Introduction
Case study
1. Subject of study
6) Present history
2010: Blurred vision and bleary eyes.
June, 2012: Left eye was operated upon for cataract and the symptoms deteriorated.
July, 2012: Dysarthria, dysphagia and paralysis of tongue suddenly appeared after a nap.
August, 2012: The patient visited a neurosurgery specialist and magnetic resonance imaging (MRI) of the brain was entirely normal.
August, 2013: Over time, the symptoms worsened and he visited a neurology department. Brain MRI and thyroid function tests were normal. After electrodiagnostic examination of his whole body including the tongue, PBP, a motor neuron disease, was diagnosed.
September, 2013: He visited another neurology specialist. After electromyography of the right side, he was diagnosed as not having amyotrophic lateral sclerosis (ALS). He started taking medication to increase peripheral circulation and follow up electromyographic examinations were performed every 12 months until he visited our hospital.
June 15, 2015: The symptoms continued to worsen and he received admission treatment in a hospital of Korean Medicine.
7) Findings at first visit
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Dysarthria
Almost no spontaneous movement of the tongue was observed, and fasciculation of the tongue was accompanied. Conversation was impossible. However, the sensations of tongue and lips were normal. There was difficulty in puckering lips. Four diagnostic examinations of Korean Medicine
① Physical appearance: Darkish complexion, skinny body type.
② Digestion: Good condition
③ Stool: Once a day, good condition
④ Urination: Good condition
⑤ Sleep: Profuse dreaming
⑥ Emotion: Stress, anxiety
⑦ Cold and heat: Upper body heat
⑧ Sweat: No abnormal findings
⑨ Mouth and tongue: Dry mouth
⑩ Tongue diagnosis: Black hairy tongue, sticky saliva
⑪ Pulse diagnosis: Floating pulse
8) Examination results
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Neurological examination
Mental state: AlertBiceps reflex: NormalKnee reflex: NormalBabinski sign: NormalAnkle clonus: NormalCranial nerve examination: The functions of olfactory nerve (I), optic nerve (II), oculomotor nerve (III), trochlear nerve (IV), trigeminal nerve (V), abducens nerve (VI), facial nerve (VII), vestibulocochlear nerve (VIII), and accessory nerve (XI) were intact, and functions of glossopharyngeal nerve (IX), vagus nerve (X), and hypoglossal nerve (XII) were not intact (Table 1). Electrodiagnostic examination
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① Electromyography (EMG)
(August 7, 2013)Multifocal denervation of the bilateral tongue, masseter, cervical paraspinalis, and the left flexor carpi ulnaris were suggested.(May 4, 2015)Monopolar needle EMG of right first dorsal interosseus, tongue, masseter, C5, C7, T1, T5, T7 muscles showed mild to moderate degree denervation potentials.EMG of right dorsal interosseous, tongue, and masseter muscles showed giant motor unit action potential (MUAPs) with reduced recruitments.EMG of right biceps brachii, vastus lateralis, tibialis anterior, L2, L3, L4, L5, and S1 paraspinal muscles were normal.There was electrophysiologic evidence of denervation and reinnervation potentials in the right craniobulbar segments and denervation potentials in thoracic paraspinal muscles. There was also electrophysiologic evidence of cervical radiculopathy (C8). -
② Repetitive nerve stimulation
(August 30, 2013)Repetitive nerve stimulation (2, 3, 5, 30 hertz) was performed in the ulnar, spinal accessory, and facial nerves. The recordings were performed on the abductor digiti minimi, trapezius, and orbicularis oculi. There was no equivocal electrophysiologic dysfunction. -
③ Nerve Conduction Study (NCS)
(May 4, 2015)Right median, ulnar motor, sensory, F responses were normal.Right posterior tibial, peroneal motor, F responses were normal.Right sural sensory response was normal.Bilateral soleus H-reflexes were normal.
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Other examinations
Antinuclear Antibody (ANA) Test: NegativeKennedy disease genetic analysis: Negative