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Q. I have fasciculations in the arm with lower back pain. Could this be the beginning of ALS?

Answered by
Dr. Hitesh Kumar
and medically reviewed by Dr. Preetha J
This is a premium question & answer published on Oct 25, 2020 and last reviewed on: Nov 02, 2020

Hello doctor,

The symptoms I have been experiencing for the past five months worry me a lot, so I would like to get your opinion on the subject. Here is the chronology of my symptoms: Seven months back, I had a pressure in my left chest that makes me go to the emergency room. There is nothing on the electrocardiogram. The next month I had significant pain in my lower back. I do not worry about it anymore, and it disappears overnight after three weeks. Five months back, I wake up with fasciculations in my right calf. Then I quickly get them all over my body in less than a week. My right leg seems to be caught in a "viselike pain," but it is not very painful, just an awkward feeling. Four months back, I have pain in my legs and always the same unpleasant feeling in my right leg.

Three months ago, I had strange tingling, not like when you take a bad position that compresses the nerve; it feels like a draught accompanied by ants. For the moment, it is just in both feet, and it is temporary. Two months ago, the strange tingling became permanent and went up from the feet to the buttocks. Always the leg was in the same state. Always fasciculations, up to 100/200 in a single day. Last month I had pain in my back, shoulder blades, arms, and hands. The slightest little effort hurts me. Always the same sensation in my right leg and fasciculations are these strange, ill-defined tingling sensations.

I did an MRI of the brain because my PC thought it was multiple sclerosis. It was negative. I did a lumbar MRI because the rheumatologist thought it was a mechanical problem; it was also negative. I did blood tests, which showed nothing unusual except for a drop in gamma. I did an EMG of both lower limbs, a back MRI, a cervical MRI, which all were negative. I do not seem to have lost any strength, but my right calf is getting flaccid compared to my left calf. I can still walk normally, but I have developed a severe intolerance to effort; doing 2 miles is like doing a long run; my legs hurt very much afterward. Could this be the beginning of ALS? I am terrified, and the doctors are powerless. They all tell me it is in my head, but I do not believe it. They do not want to believe me, and it is frustrating. Thank you in advance for your help.

#

Hello,

Welcome to icliniq.com.

As you mentioned, all your reports (attachment removed to protect patient identity), including MRI (magnetic resonance imaging) of the brain, MRI of the spine, NCV (nerve conduction velocity), and EMG (electromyography) has been normal. And your doctors have not found anything specific in the clinical neurological examination too. In such a scenario, you are not fulfilling the diagnostic criteria for ALS (Amyotrophic lateral sclerosis). ALS is a clinical diagnosis, and more symptoms or signs appear with time only. But no one can predict that if they will develop or not. Possibly you are very anxious.

I would like to know some information about you:

1. How is your sleep in a routine? Do you get sleepy soon after lying in bed? Or it takes a long time? Once got sleepy, do you have frequent awakenings during sleep? Do you feel fresh on awakening from rest in the morning?

2. How is your usual mood in day-to-day activities? Happy or toward the sad side (thinking about past events), toward the worried side (thinking about future things or irritable or something else)?

3. How is your appetite?

4. Do you have episodic palpitations or breathlessness, or feeling of impending doom?


Investigations to be done:

T3 (Triiodothyronine), T4 (Thyroxine), TSH (Thyroid stimulating hormone),
ANA-IFA (Antinuclear antibody-immunofluorescence method,
Serum for VGKC (voltage-gated potassium
channel) antibodies, and EEG (electroencephalogram).

Differential diagnosis:

Anxiety disorder.
Benign fasciculation syndrome.
Fasciculation cramp syndrome.
Neuromyotonia.

Regarding follow up:

Revert with information mentioned above for better understanding, and also, please send your neurological examination details and investigation reports, which were taken till now, for further analysis.

Hello doctor,

Thank you for your response.

I take a long time to fall asleep, and I will be exhausted in the morning when I wake up. I am indeed quite anxious and melancholy in everyday life. My appetite is quite good, but I sometimes have stomach aches, which prevent me from eating as much as I want, feeling "full" in the stomach. I sometimes have sudden palpitations and trouble breathing. My MRIs do not give anything so far except the last one, which specifies this in conclusion: "Slight nonspecific distension of the ependymal duct on the thoracic level. We can discuss the underlying medulla. " Thank you again for your reassuring response. My PC is also telling me about a possible Lyme disease; what do you think? You can also find my EMG here.

#

Hello,

Welcome back to icliniq.com.

As per your description, you commonly have worried and sad moods along with sudden, episodic palpitations and trouble breathing can be "panic attacks," which points toward mixed anxiety or depressive mood. And it is affecting the sleep already. Maybe your fasiculations be due to anxiety itself. It is good that MRI has not revealed anything significant. I tried to have a look at EMG, but it is not in English. Moreover, EMG assessment is more in real-time, not by printed graphs. In such a scenario, I suggest you meet a psychiatrist and psychologist for detailed psychological assessment and medications accordingly. Also, I suggest not to think much about your symptoms, though also need to be vigilant about other new symptoms or progression of symptoms.


Investigations to be done:

T3 (Triiodothyronine), T4 (Thyroxine), TSH (Thyroid stimulating hormone),
ANA-IFA (Antinuclear antibody-immunofluorescence method,
Serum for VGKC (voltage-gated potassium
channel) antibodies, and EEG (electroencephalogram).

Differential diagnosis:

Anxiety disorder.
Benign fasciculation syndrome.
Fasciculation cramp syndrome.
Neuromyotonia.

Treatment plan:

Consult a psychiatrist and psychologist.
Keep a watch on any progression and development of new symptoms.

Preventive measures:

Daily exercise program or jogging for 20 to 30 minutes in the morning.
You can also try meditation.
Keep yourself engaged in activities that you like or work.

Regarding follow up:

Review with investigation reports (as suggested).


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