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Balance problem. loose motions, fatigue. All tests normal. What is the problem and its treatment?

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This consultation is for my wife XXXXXXX rath. She is 41 years old, married, and a homemaker.
Since March 2010 (she was completely healthy prior to that), she is having a problem of imbalance while standing, dizziness, and a passing out/blackout sensation (but she has never passed out). The sensation is not as if the objects around are rotating, but as if she is going to fall.Then she got episodes of sweating, tingling sensation on right side of head, palpitations, loss of appetite, high acidity, continuous burping, nausea (she still gets them). But she has never vomited or passed out. CT/MRI scans were done for brain/temporal bone, but results were clear, with only degeneration of atlanto-axial joint as the only significant note.She then had a long episode (nearly 15-20 days) of loose motions. Even now, she gets it on and off, particularly after a heavy meal. She had an endoscopy done, which showed a mild collapse of esophagus, but doctor did not feel it necessary to give any medication for that.She is continuously feeling fatigued, is almost rooted to the armchair and immobile.In January 2011, She had an episode of pain in the abdomen, and we got sonography done, which showed pelvic pleural effusion. Gynac prescribed amoxillin/meftal. The infection went away in repeat sonography.In March, she was hospitalized for weakness, loss of appetite. While in hospital, she developed high fever spikes (upto 105 centigrade). CT scan of chest showed pleural effusion in lungs (pneumatic patch), was treated with mild antibiotics and repeat chest xray showed that the liquid had dried up. However, CT scan had also shown a large node in left side (chest). Doc has not seen this as significant, but asked us to monitor the node after few months.All standard tests have been done and repeated several times, like urinary tract,2D-echo, holter test, CBC, thyroid, stool culture, etc. All levels were clear and ok. Her weight has remained more or less constant throughout the period (around 49-50kgs)Now, she continues to get imbalance while standing, gets fatigued if she tries to walk a few metres, episodes of chills and cold even when conditions are warm, palpitation, nausea, breathlessness, heaviness in chest, acidity, loss of appetite. Symptoms are generally much worse in the mornings, while standing/walking, in-between meals and on physical exertions. Her ESR has been repeated several times, it was 98 at the time of fever spikes, but came down to 40 last time we tested it.Recently (this month), we did a Head-up tilt table test, which came out positive, with blood pressure dropping from 120 to 84 within 40 minutes of test period.
Neurologist here, who is treating her for last 17 months initially prescribed Vertin 16 and Stugeron (one after another), but it did not help. Now, he has opined that sudden BP drop is causing her imbalance, but has no answer to other symptoms, as clinical tests have proved negative. She was prescribed Betacap 20 (thrice a day), iron supplements (her hemoglobin hovers around 10-11) and Pantocid DSR (pantoprazole), but these haven't really helped. Physicians do not have a clue to her symptoms. Gynac has tested all standard parameters/tests, she has not found anything of note, exce[pt a fibroid/bulky uterus
A 3T MRI of brain done on October 2 has revealed a focal lesion in right frontal lobe which might be indicative of demyelination (scans attached). The MRI report says: "A focal hyperintense area is seen in the right frontal lobe white matter; could be non-specific or could be demylienating in nature. A tiny non-specific hyperintense focus is seen in left frontal lobe."
A neurologist here has advised a repeat MRI with area of focus on the right frontal lobe lesion. Is it advisable to repeat the MRI? She has already had two.
Can you help us with information about the problem she might be facing and the further steps of managing this ongoing problem. If I could have a response with detailed medical advise and alternative medications, that would be great.I want to stress that my wife is mentally fine and wants to get out of her ailment asap. I have noticed that in the absence of any clinical proof, docs here tend to be dismissive and disregard all her symptoms which are very much there and very real. She needs to be treated quickly as I have noticed that the symptoms are just not going away and have really affected her lifestyle.
Posted Sat, 5 May 2012 in Brain and Spine
Answered by Dr. Shiva Kumar R 2 hours later
Hello and thank you for the query.

Your question is a good one and I will try to provide you with some information and recommendations regarding what is going on.

Based on the details provided to me looks like she is suffering from Postural hypotension which can cause dizziness in the standing position. I probably feel she has autonomic disturbances. It can be due to problems in the nerves of the legs or in the brain. You need to see a neurologist who is working in this field.

I am sorry you are dealing with this frustrating concern and I hope you can find yourself in better health soon with the help of your Neurologist.

Till then to decrease dizziness when standing, try standing slowly, in stages. It may also help to flex the feet and grip your hands for a few seconds before standing up, to increase blood flow. After standing up, try tensing the leg muscles while crossing one leg over the other a few times to increase blood pressure.

It also may help to raise the head of your bed by about one foot (30 centimeters) and sit with your legs dangling over the side of the bed for a few minutes before getting out of bed.

Degeneration of atlanto-axial joint is also significant in causing these symptoms. Please repeat the MRI as it is necessary both for diagnosis and further treatment.

I thank you again for submitting your query. I hope my response was both helpful and adequate.

If you have any additional questions I would be happy to address them.

Above answer was peer-reviewed by
Follow-up: Balance problem. loose motions, fatigue. All tests normal. What is the problem and its treatment? 2 hours later
Many thanks, doc. a few more queries for which I request your opinion/advise:
Is the focal hyperintense area seen in the right frontal lobe significant and a cause of her symptoms (I'd attached a few scans in my initial query)? If yes, what is the treatment line?
Are such lesions malignant?
Will a repeat MRI of the same area reveal anything new? Are there any other diognostic tests open to us for diagnosing her condition?
She also had an angiography done for intracranial and neck vessels, but the test was normal (report was attached with initial query). So where could the problem lie/what is the future course of action?
How would you explain/diagnose/advise action for the following:
She experiences constant discomfort in her right temple area (tingling sensation) and her eyes feel very very weak (she has to make an effort to keep them open). Her vision is okay. She also experiences shaking/tremours of her legs, and her right leg trembles when she puts weight on it to stand.
Could her fibroid uterus be a reason for her symptoms, however far-fetched? Or is it a separate issue?
Is there any danger to life with her set of neuro problems/symptoms? Is there a slow progression of the desease? If yes, how to retard this progression?
Any medication that will help reduce the symptoms?
Best regards,

Follow-up: Balance problem. loose motions, fatigue. All tests normal. What is the problem and its treatment? 6 minutes later
Would just like to add:
Often she also feels a numbness in the face/facial muscles, alongwith with weakness. What could be the cause of this?
Thanks, doctor!
Answered by Dr. Shiva Kumar R 7 hours later

Thanks for getting back to me.

MRI findings to not indicate of any malignancy. Repeat MRI is not required. I would have not done a angiography in a case like your's.

A detailed physical examination will be necessary to locate the problem.

Yes, there is a chance where the symptoms could be due to fibroids indirectly due to hormonal imbalance met in fibroid disease.

Medication would be best if decided after a confirmed diagnosis which cannot be made without a physical examination.
Weakness and facial numbness can be a part of the neurological syndrome as suggested earlier.

Wish you good health.

Take care,
Above answer was peer-reviewed by
Follow-up: Balance problem. loose motions, fatigue. All tests normal. What is the problem and its treatment? 33 hours later
Thanks so much, doctor. Just the last batch of queries:
As I asked earlier, is the extent of the hyperintense focal area seen in the MRI a cause for concern/cause of her symptroms?
Any possibility of the onset of MS (M. Schlerosis) or MG (M. Gravis)?
If not a repeated MRI, is there any other diagnostic means/test to ascertain cause of her neuro problems? [I've noticed that there is a slight trembling throughout her body when she is alseep, and she alsooften complains of pressure on her chest although cardiac tests done about a year ago were normal.]
Is there any specific test(s) that you would recommend for ascertianing the possibility of hormone imbalance? We just got a sonography of the abdomen repeated yesterday, and the fibroid size is 5.1 x 4.7 cm; other parameters (lever/kidney, etc) are normal.
I really think your answers will lead us somewhere towards her diagnosis. Many thanks for your patience!
Follow-up: Balance problem. loose motions, fatigue. All tests normal. What is the problem and its treatment? 30 minutes later
Doctor, any possibility of Mal de Debarquement Syndrome (MDD or MdDS)? She has a rocking sensation when she stands...(just thinking aloud!)
Answered by Dr. Shiva Kumar R 2 hours later
Thanks for getting back to me.

I personally feel it is not MS(multiple sclerosis) or MDD ( Mal de Debarquement Syndrome)as repeat scans must have shown increase in the hyperintense signal changes.

More so her symptoms does not suggest MS. Myasthenia usually present with generalized weakness, drooping of the eye lids and if not treated will present with swallowing and breathing problems.

Regarding the fibroid you will have to discuss with the Gynaecologist for the next step of management.If it is causing any symptoms you will have to get it removed.

No other diagnostic tests are required for her current problems.

Number of hormonal tests are available in all diagnostics for hormonal assay.
Contact your physician or Endocrinologist for more suggestions.

Wishing you good health.
Thank you, Bye.
Above answer was peer-reviewed by
Follow-up: Balance problem. loose motions, fatigue. All tests normal. What is the problem and its treatment? 21 hours later
Thanks doctor.. One last query: Neurologically, if she has the hyperintense area in her RIGHT frontal lobe white matter, should she feel discomfort in her RIGHT temple area or LEFT temple area...Her neurological symptoms are located on one side only, and I just wanted to ascertain whether the hyperintense area could be the cause or not.
Answered by Dr. Shiva Kumar R 2 hours later
Thanks for the follow up.

If you have hyperintense lesions on the right side the neurological symptoms will be seen on the left side .

This is if it seen in the frontal lobe.

Wishing you good health.
Above answer was peer-reviewed by
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