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What causes muscle weakness, facial droop, fine motor skills difficulty and double vision?

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Posted on Thu, 14 May 2015
Question: I've had 2 episodes of muscle weakness, lid lag, facial droop, fine motor skills difficulty double vision with blind spots, balance issues, hoarse and stecaato speech, bradykinesia, and even confusion which started within the 2 weeks after taking Humira and worse by 3rd and 4th week which required hospitalization. Stroke like symptoms. mri, ct and acetlycholine test negative. No immune testing or EMG done. no lumbar puncture during the 3 and 4th week which were most severe to point of altered mental status lasting about 2-3 days. What sort of differential could these sxS represent and what priority of testing should be done. I don't know what this is but there has to be an explanation go the changes. I have stopped Humira. Thank you!
doctor
Answered by Dr. Naval Mendiratta (1 hour later)
Brief Answer:
Demyelinating lesion

Detailed Answer:
Good evening

Thank you for writing on health care magicc

Well the sort of symptoms you are having are related to the Central Nervous system and Humira( Adalimumab) can at times cause demyelinating lesions in the brain. Although it is not a common side effect, it is still known and hence precautions are taken in giving it to patients with disease like Multiple Sclerosis or GBS.

But yes, I would advise you to get a Lumbar Puncture done to rule out any subclinical infections like a viral one. The most common being JC Virus. It normally will show up on the MRI, but if it hasnt either a repeat MRI or a lumbar puncture is needed.

Secondly, Anti TNF agents can produce ANA positivity and cause drug induced lupus. But nuerological symptoms are very rare in drug induced lupus.

I would like to know how are your symptoms currently since it has been a month. Are they getting better or is it still the same or worse?
My differential would be a viral infection first and then the rest.

Do let me know these queries and further doubts. Would be happy to answer you further

Regards
Dr Naval
Above answer was peer-reviewed by : Dr. Shanthi.E
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Follow up: Dr. Naval Mendiratta (20 minutes later)
I was hospitalized 7 days ago and just started to feel better today. Balance, fine motor, simple tasks and weakness still present but less. Do you think its wise to see rheum. Ive seen two neurologists and was told complex headache and conversion do! I wasnt under any major stress and no traumas. Exam was reflexes, strenth and walk- less then 10 min visit. Can seizures do this? What type of doctor would do the lp?
doctor
Answered by Dr. Naval Mendiratta (39 minutes later)
Brief Answer:
? Demyelinating Lesion

Detailed Answer:
Good evening

Well, that is good that you are feeling better. I am not too sure about the diagnosis of complex headache or conversion especially if the history is quite typical of episodes starting after Adalimumab. Seizures can also do this, but the episode doesnt last so long with it. If you are feeling better, it is a good sign and we can wait for the Lumbar puncture. Normally a Neurologist only carries out the procedure, that is if they think it is some infectious cause.

But yes, let your rheumatologist know the problems you experienced. They will be more versed with the complications of the medications and will be careful not to choose the same class of drugs in the future. Also, just discuss with your neurologist regarding a viral infection triggered by Adalimumab.The good part, you are getting better.

Hope the information was useful

Do let me know for more queries

REgards
Dr Naval
Above answer was peer-reviewed by : Dr. Shanthi.E
doctor
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Follow up: Dr. Naval Mendiratta (31 minutes later)
Does mri always show ms? Also, im
doctor
Answered by Dr. Naval Mendiratta (6 hours later)
Brief Answer:
MRI findings

Detailed Answer:
Good evening

Well, mostly yes..The symptoms a person has normally collaborates with the lesions in the brain in Multiple Sclerosis. One ends to see multiple spots around which gives us a clue. Rarely, one may not pick up MRI findings which can then be ruled out with Lumbar puncture to look for oligoclonal bands. Plain MRI may not pick up a viral infection unless done with Contrast or one has a high suspicion for meningitis.

It is definitely an Usual case to have such side effects after Adalimumab. I have only read about it as of now, but never got to see it yet in our daily practice.

Do let me know about your queries

Would be happy to help out

Regards
Dr Naval
Above answer was peer-reviewed by : Dr. Pradeep Vitta
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Follow up: Dr. Naval Mendiratta (1 hour later)
Does conversion disorder have mild syptoms in between episodes? For instance, fine motor trouble like texting and knocking things over, balance issues when closing eyes or on one foot, and headaches?
doctor
Answered by Dr. Naval Mendiratta (3 hours later)
Brief Answer:
? Conversion disorder

Detailed Answer:
Good evening

Well conversion disorder is more of a diagnosis of exclusion, that is we have done all the tests and they are negative so we label it as a Conversion disorder. But as you said you are not under any stress or anything, it may be less likely a possibility as Stress is a major factor which causes this disorder. Secondly, if there is a link between Adalimumab and your symptoms it again decreases the possibility of conversion disorder. It can still be, but yes after we are fully sure there is nothing serious going on.

Regards
DR NAval
Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
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Follow up: Dr. Naval Mendiratta (20 minutes later)
Ok- i believe that something more us going on, and humira has made it more prominent. Ive stopped the humira at the rec of my dr. I see rheum May 7th. Would early myopathies and early ms always have neuro exam findings? Im sorry to keep asking but i want to get to the bottom of whats going on. I am sending you a picture of me 2 weeks before this episode happened and the second picture, shows the eye and face issue which is slowly getting better. Would the things you think this may be cause eye lid and facial weakness?
doctor
Answered by Dr. Naval Mendiratta (49 minutes later)
Brief Answer:
Pictures

Detailed Answer:
Good evening

The symptoms you have described do not fit in with myopathy , as myopathy usually presents with muscle aches and difficulty in getting up from squatting position.You have more of the motor and sensory symptoms along with history of loss of balance.

Early MS does have initial examination findings but it can disappear with time. There are 4 variants of MS and the most common being Relapsing REmitting( i.e. You have a single episodes, it disappears with time and then you are normal in between the episode, but it reappears again few months or years later). Others are progressive ones, and we dont expect that you will improve from it without treatment( if the diagnosis is really MS). They have already ruled out the possibility of Myaesthenia Gravis as well.

As for the pictures, I received only 1 and the other was a MRI report. Could you please re attach it again, so I can have the look.

But yes, if you are improving I would like to wait and repeat a scan later on to look for any new findings if they crop up.

Do let me know when you attach the pictures

Regards
Dr Naval
Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
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Follow up: Dr. Naval Mendiratta (19 minutes later)
So, i am reading the mri report and ct which shows hypersensity of the basilar tip- the dr saw it on ct as well and said it was something to be "gorked out" which i was. I was confused and forgetful. Both episodes, caused about a 2 day timeframe of this. my regular doctor saw me withing that time frame and said "you are presenting like a stroke, i will call for an ambulance or walk you to the hospital myself". The hospital is behind his office but that is how concerned he was while it was occuring. What are your thoughts on mri and ct report. If it acts like a stroke and you have that radiology finding, then why was it brushed off?
doctor
Answered by Dr. Naval Mendiratta (15 hours later)
Brief Answer:
ct findings

Detailed Answer:
Good evening.

Sorry for the delayed reply. Was on emergency duty. Well I have read the ct findings. It is a very non specific thing which they didn't focus on. As mentioned it is just a hyper intensity. As such it does not collaborate with the symptoms you had. As you know everyone part of brain manifests as a different clinical features. Since your symptoms didn't fit in with the area involved it wasn't given much importance

Secondly it is always better to repeat the MRI after a couple of months to know how the other disease intensity is.

My other school of thought was ..was it a transient ischemic attack, as you have mentioned the doctor saw you in a very distressed state. It is a self.limiting thing with no residual defect and quick recovery with hardly any MRI findings. You can discuss this out as well and get worked up for ANA and antiphospholipd syndrome. This is just another school of thought.

Do let me know for more queries

Regards
Dr naval
Above answer was peer-reviewed by : Dr. Pradeep Vitta
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Dr. Naval Mendiratta

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What causes muscle weakness, facial droop, fine motor skills difficulty and double vision?

Brief Answer: Demyelinating lesion Detailed Answer: Good evening Thank you for writing on health care magicc Well the sort of symptoms you are having are related to the Central Nervous system and Humira( Adalimumab) can at times cause demyelinating lesions in the brain. Although it is not a common side effect, it is still known and hence precautions are taken in giving it to patients with disease like Multiple Sclerosis or GBS. But yes, I would advise you to get a Lumbar Puncture done to rule out any subclinical infections like a viral one. The most common being JC Virus. It normally will show up on the MRI, but if it hasnt either a repeat MRI or a lumbar puncture is needed. Secondly, Anti TNF agents can produce ANA positivity and cause drug induced lupus. But nuerological symptoms are very rare in drug induced lupus. I would like to know how are your symptoms currently since it has been a month. Are they getting better or is it still the same or worse? My differential would be a viral infection first and then the rest. Do let me know these queries and further doubts. Would be happy to answer you further Regards Dr Naval