Complex Cases

[Michael Ray]

If you are a clinician who is struggling with a complex case (happens to ALL of us) - feel free to list pertinent details and the community will try and help.

***NOTE: Please be cognizant of HIPAA.***

[nchu]

I have a patient who is male, 53 years old, occupation includes getting in and out of pick up truck at residential work sites, walking, and stairs. Reports 3-4 years ago began noticing his legs were getting "weaker" and denies any strength training to mitigate symptoms. Has had CT scans and MRIs of his lumbar spine from neurology consults and general blood work as is typical in annual physicals. Has been, per MD, ruled out of "anything significant or spinal".

On evaluation his gait was significantly ataxic, has self-reported falls and notable weakness after just 1 block of walking. Even demonstrated a loss of balance that required an assist from me when attempting to an air squat and after getting off of a stationary bike. I've called his nurse practitioner and she and I both agreed he needs a better neurology consult to rule out anything else neurodegenerative. Another GP that he knows has convinced him that any other testing would turn him into a guinea pig and he is experiencing "use it or lose it" in his quads, despite my continued push for him to advocate for additional testing.

Where would you guys go with this? Any specific tests I could use by name to give him a broader vocabulary when he speaks with a neurologist? Any differential diagnoses you would start with? I'm thinking myasthenia gravis...

Thanks for constructive input!

[Derek Miles]

Neville,
There certainly does sound like something off about this case. I'm going to ask the obvious questions first. What does his neuro exam look like? Reflexes, Babinski, Clonus? How have you measured strength? With a dynamometer of the normal 5/5 scale? There are a host of things regarding this case that would give me pause. If he is an active individual noticing progressive weakness I would be looking to r/o neuro diagnoses. Have you asked if there is a family history of neurological disorder (MS, myelin diseases, CMT, etc)? While I would typically side with the GP's advice, this case certainly warrants further work up by someone who specializes in neurology.

[nchu]

Hey Derek,

Thanks for responding.

Reflexes - normal
Babinski - absent
Clonus - none

No dynamometer in our clinic but MMT in quads is 5/5. Family history is unremarkable in neuro or cardiovascular cases.

I've been pushing the patient to find a new neurologist. GP agrees with me that this seems like myasthenia gravis.

[Michael Ray]

Hey Derek,

Thanks for responding.

Reflexes - normal
Babinski - absent
Clonus - none

No dynamometer in our clinic but MMT in quads is 5/5. Family history is unremarkable in neuro or cardiovascular cases.

I've been pushing the patient to find a new neurologist. GP agrees with me that this seems like myasthenia gravis.

Why are you leaning towards MG? Out of curiosity, is he presenting with any other neuro symptoms such as fascial musculature alterations like ptosis; or perhaps vision alterations like diplopia?

Also - is he currently on any medications? Any other relevant social behavior (alcohol/illicit drug use/etc)?

[nchu]

Has denied alcohol or drug use. No medications. He doesn't have the facial drooping that is often associated with MG but I don't have a baseline of what his face looked like before. He does speak slowly sometimes and can get lost in thought when talking. Again, not sure if that is his baseline.

Watched him walk out to his car today after an appointment and he kept a hand on his hood and side of the car as he walked around it.

I've spoken to him about reaching out to his GP for another neuro consult referral but he continues to give reasons why he can't/won't/doesn't want to do that. Any other methods of patient advocacy you would recommend?

[JHG]

If I may participate in this exercise, Neville, is there a history of any comorbidities (i.e. hypertension, diabetes, obesity, dyslipidemia, hypothyroidism etc)?

Given the patient’s occupation and information provided thus far, my initial impression is claudication due to peripheral artery disease per the report of lower extremity weakness with walking for 1 block (but this hinges on his health history). The claudication may also be neurological in nature.

I am assuming there were no glaring discrepancies in muscle bulk (as there is no report of this) and report of MMT 5/5.

While there was no mention of upper extremities symptoms, this presentation may coincide with polymyalgia rheumatica.

Is this patient normally physically active or does he lead a relatively sedentary lifestyle?

Has there been any change in his condition since your initial post?

[johnbugay]

On a related note, is it possible for a person with myasthenia gravis to participate in a training or exercise program that would be beneficial to them: