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Severe sleep apnea, torn miniscus, had pneumonia, word slurring, dizziness. Has arthritis in his sternum. Now what?

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Hello, my husband is a 38 y/o white male, 6'1, 235lbs but in very good shape and currently has 48inch shoulders and 38inch waist now but he's gained 20lbs in the last 4 months so his waist has gained 4 inches in that time. He smokes a pack a day for 20 years. Does not drink alcohol at all. No drug use. No DM. He's active military - Navy Chief.

Hx: He has severe sleep apnea [diagnosed 2 weeks ago, CPAP on its way], tennis elbow, another torn miniscus, constant severe pain in both knees and both hips [multiple xray and MRI have both come back clean and hisdoctors are dumbfounded]. He has had knee surgery for torn miniscus 3 years ago, has had pneumonia 5 times, food poisoning on the boat 7 times and the "Mystery XXXXXXX Flu" that apparently everyone on the XXXXXXX XXXXXXX gets 10-30 days afterboarding the ship [but he hasn't been on the XXXXXXX for over a year and a half. He said he's had the weird tingling for several years but it usually "comes and goes" lasting about 5-15 minutes but now, there is swelling which has never happened before. He has been ruled out for CHF, RA, SLE, MS. His family has NO Hx of CHF, CVA, cardiac problems, no arthritis, no DM. He complains of constantly being exhausted and occasional spouts of feeling "high" [for like of a better description] where he feels he has a head full of wool, like feeling like being REALLY drunk but knowing he shouldn't feel that way, the low cognitive skills, word slurring, dizziness. His mother did tell me that she has had the same tingly/prickley sensation in her right arm so I don't know if there's a genetic factor. He sporadically gets ocular migranes [he can have none foryears then about 10x a month to 4 a day in a month] His cholesterol is normal, he does not have high BP, no fevers [other than the pnuemonia and foodpoisoning, he's never sick, no fevers, no rashes, no swollen lymph nodes, no bilateral pain, no seizures, no strokes, etc.
He has been complaining of many things but the real complaint is the major pain in his right arm. His right arm is swollen [shoulder to finger tips], and the swelling has been ongoing for about a month. He described the feeling in his arm as 3 stages: stage 1, desensitizing sensation that starts in the tip of his thumb, then goes to the first finger to the pinky o the had. Stage 2: cold tingling/prickely sensation tstarts to rapidly spread to his entire hand. Stage 3: the tingling sensation spreads to his entire arm almost instantly and his entire arm up to his shoulder and then the entirearm feeling like it is on fire along with numbness and tingling. The tingling and burning is reported on a 10/10 pain scale continuing for about a month. The doctors have done extensive EKG's, full blood panels, XXXXXXX panels, thyroid panels... they've pretty much ruled out many possible diseases/syndromes but noone can tell us wha he's got. His shrink thinks he also has sjogren's syndrome because he's always drinking something otherwise his lips dry out and he feels like his eyes are full of sand.

Meds: He has been Rx'd Motrin,and Vicodin for the pain but he rarely takes the vicodin. Prior, he was Rx'd Celebrex because he had pain in his back, knees, and 2 nuckles but his MD took him off of it after a month because that's when we estimate the symptoms started and she wasnt sure if his symptoms may have been caused by Celebrex. Now, a month off of Celebrex, his symptoms continue.

Currently, he's in constant pain ranging 7/10 to 10/10 constantly. His Rheumatologist has ruled out OA and RA but said he has arthritis in his sternum [I'm not a doctor but it's the first timeI heard that one], and his 3rd and 4th right fingers, along with tennis elbow in this right arm. He is fatigued all the time, he now has mood swings because of the constant pain, and all his doctors don't know what's wrong with him other than the 90% chance he has Sjogrens.
He has had XRAY's of right shoulder, neck, spine [lumbar, thorax, and cervical], both knees, right elbow, and right wrist - all reports stating "no significance" and 3 doctors and a chiropractor all say there's no evidence of abnormalities.

He had MRI to Right shoulder, neck, spine [cervical and thoracic], both knees, and right ankle - all findings came back as "no evidence of abnormalities"

Rheumatologist ruled out OA, RA, SLE with XXXXXXX panel, RH factor was 14, XXXXXXX tendon reflexes are normal, the fingers - he has had consistant pain, swelling, and can't hold a wrench for more than 10 minutes when working on planes or cars.
They have him scheduled for nerve conduction study next week. The rheumatologist said he had arthritis in his sternum after pressing different spots on his chest and pinpointing the spots that really hurt. Regarding neck pain, he said he always had someneck/backpain for the last 15 years but MRI's and Xrays always come back clean. The pain extends only tohisshoulder and does not reachthe neck. No pinched nerves or slipped disks. The pain in his arm is not brought on by exercise but it worstened by lack of motion. He says the pain gets better if he stands up and raises his hand and shakes it for several minutes [for some reason, sitting down and shaking his arm doesn't help.
He does not have tender spots, he's not depressed [but everyday our 16 year old drives us both up the walls so stress is pretty much elevated constantly]. As for his sleep, he was diagnosed with severe sleep apnea a couple weeks ago and we are waiting for the CPAP to come. The sleep study came back saying he actually goes into REM sleep for 20-45 minutes total per night so I know that's not helping. The oxygen deprivation at night and lack of sleep is definately taking a toll on him, combined with daily stress of our [very angry and moody] son keeps him in a "not so great" mood. We had a serious open conversation about depression because he has had it in the past and was taking Welbutrin for some time until it sent his BP soaring to 190/110 [I thought hypertensive crisis territory personally but the MD at the Emergency Room diagnosed him with Headache of Unknown Origin and sent him home]. I called his psychiatrist and she weaned him off over a period of 10 days - but this was about 6 months ago. Since he was off that, she put him on Celebrex for the joint pain and Zoloft but then the arm pain started so she was concerned that Celebrex could be causing it so she discontinued the Rx but his symptoms persisted. That's when she took him off everything, thinking that there is something going on and we don't want meds masking symptoms that may otherwise be there and this entire diagnosis journey started.

That's the long story that brings me here hoping for some kind of answers and suggestions. He is now scheduled forthe nerve conduction study, then I want him to consult with a neurologist, cardiologist, and as many "ologists" as it takes.

He has been ruled out for DVT, his platelets and WBC counts are well within normal limits, with platelets at 200,000 [normal is considered 150,000 to 350,000], and negative Homan's sign. They have not done a Doppler on his shoulder/arm when he went to the Emergency Room, the doctors there gave him analgesics and toldus they do not do diagnostics and his bloodwork did not suggest DVT.

I do not know if they checked him for cervical spondylosis, is that something that would be seen with xrays or MRI? I would assume that he would have chronic neck pain or that Xray or MRI would show something. I asked him again this morning about the neck pain and he said he actually has not had neck pain but if he overworks his back, he will get XXXXXXX muscle pain in between his shoulder blades and if he REALLY overworks hisback, it will hurt to the point where he cannot twist or reach over.

I looked at his right leg this morning and I think the right side or his body is swelling because he now has 2 blisters on his right foot from where the top of his boots rub. I checked for pitting edema and it's not pitting, maybe almost a 1 on a 1-4 scale but he said he did not notice until just today. There is no pain, reddness,coldness, no tingling, no abnormal sensations but I'm sure swelling is not normal, and it's only the right foot. I checked Homan's just in case and it's negative.

He brought back some lab work results his Rheumatologist gave him. I don't know if it will help but here are the results:
RF - 9.7 [normal is 0-13 IU/mL]
ESR - 14 [normal is 0-15 mm/hr]
glucose - 91 [normal is 75-110]
BUN/Creat, Na,K, Cl,CO2, and CA all within normal limits
Protein total 7.7, albumin 4.1, AST 25, ALT 41, Alk Phos 93, bilirubin 0.8,
TSH 2.16.

RNP ENA -negative XXXXXXX ENA- negative
SSA AB- negative
dsDNA- SLE 45%, SLE 28%, MCTD 12%, SJOGREN'S 6%, SCLERO 9%, POLYMYO <2%
Centromere - SLE 12%, SLE 3%, MCTD 7%, SJOGREN'S <2%, SCLERO 27%, POLYMO <2%

DNA DS AB- 1 [normal is 0-4]
XXXXXXX SCR - Positive H

That's his latest labs for the last weeks.

Again, thank you so much for your continued help and advice through all this. Your input is really very helpful.
Posted Sun, 1 Jul 2012 in General Health
Answered by Dr. Chakravarthy Mazumdar 8 hours later

Thank you for a valuable description.

The issues are more about the right arm pain, tingling and numbness apart from the severe sleep apnea. It couples with some stress in life which definitely makes the living intolerable and unable to do daily activities. I could note that there are joint problems coupled with tennis elbow.

I am happy that the major systems were functioning well. There is no danger detected to the life given a thorough assessment was already done.

So let us discuss about the arm pain alone. Thanks for your beautiful description of the swelling (up till shoulder from the tip) and pain in the arm.

Stage 1, desensitizing sensation that starts in the tip of his thumb, then goes to the first finger to the pinky of the hand. Stage 2: cold tingling/prickly sensation starts to rapidly spread to his entire hand. Stage 3: the tingling sensation spreads to his entire arm almost instantly and his entire arm up to his shoulder and then the entire arm feeling like it is on fire along with numbness and tingling.
You had given us a good description of the pain but the description is not associated with a single condition that can figure it out.

You should also understand my limitations here. Your husband's doctor had the opportunity to examine and follow up with him to compute the possibilities and plan the therapy.

My assessment goes thus:
The problem appears to be localized to the arm alone. The work up came back normal. We should rule out Nerve conduction tests). A color Doppler should be worthwhile to understand the vascular channels.

The Rheumatology panel has few interesting facts with SSB positivity. Sjogren's syndrome are high as per the blood results. This may be untrue as there are no other symptoms as per its text book description.

Among the possible causes I would also wish to associate the problem with the following conditions which may be worth considering:
Fibromyalgia – Painful spots on the chest
Hyperventilation – short history of sleep apnoea
Migraines and
Deficiency of some B vitamins

I will also try to take some curbside consults with my colleagues and let me know if anything else takes a priority.

All the best.

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