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97 My Inner Blizzard: Effect of Weather on Multiple Sclerosis Exacerbation
- Chevelle R. Winchester, Priya Batta, Dhillon Davinder, Alan R. Hirsch
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- Journal:
- CNS Spectrums / Volume 24 / Issue 1 / February 2019
- Published online by Cambridge University Press:
- 12 March 2019, p. 223
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Study Objective
Exacerbation of Multiple Sclerosis (MS) symptoms prior to weather change has not heretofore been described.
MethodsCase Study: A 60 year old right handed female with lifelong anxiety and four years of depression presented with a 20 year history of MS manifested by bilateral lower extremity pain and weakness and urinary incontinence. Since the onset, she observed that approaching storms or weather changes cause her symptoms to worsen. This manifests one day prior to the meteorological shifts of rain or snow. This occurs whether she is at home or on vacation and unlike the weatherman, “she is never wrong.” The aggravation of symptomatology would consist of worsening leg pain and weakness of both lower extremities so that her functional status changes from using a cane to a wheelchair. These symptoms begin one day prior to the storm and gradually worsen to the point of maximum intensity as the storm arrives. The baseline pain is usually 5/10 in severity but with the storm it increases to 8/10. The pain, which progressively worsens as the storm advances, is a vice-like numbness in her shins and spasm in her legs. The pain and weakness will persist for as long as the storm lasts. The pain diminishes and the motor symptoms improve six hours after the storm is over. She can differentiate approaching snow or rain such that snow causes more intense symptoms. She denies change in symptomatology on airplanes or when she is present at high altitude such as Las Vegas or Colorado. She also affirms that her symptoms are worse when she is in a hot tub and better in a cold-water bath. She reports that there is a family history of similar ability to predict the weather in a cousin and nephew, both who also suffer from MS.
ResultsAbnormalities in Neurological Examination: BP 159/115. Pulse 100. Mental Status Examination: disheveled. Depressed mood with congruent affect. Short-term memory: 5 digits forwards, 2 digits backwards. Recent memory: able to recall none of 4 objects in 3minutes without improvement with reinforcement. Unable to interpret similarities or proverbs. Poor ability to calculate. Reflexes: 3+ bilateral lower extremities. Clock Drawing Test: 1 (abnormal).
ConclusionsUhthoff’s phenomena (hot bath test) is well described in MS (Humm, 2004), however the worsening of symptoms prior to weather change has not been reported. Possible mechanisms include meteorological induced anxiety and depression with associated exacerbation (Ackerman, 1998). Other possible mechanisms include misattribution, selective recall, or a misreporting due to psychological needs for acceptance by examiner, similar to the Hawthorne effect (observer effect) (Adair, 1984). With the approaching storms there could be a change in internal temperature, which then preferentially affects areas of demyelination (Kudo, 2014). It is worth querying those with epoch associated neurological disorders as to linkage with meteorological events.
125 Short Duration Monoballismus
- Davinder Dhillon, Priya Batta, Alan R. Hirsch
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- Journal:
- CNS Spectrums / Volume 23 / Issue 1 / February 2018
- Published online by Cambridge University Press:
- 15 June 2018, pp. 79-80
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Study Objective
While monoballismus has been reported to be associated with hemorrhagic lesions in the subthalamic nucleus (Ohnishi, 2009) and multiple sclerosis (MS) (Rosa, 2011), the duration has been reported to be at least six days (Soysal, 2012). A patient with epochs of monoballismus lasting for 45 minutes is presented.
MethodsCase Study: A 57 year old right handed female with attention deficit hereditary disorder predominantly inattentive on amphetamine sulphate, presented with two years of memory loss. For instance, after ordering food in restaurants, by the time the food arrives, she could not recall what she ordered. At the onset of this symptom, she noted three epochs of her left arm jerking for 45 minutes. The jerking would begin with low amplitude and low frequency and rapidly progress to the forearm and arm of greater magnitude and low frequency. With her right hand she would try to hold down her left arm without success. There was no associated paresis, sensory phenomena, headaches, dizziness, presyncope, loss of consciousness, or strong emotions. She admitted to frequent jamais vu.
ResultsAbnormalities: Neurological Examination: Mental Status Examination: Memory: Immediate Recall: 5 digits forward and 2 digits backwards. Cranial Nerve (CN) Examination: CN I: Alcohol Sniff Test 8 (hyposmia). CN XII: tongue tremor on protrusion. Motor Examination: Drift Test: positive right pronator drift. Gait Examination: Tandem Gait: unstable. Reflexes: 0-1 throughout. Neuropsychiatric Examination: Go-No-Go Test: 6/6 (normal). Animal Fluency Test: 15 (normal). Clock Drawing Test: 3 (abnormal). Center for Neurologic Study Lability Scale: 16 (pseudobulbar affect). Other: MRI with and without infusion: normal.
ConclusionTransient tonic-clonic movements of one limb have been described with focal epilepsy associated with diabetic non-ketotic hyperglycemia (Grant, 1985). A metabolic abnormality such as transient hypoglycemia or hyperkalemia can cause a focal dystonia (Soysal, 2012), which theoretically could manifest with monoballismus. This could be a somatic manifestation of underlying conflict, conversion disorder, or as a result of a physical manifestation of panic attack with hyperventilation and tetany (Mihai, 2008). This may be the first manifestation of a generalized cerebral disorder associated with chorea or ballismus such as Wilson’s disease, or Huntington’s Chorea (Mihai, 2008). It is possible that this is a variant of Alien Hand Syndrome with parietal lobe involvement (Shrestha, 2015). But this is unlikely given the absence of hemineglect or hemiagnosia. It is possible that amphetamines may have induced a monochorea. Chronic amphetamine use has been demonstrated to cause chorea (Klawans, 1974) and it theoretically could have caused ballismus movements in this case. In patients who present with short duration monoballismus, evaluation for subthalamic nuclei function, seizure disorders and other origins of ballismus are warranted.
Funding AcknowledgementsSmell & Taste Treatment and Research Foundation
175 Burning Mouth Syndrome Equivalent to Restless Leg Syndrome
- Priya Batta, Sarosh Majeed, Davinder Dhillon, Alan R Hirsch
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- Journal:
- CNS Spectrums / Volume 23 / Issue 1 / February 2018
- Published online by Cambridge University Press:
- 15 June 2018, p. 101
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Study Objective
Stuginski-Barbosa reported a patient with Burning Mouth Syndrome (BMS), whose symptoms were transiently improved with tongue movement, postulated to be an oral equivalent of restless leg syndrome (RLS) (Stuginski-Barbosa, 2008).
MethodsFour Case Studies are described.
ResultsCase 1: A 35 year old pathological left handed woman presented with one-year history of burning and stinging sensations on the sides of the tongue and lips without any known precipitant. It is reduced with chewing gum and eating. For the last few months she noticed tongue movement reduced the burning sensation. Two to three seconds of tongue movement alleviated the burning from 3/10 to 0/10 in intensity, which persists for one minute after cessation of tongue movement.
Case 2: A 57 year old right handed female, three years prior to presentation, had multiple teeth extractions. Four months later, she perceived a rough sensation of her tongue, which has gradually changed to a burning sensation which has persisted since then. The burning is 10/10 in severity and constant. Chewing 24 pieces of gum a day reduces the pain. Movement of the tongue including anterior-posterior protrusion and retraction, side to side movements without contacting surrounding oral mucosa, converted pain from 9/10 to 5/10, which lasted approximately 1 minute.
Case 3: Eight years prior to presentation, this 60 year old woman developed BMS, after dental extraction. The pain involves the tongue (right and center of palate) accompanied by a gritty sandpaper-like sensation. The burning is a level 5/10 in intensity and progressively worsens throughout the day. Burning mouth pain is made less intense with chewing gum and using dental wax. Baseline burning mouth severity is at level 5/10 however, with protrusion, retraction, and side-to-side movement of the tongue, the intensity dropped to 3/10.
Case 4: Three years prior to presentation, a 59 year old female patient suffered severe allergies with onset of burning mouth and absent taste. The burning is in the middle of her tongue, rarely, her palate, but never on her lips. Severity is 2/10 and is worse in the morning, with drinking red wine, and hot drinks. It is better with cold drinks and ice cream. Movement of her tongue side-to-side eliminates the burning severity from 2/10 to 0/10, lasting one minute.
ConclusionLike the patients described by Stuginski & Barbosa 2008, these four patients showed reduced pain in response to tongue kinesia (Stuginski-Barbosa, 2008). Their mandibulation of gum as an analgesic maneuver may have been due, not to the taste of the gum, but rather to the associated tongue movement that mastication induces. Through moving, large nerve fibers of proprioception are stimulated, which may act through the Gate Controlled Theory of Pain of Melzac and Wall, to reduce unrestricted small nerve fiber discharge, thus inhibiting pain. Query regarding movement or gum chewing inhibition of BMS is warranted.
Funding AcknowledgementsSmell & Taste Treatment and Research Foundation.
174 Pseudogout Induced by Vortioxetine
- Priya Batta, Davinder Dhillon, Alan R Hirsch
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- Journal:
- CNS Spectrums / Volume 23 / Issue 1 / February 2018
- Published online by Cambridge University Press:
- 15 June 2018, p. 100
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Study Objective
Vortioxetine induced monoarticular pain has not heretofore been described. Such a case is presented.
MethodCase study: A 49 year old right handed female with a past history of multiple hospitalizations for chronic severe migraine, presented with complaints of depression and stress. She has had depression for 20 years, which has been constant and worsened in the past 5 years. As her migraines became more frequent, her depression also worsened. She has never been suicidal, but does endorse sadness, crying spells, fatigue, demotivation, lack of interest, poor concentration, irritability, anger, guilt, hopelessness, helplessness, anorexia, PM insomnia with frequent awakenings, absent libido and racing thoughts.
ResultsAbnormalities in her mental status examination: Orientated times 2. Disheveled. Defensive. Motor retardation. Mood: depressed, anxious and irritable with blunted affect. Remote memory: President: Obama,?. Beck Depression Inventory II: 23 (moderate depression). Beck Anxiety Inventory: 25 (moderate anxiety).
The patient was begun on 5 mg of vortioxetine every night. Within two days, she developed pain and swelling of the distal interphalangeal joint of the left great toe. The pain was so severe that she demonstrated an antalgic gait. After five days the medication was discontinued and two days later, there was full resolution of the swelling and pain, and ambulation returned to normal.
ConclusionsThe mechanism whereby vortioxetine induced this monoarticular pain is unclear. Underlying depression alone can precipitate arthritic exacerbation (Trivedi, 2004). This was unlikely given the long duration of her depression as well as the timing of the precipitant (vortioxetine use) and resolution shortly after the medication was discontinued. Alternatively, in the depressed state, there may be a greater perception of somatic pain, which allowed her to appreciate any arthritic pain which may have pre-existed the use of vortioxetine (Howard, 1991). As such, this may have represented a correspondence bias (Gilbert, 1995). Furthermore, mild new pain is perceived as more intense in those who are depressed (Howard, 1991). Thus, any minimal arthritic injury may be viewed as more intense. Vortioxetine may have paradoxically exacerbated anxiety and anxiety can precipitate pain (Narasimhan & Campbell). Alternatively, vortioxetine could have caused a generalized allergic reaction, which may have initially manifest in the great toe. If the patient continued the medication, she may have developed a generalized systemic reaction including involvement of multiple joints. Another possibility is that it caused an allergic histamine mediated hive like reaction, generalized, as well as on the toe. Continued use of the joint may have caused this to be intensified, with associated swelling, while the general reaction subsided. Inquiry about monoarticular involvement in those taking vortioxetine is warranted.
Funding AcknowledgementsSmell & Taste Treatment and Research Foundation
124 Epochs of Anosmia and Ageusia in Multiple Sclerosis: Chemosensory Uhthoff’s Phenomenon
- Davinder Dhillon, Jasir T Nayati, Priya Batta, Alan R. Hirsch
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- Journal:
- CNS Spectrums / Volume 23 / Issue 1 / February 2018
- Published online by Cambridge University Press:
- 15 June 2018, pp. 78-79
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Study Objective
To reveal that while long duration of anosmia and ageusia has been seen with Multiple Sclerosis (MS) [Doty 1997], repetitive shorter epochs ofanosmia and ageusia has not heretofore been presented.
MethodsCase Study: A 39 year old right-handed male, with a history of MS, presents with six years MS concurrent with epochs of anosmia and ageusia. The anosmia andageusia present concurrently, preventing him from smelling and tasting his meal. At baseline, he is able to smell and taste coffee, peppermint, gum, sweet and salty foods, rating his smell and taste at 70% normal. However, during the epochal events, he reports the inability to smell and taste white rice, shrimp, meat, butter, carrots, onions, spinach, and sour foods. He states that these episodes occur approximately ten times a week, last for two hours, and rates his smell and taste from 0-10% during these events.
ResultsAbnormalities Neurological Examination: Cranial Nerve (CN) Examination: CN II: bilateral pale discs. CN III, IV, VI: bilateral ptosis. CN IX, X: decreased gag reflex bilaterally. Motor Examination: Drift Test: positive left pronator drift, with right adductor digiti minimi sign and right cerebellar spooning. Sensory Examination: Ipswich Touch Test: decreased in left lower extremity. Temperature: decreased in left lower extremity. Rydel-Seiffer Vibratory Test: bilateral upper extremities 5 and bilateral lower extremities 3. Tandem Gait: unstable. Cerebellar Examination: Holmes Rebound Phenomena: positive with left greater than right. Reflexes: 1+ bilateral upper extremities, absent bilateral lower extremities. Neuropsychiatric Examination: Animal Fluency Test: 15 (abnormal). Clock Drawing Test: 3 (abnormal). Center for Neurologic Study Lability Scale: 16 (pseudobulbar affect).
ConclusionPrimary olfactory dysfunction with secondary inhibition of retronasal smell and perceived taste [Gruss 2015] can be an etiology. Such an olfactory dysfunction may reflect variation in nasal mucosal engorgement due to normal variability of the olfactory cycle [Eccles 1978]. This phenomenon is an unlikely due to the short duration ofepochs.
The cause of anosmia and ageusia in this patient suggests a central lesion involved in the processing of both smell and taste. Transient rapid symptoms associated with temperature change, as in Uhthoff’s phenomenon seen in MS, can manifest with deficiency in special senses including visual field loss [Davis 2010]. Such also may be the origin for the chemosensory loss seen here. While this phenomenon may be induced by hot baths, more subtle temperature changes may also induce such symptoms [Romani 2000]. Given that olfactory threshold changes have been demonstrated in acute inflammatory changes in MS, such a temperature related etiology is more likely to manifest [Lutterotti 2011]. MS patients should be screened for chemosensory dysfunction, and those with chemosensory dysfunction should be assessed for demyelinating disease.
Funding AcknowledgementsSmell and Taste Treatment and Research Foundation