Leg Weakness And Fatigue Post PFO Repair Procedure?

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Posted on Fri, 19 Feb 2016
Question: I have a recent onset of 60 days of leg weakness and pain in feet and stiffness both legs..Unable to walk well, was off balance before this started. I had a TIA and DVT in July when they found a PFO. I had PFO repair with metal piece in heart, that is not healed completely. I am over weight 55 yr old female with very active job. I have Lupus/Hypothyroid/hypertension On Eliquis/plaquenil/synthroid/ meloxicam. Unable to stand more then 2 hours and unable to walk either. treated with steroids and rest. Still not better. I have neck and spine pain had MRI of lower back they tell me its neuropathy. I have a foot drop that is getting more numbness.
doctor
Answered by Dr. Olsi Taka (1 hour later)
Brief Answer:
Read below.

Detailed Answer:
I read your question carefully and I understand your concern.

Looking at your medical history it seems a difficult case in that you have several diagnosis which can both cause weakness and fatigue on their own as well as cause neuropathy.

Both lupus as well as hypothyroidism lead to an increased propensity for developing neuropathy. So the first step in the management is treating those two conditions. For hypothyroidism in particular it is important to follow up treatment with periodic TSH measurements in order to make sure the medication dosage is adequate, as hormone replacement dose may vary among patients, so it may be that you are under medication but not enough of it.

Also depending on how long you've been on steroids they can have side effects and lead to myopathy which also manifests with weakness. So if you have been using them for a long time that should be taken into account.

One other consideration to make is the need to complete tests. Your diagnosis is not complete without nerve conduction studies and electromyography (EMG) test. It is an essential part of neuropathy diagnosis and also will differentiate with other possible causes such as the steroid induced myopathy I mentioned.

Regarding treatment, if the MRI has evidenced back problems and those are considered as a possible cause, an important part is also physical therapy. If there is nerve root, cord or peripheral nerve compression also surgery may be considered.

To resume, neuropathy can be of different types and have many different causes, like thyroid dysfunction, lupus, compression of nerves in the spine. So the first step is to clear with your doctors which type you have and what is the main cause. Also if for a long time on steroids should exclude a myopathy.
Medication like Gabapentin do not alter the course of the disease, they only alleviate symptoms like pain. Only if cause is found and addressed (thyroid medication adjustments, surgery if needed, physical therapy) can the course of neuropathy be affected.

I remain at you disposal for other questions.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Olsi Taka (42 hours later)
Sorry I am waiting on the MRI results. Today maybe I will get them. but I was not so clear with my treatment course. I had a Prednisone burst of 6 days twice in the last 60 days only. It was a 4mcg. dose.
My TSH is perfect. and has been maintained for over 2 years as stable.
I have also as symptoms stiff muscles of the extremity's legs only. with swelling and for some reason I have blood or bruising under my toes nails with no injury.
They are hesitant to give me a lot of prednisone as I was Septic in 2014. My immune system is weak. basically I need to get back to work and I can not. I can not stand and walk for more then 2 hours of cleaning or just grocery shopping and I have to sit or I have severe muscle stiffness and pain in the leg at the knee/ankles/left side of back. Right leg is better but have foot and ankle pain with numbness all new in the last 60 days.
I took the gabapentin but it really gives me headaches/ I feel so out of sorts. that I am not using it. They say I will get over the side effects but I did not. Thanks for your help, I did have nerve studies on the left leg 7 years ago and was diagnosed with foot drop. This far worse then that. I was working fulltime. I just want to go back to work.
doctor
Answered by Dr. Olsi Taka (2 hours later)
Brief Answer:
Read below

Detailed Answer:
Thank you for the update!

In view of the new information I do not think that Prednisone is the cause.

I still am not clear on the reason of your foot drop though. The nerve studies are not done to say you have foot drop, that should be noticed by the clinical exam, the nerve studies are done to elucidate the why. Foot drop may be due to lumbar spinal disease but also due to compression of a peripheral nerve or metabolic damage to peripheral nerves. So (also because it's been 7 years) I think nerve conduction studies are necessary. They are also necessary to evaluate the muscles as the muscle stiffness you mention shouldn't accompany foot drop, foot drop is related to flaccid paralysis normally.

I am not gonna lie and say that exams always are the solution, the causes of peripheral neuropathy are numerous and many blood and other tests are done to find the cause. Even after extensive testing in about 25% no cause is found, or in your case it might simply be left due to the connective tissue condition (lupus) which is known to affect many tissues. However before reaching to that conclusion some basic tests have to be completed and the conclusions on the cause be presented by your doctors.

If gabapentin caused you side effects it is ok to interrupt it, as I said it merely alleviates the symptoms not affect the course of the disease so should be used only if it provides benefit on how you feel. Another option for chronic neuropathic pain might be antidepressants like duloxetine, though as all drugs it has possible side effects.

I hope things work out for the best.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Answered by
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Dr. Olsi Taka

Neurologist

Practicing since :2004

Answered : 3672 Questions

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What Causes Severe Leg Weakness And Fatigue Post PFO Repair Procedure?

Brief Answer: Read below. Detailed Answer: I read your question carefully and I understand your concern. Looking at your medical history it seems a difficult case in that you have several diagnosis which can both cause weakness and fatigue on their own as well as cause neuropathy. Both lupus as well as hypothyroidism lead to an increased propensity for developing neuropathy. So the first step in the management is treating those two conditions. For hypothyroidism in particular it is important to follow up treatment with periodic TSH measurements in order to make sure the medication dosage is adequate, as hormone replacement dose may vary among patients, so it may be that you are under medication but not enough of it. Also depending on how long you've been on steroids they can have side effects and lead to myopathy which also manifests with weakness. So if you have been using them for a long time that should be taken into account. One other consideration to make is the need to complete tests. Your diagnosis is not complete without nerve conduction studies and electromyography (EMG) test. It is an essential part of neuropathy diagnosis and also will differentiate with other possible causes such as the steroid induced myopathy I mentioned. Regarding treatment, if the MRI has evidenced back problems and those are considered as a possible cause, an important part is also physical therapy. If there is nerve root, cord or peripheral nerve compression also surgery may be considered. To resume, neuropathy can be of different types and have many different causes, like thyroid dysfunction, lupus, compression of nerves in the spine. So the first step is to clear with your doctors which type you have and what is the main cause. Also if for a long time on steroids should exclude a myopathy. Medication like Gabapentin do not alter the course of the disease, they only alleviate symptoms like pain. Only if cause is found and addressed (thyroid medication adjustments, surgery if needed, physical therapy) can the course of neuropathy be affected. I remain at you disposal for other questions.