MERALGIA PARESTHETICA

MERALGIA PARESTHETICA

Introduction

Meralgia paresthetica is a condition, characterised by sensations of burning, tingling and pain in the upper outer aspect of thigh.

What is the underlying cause of meralgia paresthetica?

It is caused by entrapment or compression of the nerve that supplies sensation to the upper, outer aspect of thigh. The nerve is commonly called as lateral femoral cutaneous nerve of the thigh.

The condition can get aggravated by sitting in one position for a long time, wearing a tight belt, wearing skinny jeans, or compression of nerve by protruding abdomen in an obese person. 

What are the common symptoms of meralgia paresthetica?

The common symptoms include one or more of the following symptoms, affecting the upper/mid thigh region:

• Numbness,
• Tingling,
• Burning, 
• Pain. 

These symptoms occur more on sitting or standing, and get mildly relieved on lying down down. They may be more severe at night.

The picture (shaded area) below shows the location of symptoms over thigh in meralgia paresthetica.

How is the diagnosis of meralgia paresthetica confirmed?

The diagnosis is made on the basis of clinical symptoms and signs and no tests are often necessary. However, nerve conduction studies of femoral nerve can be done in some cases. In atypical cases, MRI of lumbo-sacral spine may be required to exclude pinching of nerves in the lower back.

How do we treat meralgia paresthetica?

The treatment is with medications such as pregabalin, gabapentin, duloxetine, etc, which are very effective in reducing nerve-related pain, burning and tingling.

In addition, if the person is obese/overweight, then, weight reduction is advised. Prolonged sitting should be avoided.

In 90% of cases, the above treatment would succeed. However, in 10% of cases, symptoms do not improve with medical treatment, and surgery may be required.

The surgical options include decompression of the nerve or division of the nerve. Division of the nerve may leave numbness in the affected region.

What is the outcome of meralgia paresthetica?

Most people do well with treatment and no long-term residual symptoms or disability occurs in patients suffering from this condition.

I hope this article would help patients suffering from this condition, and also enrich the knowledge of readers. I would be pleased to answer any queries related to this condition. My email is drsudhirkumar@yahoo.com 

Dr Sudhir Kumar MD (Internal Medicine) DM (Neurology)

Senior Consultant Neurologist,

Apollo Health City, Hyderabad

Phone: 0091-40-23607777

email: drsudhirkumar@yahoo.com 

Online consultation: http://members.tripod.com/sudhirkumar_5/neurologist/id6.html

MYASTHENIA GRAVIS

MYASTHENIA GRAVIS

Introduction

Myasthenia gravis is an uncommon auto-immune disease, characterised by muscle weakness.

Common symptoms of Myasthenia Gravis

Myasthenia gravis presents with symptoms due to weakness of various muscles. 

Common presentations of this include:

1. Drooping of one or both eyelids (usually, there is a difference in the degree of eyelid drooping). Drooping of eyelid is also called as ptosis. 

2. Double vision, on looking up, down, left, right or sideways.

3. Slurring of speech or nasal twang in voice,

4. Difficulty in chewing food,

5. Difficulty in swallowing food, or nasal regurgitation of liquids, 

6. Weakness of arms or legs,

7. Breathing difficulty,

8. Difficulty in holding neck straight (tends to droop forwards)

Please note

The sensations are normal in the affected parts of body.

Urinary and bowel control is preserved. 

Please also note

1. Symptoms may vary at different times of day, most often they are worse in evenings,

2. There is fatiguability, symptoms get worse on repeating the same movements,

3. There may be periods (days to weeks) of remission, when all symptoms seem to disappear, only to return back later. 

The following factors may trigger or worsen exacerbations:

• Bright sunlight
• Surgery
• Immunization
• Emotional stress
• Menstruation
• Intercurrent illness (eg, viral infection)
• Medication (eg, aminoglycosides, ciprofloxacin, chloroquine, lithium, phenytoin, beta-blockers, statins)

How do we confirm the diagnosis of myasthenia gravis?

1. Clinical symptoms, as described above make us suspect a diagnosis of MG, 

2. Tensilon test- where tensilon (edrophonium) injection is given, after which there is temporary improvement of symptoms such as ptosis,

3. Repetitive nerve stimulation- This test in done in the electrophysiology laboratory, where the muscle fatigue is shown (by seeing reduced amplitude with repeated stimulation of muscles),

4. Anti-Acetylcholine receptor antibody levels are elevated in about 80% of people. These antibodies are supposed to be released from thymus gland (located behind the upper chest wall in the centre). These antibodies prevent the action of acetylcholine on the muscles, making them weak. 

5. CT scan of chest is done to look for enlargement or tumor in thymus gland. 

6. Other less common antibodies seen in some patients with MG are anti-straited muscle antibody, anti-MuSK antibody, and anti-striational antibody.

What is the medical management of Myasthenia Gravis?

The medical management is classified into two categories:

1. Symptomatic treatment- to improve the symptoms. Pyridostigmine is commonly used.

We usually start a dose of 60 mg two times daily, and the maximum dose can be unto 720 mg per day.

Common side effects include increased salivation, abdominal pain and cramps, diarrhoea, muscle twitchings, etc.

2. Definitive treatment- is used to suppress the antibodies.

Steroids are commonly used. 

Other agents used are azathioprine, mycophenolate, cyclosporine, methotrexate, and cyclophosphamide.

3. In patients with myasthenic crisis (severe disease requiring feeding tube due to swallowing problem), or requiring mechanical ventilation (due to respiratory distress), PLASMAPHERESIS (blood is purified, and antibodies are removed, something similar to dialysis) or IV IMMUNOGLOBULINS (injections are given by drip over five days) are required.

4. THYMECTOMY- the best and permanent treatment for MG is thymectomy operation. In this, the thymus gland located behind the sternum bone (chest wall) is removed by operation. This removes the source of antibodies and the disease gets cured in most people.

What is the outcome of myasthenia gravis after treatment?

Earlier, the disease had a high morbidity and mortality, as treatments were not available. However, now, with good treatments available, more than 95% people do well and are fully cured.

I hope this articles helps people with myasthenia gravis as well as their caregivers. I would be pleased to answer any further queries. 

Please send email at drsudhirkumar@yahoo.com 

If anyone prefers ONLINE CONSULTATION, please visit http://bit.ly/Dr-Sudhir-kumar

DR SUDHIR KUMAR MD (INTERNAL MEDICINE) DM (NEUROLOGY)

SENIOR CONSULTANT NEUROLOGIST

APOLLO HEALTH CITY

Phone (for appointment): 0091-40-23607777 (extension 6634/3011)

Email: drsudhirkumar@yahoo.com 

Online consultation: http://members.tripod.com/sudhirkumar_5/neurologist/id6.html

TREMORS OR SHIVERING OR SHAKING

TREMORS OR SHAKING OR SHIVERING

DR SUDHIR KUMAR MD (INTERNAL MED.) DM (NEUROLOGY)

SENIOR CONSULTANT NEUROLOGIST

APOLLO HOSPITALS, HYDERABAD

1.  What are tremors?

A: Tremors are commonly referred to as shaking or shivering also. They are involuntary movements (occurring without one’s control) of a part of body.

2.  What are the common causes of tremors?

A: The most common causes of tremors are:

·      Physiological or normal

·      Essential or familial

·      Parkinson’s disease

3.  What are physiological tremors?

A: We all remember shivering of our hands during oral or viva examinations, or while learning to drive, or during any state of anxiety. Such tremors occurring during stress or anxiety is referred to as physiological. Most often, only hands are affected. Since, these affect most people at some time in life, they are also called as normal (or exaggerated normal). These do not require any treatment.

4.  What are familial or essential tremors?

A: These are probably the most common cause of tremors, which are pathological (abnormal).

·      They often start in adolescence or early adulthood.

·      Hands are most often affected, leading to difficulty in writing, signing, drinking tea or coffee, buttoning or unbuttoning, opening a lock or anything that requires fine finger movements.

·      Head may also be affected, with either side-to-side or front-to-back movements.

·      Voice tremors are also common.

·      These occur in families and so are supposed to be of hereditary origin.

·      Severe disability is uncommon with these tremors.

·      Good medications are available to treat them. These include beta-blockers, clonazepam, primidone, and botox injections. Consulting a neurologist would help you choose the best medicine.

PARKSINSON’S DISEASE has already been described in one of my previous blog articles. This can be found at http://bestneurodoctor.blogspot.in/2013/03/parkinsons-disease_12.html

If you have any further queries on tremors or shaking, please send an email: drsudhirkumar@yahoo.com

For online consultation with Dr Sudhir Kumar, please click http://members.tripod.com/sudhirkumar_5/neurologist/id6.html

MULTIPLE SCLEROSIS

DIAGNOSIS AND TREATMENT OF MULTIPLE SCLEROSIS

1. What is multiple sclerosis?

Multiple sclerosis is a demyelinating disease of central nervous system-CNS (brain and spinal cord), which is characterized by involvement of “multiple” parts of CNS.

The disease is also characterized by remissions (improvement of symptoms) and relapses (occurrence of new symptoms) over a period of time, causing “multiple” episodes of symptoms.  

Multiple sclerosis is an autoimmune disease, which means the antibodies produced in the body attacks own healthy tissues.

2. What is the meaning of demyelination or demyelinating illness?

Nerves in central nervous system are like “electric wires”, that is, they have a central core surrounded by an insulation or covering. This covering of the nerves is called “myelin sheath”.

A disease, where the myelin sheath is affected or damaged is called a demyelinating disease or illness, and the process is called as demyelination. Multiple sclerosis is one of the most common demyelinating diseases of the CNS.

3. Who are the common people affected by multiple sclerosis?

·        Multiple sclerosis is commonly seen between the ages of 10 and 60 years, which means, it is uncommon in children below 10 years and those adults who are above 60 years of age.

·        Multiple sclerosis is typically more common in young women (between the ages of 18-36 years),

·        Multiple sclerosis is seen all over the world, probably more common in the West, as compared to Asian countries.

·        Also, the severity of multiple sclerosis seems to be lesser in Asians, leading to lesser degrees of disability, which has led some people to label Asian multiple sclerosis as relatively “benign form” of multiple sclerosis.

4. What are the common symptoms of multiple sclerosis?

Common symptoms of multiple sclerosis include:

• Sudden onset diminished vision in one or both eyes, which may get worse over a few days,
• Numbness of arm or leg on one or both sides of body,
• Weakness of arm or leg on one or both sides of body,
• Imbalance while walking,
• Bladder symptoms,

Less common symptoms of multiple sclerosis include

·        Memory disturbances,

·        Seizures or fits,

·        Depression

It is important to note that a patient with multiple sclerosis may have only one or more than one symptom described above at one point of time, or different symptoms may occur during multiple episodes of the disease.

5. How is the diagnosis of multiple sclerosis confirmed?

A person who has one or more symptoms suspicious of multiple sclerosis should consult a neurologist. A neurologist would take history and do a clinical examination to ascertain the number of episodes of illness, and also to identify the affected the parts of central nervous system.

After that he would order for investigations to confirm the diagnosis of multiple sclerosis.

6. What are the important investigations for confirming a diagnosis of multiple sclerosis?

• MRI (Magnetic resonance imaging) of brain and spinal cord- this is the most important investigation. MRI shows the involvement of different parts of brain and spinal cord. The white matter of brain and spinal cord are typically affected in multiple sclerosis. The diseased part of brain and spinal cord are also referred to as “lesions” or “plaques”. A new or active lesion shows enhancement on MRI with contrast dye injection. In addition, there may be swelling around the active lesions. MRI is also able to distinguish new versus old lesions, and is useful to monitor the disease progression or improvement and also the effectiveness of treatment.

• CSF (cerebrospinal fluid) analysis- CSF is removed by lumbar puncture (LP) by inserting a needle in lower back. In multiple sclerosis, the CSF protein is elevated; however, the number of white blood cells (WBCs) is either normal or only slightly elevated. CSF sugar is often normal. CSF is also tested for the presence of oligoclonal bands (OCBs), the presence of which indicates an active disease.
• Evoked potential studies may be ordered to look for involvement of optic nerve (visual evoked potential or VEP) or spinal cord (somatosensory evoked potential).
• Blood tests (such as ANA, Anti-dsDNA, ANCA, etc) may be ordered to exclude other diseases that can mimic multiple sclerosis.

7. What are the current treatment options for multiple sclerosis?

Treatment of multiple sclerosis can be divided into two categories- treatment of acute episodes and treatment to prevent future relapses of disease.

Treatment for acute episodes:

Steroid injections are the preferred treatment options. The drug of choice is methylprednisolone given as injections in the veins over 3-5 days. Then, steroid tablets are given for 15-20 days.

Treatment to prevent relapses of disease:

The most preferred treatment is interferon injections (such as avonex, relibeta and rebif in India). Avonex and relibeta are given as injections in the muscles, once a week, whereas rebif is given as injections underneath the skin three times a week.

Other FDA-approved treatment options to prevent relapses of disease in multiple sclerosis are:

1. Glatiramer acetate (copaxone)- given as injection underneath the skin, once a day.

2. Fingolimod- oral capsule (0.5 mg) once daily

3. Mitoxantrone- given as infusion in the vein, every three months (maximum 8-12 doses over two-three years),

4. Natalizumab (tysabri)- given as infusion in the vein, once every four weeks.

5. Dimethyl fumerate (tecfidera)- twice a day oral capsules.

6. Teriflunomide (Aubagio)- once daily tablets. 

 8. Is Multiple sclerosis curable?

As of today, there is no cure for multiple sclerosis. However, with current treatments, the disease can be kept under control and new relapses can be prevented.

9. Is multiple sclerosis always disabling?

Multiple sclerosis does cause disability in a significant number of people. However, more than two-thirds of patients suffering from multiple sclerosis are independent for their activities of daily living and are gainfully employed in a job. The good outcome depends on proper treatment as well as physical & occupational therapies.

10. Is multile sclerosis contagious or genetic?

Multiple sclerosis is not contagious and does not get transmitted from one affected person to another.

There may be genetic predisposition to get multiple sclerosis but it is not a genetic disease in a strict sense, as most patients with multiple sclerosis do not give a positive family history.

11. Is multiple sclerosis fatal or lethal?

In more than 95% of patients with multiple sclerosis, it does not lead to death. However, in a minority (less than 3%) it may lead to death either due to the direct effect of the severe disease or another complication such as pneumonia or deep vein thrombosis.

I hope this article is useful for hundreds of patients with multiple sclerosis as well as their caregivers. In addition, if someone is looking for information on multiple sclerosis (MS), it should be useful.

For any additional information, please email me at drsudhirkumar@yahoo.com

DR SUDHIR KUMAR MD (Internal Medicine), DM (Neurology)

Senior Consultant Neurologist

Apollo Hospitals, Hyderabad, India

Phone: 0091-40-23607777/60601066

drsudhirkumar@yahoo.com

PARKINSON'S DISEASE

PARKINSON’S DISEASE (PD)

What is Parkinson’s disease (PD)?

Parkinson’s disease is a disease of the brain, which is caused by selective degeneration of nerves in the basal ganglia, leading to deficiency of dopamine in brain.

What are the symptoms of Parkinson’s disease?

The most typical symptoms of this disease include:

1. Tremors- shaking of hands and feet,
2. Slowness of all activities,
3. Stiffness of arms and legs,
4. Loss of balance while standing or walking.

A patient may have only one or some or all of these at onset. However, as the disease progresses, all of them would eventually develop all these symptoms.

What are some of the other symptoms of Parkinson’s disease?

Other symptoms that may occur in a patient with Parkinson’s disease are:

1. Mask-like facies or expressionless face, (even in situations of happiness, they may fail to express it on the face),
2. Stooped posture, with head & trunk bent forwards,
3. Slurred and low volume speech (it is often difficult to comprehend what they are saying),
4. Slow speed of walking,
5. Reduced swinging of arms while walking,
6. Very small letters while writing, referred to as Micrographia,
7. Reduced blink rate (which makes them give a staring look),
8. Short, shuffling steps while walking,
9. Loss of balance while turning, leading to falling forwards.

Why this disease is called Parkinson’s disease?

This is because the very first description of this disease was given by a doctor named Dr James Parkinson, a neurologist from UK. In his honour, the disease was given his name.

Which age group is commonly affected with Parkinson’s disease?

This disease typically affects people above 40 years of age, and the incidence increases with advancing age.

Occasionally, this can occur in people younger than 40, when it is called young onset Parkinson’s disease (YOPD).

How is Parkinson’s disease diagnosed?

Like many other neurological problem, Parkinson’s disease too is diagnosed on the basis of typical symptoms (as described above).

It may be difficult to diagnose PD in very early stages, as the affected person may have only minor symptoms such as mild tremors of hands, and perfectly well otherwise. However, careful examination by a Neurologist would help confirm its diagnosis in this stage too.

Is there a very specific test for diagnosing Parkinson’s disease, especially in early stage?

In doubtful cases, or in very early stages, PET scan (positron emission tomography) can help in accurate diagnosis of PD. This facility is available in our hospital, and I do use it in some cases.

Can Parkinson's disease be transmitted genetically to the children of patients suffering from this disease?

In about 10% of cases, PD can be genetic in origin. But about 90% of cases of PD are sporadic (they have no family history of Parkinson's disease).

What are the treatment options available for Parkinson’s disease?

The mainstay of treatment of PD is medications. Various medications are available. These include levodopa/carbidopa combination (which provide direct dopamine to the brain); ropinirole & pramipexole (which increase the action of dopamine); trihexiphenidyl, amantadine, entacapone, etc.

The choice of drug depends on the patient’s symptoms as well as the severity & duration of PD.

Your neurologist is the best person to decide the most appropriate medications and their doses.

What are the common side effects with medications used for treating PD?

Though these medications are generally safe, some side effects may occur:

1. Giddiness while sitting up or standing- this is because of drop in BP while standing, which is a side effect of levodopa/carbidopa (syndopa/sinemet),
2. Behavioural disturbances- agitation, hallucinations (seeing something that is not there or hearing something when no one is speaking, etc), sleep disturbances can occur with syndopa, especially if the last dose is taken late (such as after 8 pm). 
3. Nausea, vomiting, loss of appetite may occur with syndopa.
4. Abnormal movements of hands or feet, akin to dancing or rhythmic movements, referred to as dyskinesias.

What are the common precautions while taking medications for PD?

1. Medications for PD should be taken on empty stomach, as presence of food may interfere with their absorption,

2. They should be taken on exact time, as advised by the doctor,

3. Any change in the dosage or timing of the medications should be done only after consulting the neurologist.

How long are the medications required in Parkinson’s disease?

Medications are usually required for lifelong. However, the dose would change as per the severity of disease.

Are botulinum toxin injections (Botox) helpful in treating PD?

In selected cases, where there is increased rigidity or dystonia, botox may be useful. The decision can be made by the neurologist after clinical examination.

Are there any surgeries available for treating Parkinson’s disease?

Deep brain stimulation (DBS) surgery is the standard surgery performed in some cases of PD. This surgery can be compared to pacemaker (of heart); wherein an electrode is placed in the brain.

It should be noted that not all cases of PD require surgery, nor would all cases of PD benefit from DBS surgery.

Patients with predominant tremors of hands may be the best candidates for DBS surgery.

Another group of patients who may benefit are those with inadequate response to levodopa, or those with levodopa-induced dyskinesias (see above under side effects).

The decision regarding the need or usefulness of surgery can be made by the neurologist after detailed clinical evaluation.

Is DBS surgery available in India?

Yes, many centers in India (Mumbai, Bangalore, New Delhi, Hyderabad, Trivandrum, etc) have the facilities for doing DBS surgery in India.

We perform DBS surgery in our institute too.

What kind of outcome can be expected in patients with PD after treatment?

1. There is no cure available for PD,
2. Disease continues to progress despite medical treatment, and the severity of disease would worsen over time,
3. The disease leads to severe motor disability, hampering the activities of daily living and occupation,
4. There is generally no increase in the chances of death, if the patients are looked after well.
5. However, it should be noted that a reasonably good quality of life can be maintained with proper medical treatment and physiotherapy for more than 20 years after the onset of PD symptoms.

Is there a specific diet to be followed by patients suffering from Parkinson’s disease?

Protein content should be reduced by 50%, and protein-rich foods (such as pulses, meat, etc) should be shifted to dinner time (after the last dose of syndopa has been taken). This is to ensure proper absorption of syndopa, as presence of high protein food may interfere with the absorption of levodopa.

Is there any limitation on physical activities?

No, there is none. In fact, it is better for a patient with PD to indulge in regular physical activities, including outdoor games, to maintain good physical fitness & mobility.

If you have any additional queries on Parkinson's disease, please send me an email: drsudhirkumar@yahoo.com

DR SUDHIR KUMAR MD (Medicine), DM (Neurology)

Senior Consultant Neurologist

Apollo Health City, Hyderabad, India

Phone: 0091-40-23607777

Email: drsudhirkumar@yahoo.com