Neurologist report

Here's the report from a Neurologist on my case to whom I was referred to by an Internist. It's a good summary of my history (although with some minor mistakes in his interpretation and timing here and there). It shows how complex a case like this can become and how patients can be made to go in circle from specialist to specialist who fail to see the big picture (no unifying diagnosis).

Neurophysiology
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Electromyogram (EMG)
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The electrophysiologic study showed:

1. Normal left median motor conduction between elbow and thenar eminence.

2. Normal left ulnar motor conduction between distal humerus and hypothenar eminence.

3. Normal left median nad ulnar sensory conduction across the wrist.

4. Normal needle EMG of left deltoid, vastus medialis, extensor indicis propruis and triceps.

Interpretation
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The above study was normal.

Clinical Consultation
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This 38-year-old right-handed man, who works as a system administrator for a research laboratory at *********, was seen at the request of Dr.W***** in the EMG Laboratory on June 1, 2010. He was referred due to a finding of a syrinx on his MRI and fasciculations and sensory symptoms.

Mr. *TicksSuck*'s history dates from Sept. 2008. While camping in the Kingston area, he had a tick bite. He notes that he found a picture of the tick, which was the tick related to Lyme disease. He subsequently developed a rash. Following that, in Dec. or Jan. 2009, he noted a white object in the periphery of his eye, which lasted three months. His eye was examined during this time and, evidently there were no findings. He, in addition, developed tinnitus. Subsequently in the spring, he developed right knee pain and left elbow pain. At times the pain was so severe that he had difficulty flexing his elbow. He noted twitching in his limbs and occasionally in his face. He was seen by Dr.C****** in the Infectious Diseases Clinic in July 2009, and completed a course of Doxycycline. He was further investigated for a number of infections including syphilis, HTLV, hepatitis a, B and C, along with HIV. Rheumatoid factor and ANA were negative. In addition, he had B12, folate and glucose levels, which were normal.

Subsequent to the course of Doxycylcine, he notes that he did not feel better. He does note, about 1-1/2 years ago, (before any treatment), a feeling of a surge in his neck, which he describes as a sensation as if liquid were moving up into the head. Subsequently, he had numbness in the left fingertips and toes, which lasted about one month and resolved. He has subsequently had tingling, which involved the whole body. The pain in the left elbow, and occasionally the right elbow, continued along with the right knee. He no longer has sensory symptoms. He does note widespread fasciculations. He has had a rash under his eyes and on his nose. He has taken some pictures of it with his iPhone. The pictures demonstrated a well-circumcised, flat, erythematous area just under the eyes and on the right side of the nose.

In 2009 he went to Dr.M******** in Plattsburgh, New York. He was treated with Amoxicillin, Probenecid, Metronidazole, Minocycline and Nystatin. He notes however that he did not complete all the courses of these drugs. Dr.C********* did demonstrate a vitamin D deficiency, and he has been taking vitamin D since that time. He does not feel he has improved.

There was no relevant past history.

He did have a MRI scan of the cervical spine done at the ********* Hospital, which demonstarted a small syrinx from T2 to T4. this syrinx had a maximal diameter of 2mm. There was no expansion of the cord or suggestion of another lesion accompanying the syrinx. He had a normal CT scan of the head done.

On examination, this was an alert, generally well-appearing man. His neurologic examination was normal. He had normal tone, bulk and power. Reflexes were normal and symmetrical and his gait was normal. Sensory examination was unremarkable. He did not have any phenomenon with neck flexion.

Assessment
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In summary, this 38-year-old man has had a number of symptoms since a tick bite in 2008. With regard to the specific questions posed in the referral, I do not feel that the syrinx is symptomatic. It would not explain widespread fasciculations. These fasciculations, in the face of a normal clinical and EMG examination, suggest benign fasciculations. I have discussed this with him. Mr. *TicksSuck* is understandably concerned about his condition and feels that the investigations that he has had have not helped in resolving his symptoms. He feels quite strongly that he has serologically negative Lyme disease. I have told him that I am not an expert in this area, nor in vitamin D deficiency, and these questions are best posed to Dr. W*********. He has had a number of antibiotics used without success. This would seem to mitigate against a diagnosis of Lyme disease. Nevertheless, I cannot pose a unifing neurologic diagnosis for his joint symptoms, rashes and other symptoms. The fasciculations in this setting do fit with benign fasciculations. With regard to tinnitus, I do not find evidence that this was investigated in the past. I would suggest a referral to ENT for audiogram and evaluation of the tinnitus. I shall leave this to the discretion of Dr. W*********. If there are other neuromuscular concerns, he could be re-evaluated in the EMG laboratory.

Dr. S*******, MD, FRCPC
Dictated date: 2010 Jun 01