I have developed a drop foot and the doctor is unable to diagnose the cause

I developed a unilateral left drop foot approximately 4 months ago. The neurologist requested an MRI which showed a bulging disc between l5 and S1 I believe as well as minimal left foraminal stenosis. According to the neurologist this is not the cause as no sensory problems are present. The following is a full medical report form the Dr - Can someone please assist me as no conclusive answers were given and the tests that were performed by the Dr have drained my medical aid for the entire year:

Thank you for the referral of this young man. He presents with a left sided drop foot which he noted about

3/12 ago. A year ago, they went to Thailand (his fiancé and himself) and upon returning, they both noted

they had cramps in their legs. His fiancé’s cramps improved, but his persisted to the current day.

It was noted that he started walking a bit skew already in June 2018 due to a gout flare up he had which

affected his right toe. He was also seen by an orthopaedic surgeon in February 2018 and a scope was done

on his left knee.

In October 2018 he had a fall from a truck where he fell on the left side of his body – he didn’t have any

problems after this fall that he was aware of – he had no back pain specifically.

He noted since October 2018 that he had an issue lifting his foot off the floor with weak ankle raises. He has

no problems in the arms, and no problems in his right leg that he aware of. He passes stool normally and has

no issues with his bladder control. He has no difficulty swallowing and currently still has no back pain that

he is aware of.

He is non-diabetic and uses no current medication.

Clinical Examination:

BMI is increased.

Normal Cognition/higher functions.

Cranial Nerves: These appear to be intact – specifically no overt tongue fasciculations are noted, and his

tongue size appears to be normal. He struggled to relax his tongue properly though. His gag is not increased.

Motor system: Power in his arms is normal with normal reflexes, no obvious fasciculations are noted in the

arms.

In his right leg the tone appears to be slightly floppy on the left side. The power is normal on the right leg

throughout, but he has weak toe and ankle dorsiflexion/plantar flexion on the left side. Function of tibialis

posterior muscle also appears to be affected when tested in the neutral position on the left side. Knee reflex

on the left is present but no ankle reflex is noted. No Babinski is noted. On the right side the knee and ankle

reflexes are normal.

Patient: Roets, MC Test Date: 2019/01/15 Page 2

Sensory System: There is normal sensation in the upper limbs and in the feet there is possibly a decreased

sensation over the foot, but when comparing the left and right feet, there doesn’t really appear to be any

overt sensory loss. The dorsal columns are also intact with the tuning fork.

Cerebellar system: Seem intact.

Gait: The left foot doesn’t really lift off the ground during walking and he must lift his knee on the left side

higher.

NCV & EMG Findings:

Sensory conductions in the feet are normal.

There is reduced amplitudes of the left peroneal nerve conduction using the EBD muscle, but no conduction

block over the fibular head is noted. Using the Tib ant muscle no overt conduction block is noted either over

the head of the fibular. The conduction velocity is within normal limits.

The left post tibialis nerve also shows decreased amplitude, with normal conduction velocities.

On the right the peroneal nerve shows a lower amplitude with normal conduction velocities.

The post tibial nerve appears to be normal on the right side.

Based on these findings it appears to be an axonal problem present.

EMG done of the left tib anterior: Polyphasic, smallish to medium amplitude present. Positive sharp waves

were noted at rest which were very rhythmic (1/second)

Left Vastus Lateralis: Spontaneous fasciculations were noted, some polyphasic. During activity some large

polyphasic units were noted.

Right Tib Anterior: During rest:No abnormal units noted; During activity: mildly polyphasic units.

Right Vastus Lateralis: Polyphasic fasciculation noted during rest, with activity mostly normal looking, but

at times 1+polyphasic large units.

Patient: Roets, MC Test Date: 2019/01/15 Page 3

MRI lumbar spine:

Protocol

Sagittal T1 and T2

Axial T2

Coronal T2 STIR

Level L1 - 5

Normal.

L5-S1

Degenerative disc bulging with minimal left foraminal stenosis.

No other abnormalities noted.

ASSESSMENT:

What concerns me currently is the positive sharp waves on the left ant tibialis muscle, together with

polyphasic units during action – innervated by mostly L4, where there is no real stenosis at the L4 level, and

the fact that there are abnormal wave patterns also present more proximally in the left (mostly) but also

some on the right vastus lateralis muscle.

At this stage I haven’t done any further LP, but the blood tests only indicate a low Vit B12, and a low Vit D

level. This patient has signs of a motor neuropathy involving the left posterior tibialis and peroneal nerve,

with minimal signs present on the right side, but mild EMG changes on the right side.

BLOOD RESULTS:

ANF – Negative

ENA – Negative

ANCA – Negative

Anti DsDNA – Negative

Anti-Cardiolipin – weak Positive IgM, Negative IgG

RF – Negative

Anti-B2 Glycoprotein – Negative

FBC – Normal

Ganglioside Antibodies – Negative

UE/LFT – Negative

CK – slightly elevated 313 (after EMG though)

S-ACE – 14 (low)

S-PEP – Negative

Immunoglobulins G,A,M – Negative

Random Glucose: 4.6

Negative: Calcium, Phosphate, Magnesium

Hep B/C negative

Vit D: 20

Vit B12: 227

TFT – Normal

Red Cell Folate – Normal

ESR: 6

Patient: Roets, MC Test Date: 2019/01/15 Page 4

PLAN:

As discussed with Dr N. Fourie (Wilger’s Pretoria) do the blood tests mentioned above.

Treat with low dose cortisone (Prednisone 10mg)

Perform LP

Review in 3 months’ time to evaluate progress.

Given Vit B12 and Vit D supplementation.

In addition muscle cramps have worsened even with medication prescribed by the same dr to alleviate the problem (Foot, calf, hamstrings, quad as well as popliteal fossa) of affected foot

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