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Dr. Andrew Rynne

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In the last two weeks I have had intermittent tingling

Answered by
Dr.
Dr. Dariush Saghafi

Neurologist

Practicing since :1988

Answered : 2429 Questions

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Posted on Sun, 24 Mar 2019 in Brain and Spine
Question: In the last two weeks I have had intermittent tingling and numbness in my right hand and forearm. I recently received 43 radiation treatments for prostate cancer. I am now taking Lyrica for Neuropathic Pain; Tamsulosin (Flomax) for post-radiation urinary problems; and have had one Lupron (Leuprolide) injection in conjunction with the Radiation Treatment for my Prostate Cancer. What may be the cause of the intermitent tingling and numbness in my right hand and forearm?
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Follow up: Dr. Dariush Saghafi 0 minute later
In the last two weeks I have had intermittent tingling and numbness in my right hand and forearm. I recently received 43 radiation treatments for prostate cancer. I am now taking Lyrica for Neuropathic Pain; Tamsulosin (Flomax) for post-radiation urinary problems; and have had one Lupron (Leuprolide) injection in conjunction with the Radiation Treatment for my Prostate Cancer. What may be the cause of the intermitent tingling and numbness in my right hand and forearm?
doctor
Answered by Dr. Dariush Saghafi 1 hour later
Brief Answer:
Radiation and LUPRON almost certainly not the cause of numbness

Detailed Answer:
Thank you for your question.

The differential diagnosis for your symptoms of numbness in the right hand and forearm is pretty extensive given your medical history. We'll come to that in a moment.

What I will say right off the bat is that there is almost no chance I would put radiation therapy up too high on the list of anything in this case for a couple of reasons.

1. Radiation therapy for PROSTATE CANCER is windowed so that it would be administered well below the cervical spine which is where we would have to get to for radiation to even have a CHANCE at affecting sensation in the hand and forearm of the same body side. Agreed?

2. Conventional wisdom says that the neurological after effects of radiation therapy as in radiation induced neuritis, neuropathy, or polyneuropathy is that symptoms don't start showing up for a minimum of 12 months after treatments started and in some peoples' belief systems even 18 months before we see significant residual effects. You didn't say exactly but the tone of your information in your note would suggest that you were taking these treatments fairly recently so that the 12-18 month window hasn't had a chance to really kick in yet.

So I would put radiation therapy as a cause WAY DOWN on the list of potential neuropathic causes.


As far as the Lupron is concerned here is a quick summary of the MOST COMMONLY seen and complained about side effects:

hot flashes, sweating, acne, rash, itching, scaly skin;
mood changes;
headache, general pain;
vaginal swelling, itching, or discharge;
breakthrough bleeding;
weight gain;
decreased testicle size; or.
redness, pain, swelling, or oozing where the shot was given.

Common Side Effects of Lupron (Leuprolide Acetate Injection) Drug ...
https://www.rxlist.com/lupron-side-effects-drug-center.htm
Rare Side Effects of Lupron

Nausea. Inability to control bowel movements, Unusually dark urine.
Itching.

As you can see Lupron is not likely a strong consideration as having side effects from the facts that it is only a 1 time dose so far which unlikely caused any side effects really...let alone a scenario of causing FOCAL numbness/tingling in a hand and forearm despite NEUROPATHY not even being a significant contributed side effect by Lupron.

As far as what it COULD be....well, if you were my patient I would take a look at you from top to bottom simply because you are cancer survivor and so whenever someone starts having some neurological changes going on, I tend to get a pretty robust workup going to try and discover as well as catch things as early as possible.

My workup for you if I were your treating neurologist to see how close we can come to understanding what's going on would to start with a GOOD HISTORY as well as doing a full review of medications being used.

Secondly, I would start the workup process by first getting some laboratory studies looking for metabolic causes of numbness such as SERUM LEVELS OF:

1. Vit. B12, Methylmalonic acid, homocysteine
2. Vit. B6, folate
3 Vit. D total, D2, and D3
4. Thyroid kick start with TSH, FT4

Next I would get imaging studies of the BRAIN and CERVICAL SPINAL CORD with GADOLINIUM CONTRAST and I would be looking anything that could represent a lesion in the brain (possible distant spread of the PROSTATE CA....it does happen for sure though we absolutely hope that wasn't the case in this case) or the c-spine causing compression of nerve roots C8/T1 on that right side.

I would check the neck with some plain films as well and/or a CT SCAN to look for other causes of nerve root compression or compromise such as bulging disks, herniated disks, etc.

This would be the workup I would proceed with in order to try and discover the actual cause of the numbness and tingling in the right hand.

And so, if I've provided useful or helpful information to your question could you do me the favor of CLOSING THE QUERY along with a few POSITIVE words of feedback and maybe even a 5 STAR rating if you feel it is deserving? I would be interested in getting some updated information on how things are going in the next few weeks if you can remember to drop me line at: www.bit.ly/drdariushsaghafi

You can always reach me at that address for this or other questions. I wish you the best with your symptoms and hope this information does help you cut through a bit of the workup steps to best figuring out this puzzle.

This query required 70 minutes of professional time to research, assimilate, and respond in complete form.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Dariush Saghafi 0 minute later
Brief Answer:
Radiation and LUPRON almost certainly not the cause of numbness

Detailed Answer:
Thank you for your question.

The differential diagnosis for your symptoms of numbness in the right hand and forearm is pretty extensive given your medical history. We'll come to that in a moment.

What I will say right off the bat is that there is almost no chance I would put radiation therapy up too high on the list of anything in this case for a couple of reasons.

1. Radiation therapy for PROSTATE CANCER is windowed so that it would be administered well below the cervical spine which is where we would have to get to for radiation to even have a CHANCE at affecting sensation in the hand and forearm of the same body side. Agreed?

2. Conventional wisdom says that the neurological after effects of radiation therapy as in radiation induced neuritis, neuropathy, or polyneuropathy is that symptoms don't start showing up for a minimum of 12 months after treatments started and in some peoples' belief systems even 18 months before we see significant residual effects. You didn't say exactly but the tone of your information in your note would suggest that you were taking these treatments fairly recently so that the 12-18 month window hasn't had a chance to really kick in yet.

So I would put radiation therapy as a cause WAY DOWN on the list of potential neuropathic causes.


As far as the Lupron is concerned here is a quick summary of the MOST COMMONLY seen and complained about side effects:

hot flashes, sweating, acne, rash, itching, scaly skin;
mood changes;
headache, general pain;
vaginal swelling, itching, or discharge;
breakthrough bleeding;
weight gain;
decreased testicle size; or.
redness, pain, swelling, or oozing where the shot was given.

Common Side Effects of Lupron (Leuprolide Acetate Injection) Drug ...
https://www.rxlist.com/lupron-side-effects-drug-center.htm
Rare Side Effects of Lupron

Nausea. Inability to control bowel movements, Unusually dark urine.
Itching.

As you can see Lupron is not likely a strong consideration as having side effects from the facts that it is only a 1 time dose so far which unlikely caused any side effects really...let alone a scenario of causing FOCAL numbness/tingling in a hand and forearm despite NEUROPATHY not even being a significant contributed side effect by Lupron.

As far as what it COULD be....well, if you were my patient I would take a look at you from top to bottom simply because you are cancer survivor and so whenever someone starts having some neurological changes going on, I tend to get a pretty robust workup going to try and discover as well as catch things as early as possible.

My workup for you if I were your treating neurologist to see how close we can come to understanding what's going on would to start with a GOOD HISTORY as well as doing a full review of medications being used.

Secondly, I would start the workup process by first getting some laboratory studies looking for metabolic causes of numbness such as SERUM LEVELS OF:

1. Vit. B12, Methylmalonic acid, homocysteine
2. Vit. B6, folate
3 Vit. D total, D2, and D3
4. Thyroid kick start with TSH, FT4

Next I would get imaging studies of the BRAIN and CERVICAL SPINAL CORD with GADOLINIUM CONTRAST and I would be looking anything that could represent a lesion in the brain (possible distant spread of the PROSTATE CA....it does happen for sure though we absolutely hope that wasn't the case in this case) or the c-spine causing compression of nerve roots C8/T1 on that right side.

I would check the neck with some plain films as well and/or a CT SCAN to look for other causes of nerve root compression or compromise such as bulging disks, herniated disks, etc.

This would be the workup I would proceed with in order to try and discover the actual cause of the numbness and tingling in the right hand.

And so, if I've provided useful or helpful information to your question could you do me the favor of CLOSING THE QUERY along with a few POSITIVE words of feedback and maybe even a 5 STAR rating if you feel it is deserving? I would be interested in getting some updated information on how things are going in the next few weeks if you can remember to drop me line at: www.bit.ly/drdariushsaghafi

You can always reach me at that address for this or other questions. I wish you the best with your symptoms and hope this information does help you cut through a bit of the workup steps to best figuring out this puzzle.

This query required 70 minutes of professional time to research, assimilate, and respond in complete form.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
default
Follow up: Dr. Dariush Saghafi 10 hours later
Dr. Saghafi: Thank you for your thorough analysis of the medical problem that I have presented. Here are some additional data points: (1) I recently had an MRI of the brain as a consequence of a temporary partial loss of vision in my left eye (diagnosis: Ocular Migraine). The MRI did not show any brain lesions, or anything else of note (thank heavens). (2) I recently had some blood work (CBC et al.), and the only unusual finding was low absolute lymphocytes (probably the result of the Radiation Treatments, which ended February 7, 2019). (3) I am taking Tamsulosin because of the urinary side effects of Radiation Therapy. (4) I have Hashimoto's Disease (hypothyroidism) which often makes me feel somewhat chilled. I do not take any synthetic thyroid medication. (5) I do take (on an irregular basis) (a) B=Complex Plus; (b) Vitamin D3 5,000IU; and (c) Alpha-Lipoic Acid as dietary supplements. The one issue that you raised which piqued my (medical) interest is the issue of hypothyroidism. Might that be the cause of the tingling and numbness in my right arm and hand? If not, I'm stumped.
default
Follow up: Dr. Dariush Saghafi 0 minute later
Dr. Saghafi: Thank you for your thorough analysis of the medical problem that I have presented. Here are some additional data points: (1) I recently had an MRI of the brain as a consequence of a temporary partial loss of vision in my left eye (diagnosis: Ocular Migraine). The MRI did not show any brain lesions, or anything else of note (thank heavens). (2) I recently had some blood work (CBC et al.), and the only unusual finding was low absolute lymphocytes (probably the result of the Radiation Treatments, which ended February 7, 2019). (3) I am taking Tamsulosin because of the urinary side effects of Radiation Therapy. (4) I have Hashimoto's Disease (hypothyroidism) which often makes me feel somewhat chilled. I do not take any synthetic thyroid medication. (5) I do take (on an irregular basis) (a) B=Complex Plus; (b) Vitamin D3 5,000IU; and (c) Alpha-Lipoic Acid as dietary supplements. The one issue that you raised which piqued my (medical) interest is the issue of hypothyroidism. Might that be the cause of the tingling and numbness in my right arm and hand? If not, I'm stumped.
doctor
Answered by Dr. Dariush Saghafi 10 hours later
Brief Answer:
As recommended in my initial answer-THYROID FUNCTION TESTS are important

Detailed Answer:
Thank you for your additional information. I've read your updates very thoroughly and would like to say that I agree with the thought that THYROID function needs to be checked carefully since you are now telling us that in fact, you're diagnosed with Hashimoto's thyroiditis. You did not say whether you take replacement for it or not. You did say that you do not take SYNTHETIC medication but perhaps you are on some form of bioequivalent. No matter. Please take a look at the copied paragraph from my previous response:

"Secondly, I would start the workup process by first getting some laboratory studies looking for metabolic causes of numbness such as SERUM LEVELS OF:

1. Vit. B12, Methylmalonic acid, homocysteine
2. Vit. B6, folate
3 Vit. D total, D2, and D3
4. Thyroid kick start with TSH, FT4"

In #4 I am specifically recommending a "kick start" check of the thyroid axis by obtaining both serum TSH and FT4 (Free T4) levels. If there is still suspicion that your thyroid function may still be low for some reason based upon clinical symptoms then, a more detailed panel can be obtained to include T3 and FT3 as well as TRH antibodies to see if the HYPOTHALAMUS may be dysfunctional which is sometimes the case.

The only thing I'm not entirely with with the thyroid "hypothesis" as being responsible for your problem is that fact that your numbness and paresthesias are only UNILATERAL. When there is a metabolic problem that is the root cause of something like numbness, tingling, pain and even weakness in a limb the more common presentations we see involve NONFOCAL affectation of the body....In other words, some OTHER part of the body becomes involved...perhaps not at the same time but at some point in a not so distant future patients will complain of something coming out of nowhere and affecting let's a foot, an ankle, part of a leg on the the opposite side. Or even affecting the torso, the shoulder, or part of the leg on the SAME side of the hand being affected. Make sense? So when there's a metabolic problem involving low hormones or diabetes or electrolyte disturbances then, multiple body parts and functions seem to be involved.

In your case there is only one very focal area of the body affected.....that is what makes me think that the ORIGIN of the problem is also FOCALLY LOCATED. Logical, yes? So we look at the brain, the spinal cord in the neck, and because the hand is involved....I might even suggest that you be screened for Carpal tunnel on that side with something as simple as asking the doctor to tap your wrist over the FLEXOR RETINACULAR area to see if a TINEL'S sign can be evoked. And if that's not positive then, the doctor could try and elicit a PHALEN'S sign to see if that hand and fingers can have their paresthesias reproduced. In those cases the next step would be to request an EMG/NCV test be done..especially if the MRI of the c-spine and everything else were to come out without any remarkable findings.

I must comment on a couple of things. I am not a particular fan of MULTIVITAMINS which have recently been looked at by studies which are showing that they are nothing more than hype and expensive ways of making oneself feel good for the most part as opposed to really doing anything that is measurably good for the body. If you are deficient in a specific vitamin or mineral then, the best and most definitive way of solving that problem is to specifically take what is missing, or use proper nutritional supplementation, or make sure other medications are not causing wasting of that particular nutrient and to fix that problem. Multivitamins, or B-complex vitamins have little to no role in either PREVENTATIVE MAINTENANCE for any nutritional deficiencies or therapeutically.

On the opposite side of the fence I see you are specifically taking Vitamin D at 5000IU's (daily I presume- you didn't specify). That is a rather high dose....Once my patients go beyond 3500IU's I start to keep them on strict monitoring....at least every 12 weeks I get a full vitamin D panel on them (Total D, D2, and D3) to make sure they are not hitting toxic levels since Vitamin D is fat soluble so unlike things such as B12, B1, or B2 cholecalciferol (Vit. D) can and does easily build to toxic levels which can cause..among other things...PARESTHESIAS, tremors, and foggy thinking. Therefore, if you've not had a Vitamin D screening in the past 12 weeks I would do one.

So, the bottom with your bottom line is that you need to get levels and you also need to think about the possibility that the elevated dosage of 5000IU could be a problem if you've only been on that dose for a relatively short time...if Vitamin D is relatively new to your regimen of medications what is the timing between when you really started escalating the dose and when these symptoms in the hand appeared? Any possible correlation?

As long as you come out to somewhere between 60-80 then, I wouldn't be terribly concerned.....if it's much more than that and especially if >100 I would stop the Vitamin D immediately and keep on a holding pattern until the next blood draw in 8 weeks to see where the levels go. It'll take a little while for them to drop since they are depot'ed in the fat stores of the body which will take time to leach out. There's nothing you can do to expedite Vitamin D from your body.

If you've not seen any improvement in your symptoms for at least a 60 day period on Alpha Lipoic Acid then, I would stop that medication...unless you are taking it for another expressed reason for which I'm unaware. I've not had a lot of success using ALA in my patients and I've probably tried at least 100 or so in the past several years. It is written to be useful for paresthesias and even pain syndromes of a neuropathic nature....but I suspect that is very anecdotal in nature and does not consistently work even in MOST people....so I've pretty much abandoned its use unless someone tells me that it definitely helps and by not taking it their symptoms return. So far, nobody of that category to report on ALA.

Once again, if I've provided useful or helpful information to your question could you do me the favor of CLOSING THE QUERY and include just a few POSITIVE words of feedback along with a 5 STAR rating if you feel it deserving? Keep me in the loop my good man on how things are going in the next few weeks by dropping me a line at: www.bit.ly/drdariushsaghafi

You can always reach me at that address for this or other questions. I hope this added information helps you and your doctors sort things out a bit more.

This query required 106 minutes of professional time to research, assimilate, and respond in complete form.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Dariush Saghafi 0 minute later
Brief Answer:
As recommended in my initial answer-THYROID FUNCTION TESTS are important

Detailed Answer:
Thank you for your additional information. I've read your updates very thoroughly and would like to say that I agree with the thought that THYROID function needs to be checked carefully since you are now telling us that in fact, you're diagnosed with Hashimoto's thyroiditis. You did not say whether you take replacement for it or not. You did say that you do not take SYNTHETIC medication but perhaps you are on some form of bioequivalent. No matter. Please take a look at the copied paragraph from my previous response:

"Secondly, I would start the workup process by first getting some laboratory studies looking for metabolic causes of numbness such as SERUM LEVELS OF:

1. Vit. B12, Methylmalonic acid, homocysteine
2. Vit. B6, folate
3 Vit. D total, D2, and D3
4. Thyroid kick start with TSH, FT4"

In #4 I am specifically recommending a "kick start" check of the thyroid axis by obtaining both serum TSH and FT4 (Free T4) levels. If there is still suspicion that your thyroid function may still be low for some reason based upon clinical symptoms then, a more detailed panel can be obtained to include T3 and FT3 as well as TRH antibodies to see if the HYPOTHALAMUS may be dysfunctional which is sometimes the case.

The only thing I'm not entirely with with the thyroid "hypothesis" as being responsible for your problem is that fact that your numbness and paresthesias are only UNILATERAL. When there is a metabolic problem that is the root cause of something like numbness, tingling, pain and even weakness in a limb the more common presentations we see involve NONFOCAL affectation of the body....In other words, some OTHER part of the body becomes involved...perhaps not at the same time but at some point in a not so distant future patients will complain of something coming out of nowhere and affecting let's a foot, an ankle, part of a leg on the the opposite side. Or even affecting the torso, the shoulder, or part of the leg on the SAME side of the hand being affected. Make sense? So when there's a metabolic problem involving low hormones or diabetes or electrolyte disturbances then, multiple body parts and functions seem to be involved.

In your case there is only one very focal area of the body affected.....that is what makes me think that the ORIGIN of the problem is also FOCALLY LOCATED. Logical, yes? So we look at the brain, the spinal cord in the neck, and because the hand is involved....I might even suggest that you be screened for Carpal tunnel on that side with something as simple as asking the doctor to tap your wrist over the FLEXOR RETINACULAR area to see if a TINEL'S sign can be evoked. And if that's not positive then, the doctor could try and elicit a PHALEN'S sign to see if that hand and fingers can have their paresthesias reproduced. In those cases the next step would be to request an EMG/NCV test be done..especially if the MRI of the c-spine and everything else were to come out without any remarkable findings.

I must comment on a couple of things. I am not a particular fan of MULTIVITAMINS which have recently been looked at by studies which are showing that they are nothing more than hype and expensive ways of making oneself feel good for the most part as opposed to really doing anything that is measurably good for the body. If you are deficient in a specific vitamin or mineral then, the best and most definitive way of solving that problem is to specifically take what is missing, or use proper nutritional supplementation, or make sure other medications are not causing wasting of that particular nutrient and to fix that problem. Multivitamins, or B-complex vitamins have little to no role in either PREVENTATIVE MAINTENANCE for any nutritional deficiencies or therapeutically.

On the opposite side of the fence I see you are specifically taking Vitamin D at 5000IU's (daily I presume- you didn't specify). That is a rather high dose....Once my patients go beyond 3500IU's I start to keep them on strict monitoring....at least every 12 weeks I get a full vitamin D panel on them (Total D, D2, and D3) to make sure they are not hitting toxic levels since Vitamin D is fat soluble so unlike things such as B12, B1, or B2 cholecalciferol (Vit. D) can and does easily build to toxic levels which can cause..among other things...PARESTHESIAS, tremors, and foggy thinking. Therefore, if you've not had a Vitamin D screening in the past 12 weeks I would do one.

So, the bottom with your bottom line is that you need to get levels and you also need to think about the possibility that the elevated dosage of 5000IU could be a problem if you've only been on that dose for a relatively short time...if Vitamin D is relatively new to your regimen of medications what is the timing between when you really started escalating the dose and when these symptoms in the hand appeared? Any possible correlation?

As long as you come out to somewhere between 60-80 then, I wouldn't be terribly concerned.....if it's much more than that and especially if >100 I would stop the Vitamin D immediately and keep on a holding pattern until the next blood draw in 8 weeks to see where the levels go. It'll take a little while for them to drop since they are depot'ed in the fat stores of the body which will take time to leach out. There's nothing you can do to expedite Vitamin D from your body.

If you've not seen any improvement in your symptoms for at least a 60 day period on Alpha Lipoic Acid then, I would stop that medication...unless you are taking it for another expressed reason for which I'm unaware. I've not had a lot of success using ALA in my patients and I've probably tried at least 100 or so in the past several years. It is written to be useful for paresthesias and even pain syndromes of a neuropathic nature....but I suspect that is very anecdotal in nature and does not consistently work even in MOST people....so I've pretty much abandoned its use unless someone tells me that it definitely helps and by not taking it their symptoms return. So far, nobody of that category to report on ALA.

Once again, if I've provided useful or helpful information to your question could you do me the favor of CLOSING THE QUERY and include just a few POSITIVE words of feedback along with a 5 STAR rating if you feel it deserving? Keep me in the loop my good man on how things are going in the next few weeks by dropping me a line at: www.bit.ly/drdariushsaghafi

You can always reach me at that address for this or other questions. I hope this added information helps you and your doctors sort things out a bit more.

This query required 106 minutes of professional time to research, assimilate, and respond in complete form.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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