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    What do my lab test results indicate?

Posted on Fri, 27 May 2016 in Brain and Spine
Question: 33 years old, female, mostly healthy, except uterine fibroids and often herpetic infections of lips. In family no serious diseases.
In 2012, I began experiencing pain in the left leg when applying mechanical pressure on it (when sitting, when would cross legs or wear tight pants) accompanied by over-sensitivity and a "pulsating feeling" in the front plantar part of the left foot (especially the last three toes). I was extremely sensitive to any type of contact with the forefoot and sensitivity when moving the said toes. I have to stretch the left leg when sitting for a longer period of time (e.g. at work or after a long car ride) after which the issues with the leg/foot would decrease. I noticed that my last three-four toes of the said foot are occasionally more bent than those on the other foot. I was having constant feeling that those toes will twich, and occasionally while in standing still position (not moving) the toes would jerked minimally. I noted how, often when I had fevers due to some virus infections, or when I had any acute pain in my body, issues with the foot would decrease, but after the withdrawal of the symptoms of acute viral infections, the issues related to the foot would become even more pronounced and then would back in usual “sensitivity-pain range”. I tried to reduce the symptoms with Diazepam and Xanax but with zero effect.
Since the said foot issues had not decreased, I had in the early 2014 self-initiatively done a brain MRI, MRI of the neck, thoracic and lumbar spine, MR of the pelvis, EMNG of lower extremities, CDFI of arteries and veins and tests regarding thyroid hormones.
The results were regular except for:
CDFI of arteries and veins (Jan 13, 2014) god: „Left saphenophemoral junction insufficient, together the valvular apparatus of the GSV, Dg. Insuff. GSV l.sin. “.     
EMNG with surface electrodes (Feb 18, 2014) „Sensory conduction velocity slightly slower in both superficial peroneal nerves, more to the left where the amplitude of SNAP (with colder feet) is also reduced. Result was suspect for easier axonal injury of the distal parts of both, especially the left superficial peroneal nerve, but this is probably the primary issue of the impact of the low surface temperature of the feet skin. I would recommend control neurographic treatment in 6 months, in case of need, earlier.”
A repeated EMNG of the left foot with surface electrodes (Feb 21, 2014) showed good results.
MRI of the lumbar spine showed minimal herniation of the disc on the level L3-L4, on the left.
MRI of the pelvis minor (Oct 21, 2014.): “a number of leiomyoma along the corpus: isthmus mural on the left (3 cm in size), anterior mural (1.1 cm), next to the corpus left sub serous (1.7 cm), left dorsal sub serous (2.8 cm), right posterior two mural (1.7 and 1.5 cm). About 5 cm large leiomyoma shows to the right with a horn and fundus, possible sub serous or in ligament. "
Further examinations were not done at the moment, nor later.
I had, with the given test results, scheduled an appointment with a neurologist on March 4, 2014 who then, due to the above test results, diagnoses me with “Dysautonomia secundaria”(Dysfunction of autonomic nerve system) she explains me how I am having serotonin dysbalance and suggests to take serotonergic therapy. The doctor disregards other clinical disorders such as the “restless leg syndrome” and dystonia due to asymmetry and due the insufficient motoric characteristics for the said dystonic disorder. The therapy includes Clonazepam ¼ 2mg, Cipralex (Escitalopram) ½ 10 mg and Deanxit 1 tablet. The dosage in the following year reaches XXXXXXX 1-2 mg of Clonazepam a day, 2x10mg/2x5 mg of Cipralex and 2 tablets of Deanxit a day.
My symptoms in the foot decreased symptomatic only due to the Clonazepam therapy, and not due to the serotonergic therapy, because when I would not use Clonazepam, the issues would be equally pronounced. The effect of the serotonergic therapy I would describe as sedating and relaxing, but with no effect on the interference with the foot. Later I was switched to Cymbalta 60 mg that has also zero effect on my foot. But I am still taking it due to horrible withdrawal side effects that I have experienced when try to stop using it.
By retrograde thinking, I had only recently remembered how before the appearance of the issues I had a skin injury of the fingers of the same foot (I had independently treated around 20 warts located between the toes and the plantar part of the foot, which had caused an injury and inflammation of the skin of the treated forefoot. My foot throbbed at the time, and I could not touch the forefoot to the ground for 1 to 2 weeks). At the beginning I haven’t connected that with later difficulties with the same foot, but now I have realized that the interference did not exist prior to the injury, and that the sensation of the foot have occurred in the same area where the skin was injured.
It has been three years since my problems begun, everything is the same, I am only reducing those problems with Clonazepam.
Please write me your opinion.
Answered by Dr. Olsi Taka 2 hours later
Brief Answer:
Read below.

Detailed Answer:
I read your question carefully and I understand your concern.

The hypothesis that you raise is a sensible one. The fact that the symptoms appeared after that episode can not be overlooked. The injury and treatment you received may have lead to damage of peripheral nerve endings. As a result there may result sensitive symptoms as well as the bending you describe, due to a weakness of some of the many small muscles innervated by the damaged nerves. Damage of these very peripheral small nerves can't be detected by nerve conduction studies you've had, they can only study nerves of a bigger caliber.

If I had to think of other possible diagnoses, given the many exams you've had evidence nothing which justifies that symptom and I suppose local exam doesn't reveal any orthopedic issue, I would consider only dystonia. I understand your neurologist doesn't agree, I wouldn't completely rule it out though, given also the response to Clonazepam. I would have given a try to botulinum toxin injection.

As for the dysautonomia diagnosis, I am not sure about that, perhaps it was though of due to other findings on neurological history and exam as I do not see the relation with this one specific issue.

I remain at your disposal for other questions.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Olsi Taka 24 minutes later
My clinic neurological examination was without any irregularities. Neurologist told me, considering long lasting symptoms, that it is impossible that diagnosis is Dystonia, because I would already have
some significant motoric problems.
1. Can you explain me more about Dysfunction of autonomic nerve system (Serotonin Dysbalance) - diagnose that neurologist gave me?
I'm asking this because I had other opinion from Psychiatrist who said "This diagnose is only psychosomatic". Can this symptom be psychosomatic?
I don't have any psychological issues. In the past I had short period of anxiety, which was successfully resolved with short Xanax therapy. When symptoms with foot started I have tried to take Diazepam and Xanax few times,
which is very anxiolitic for me, but didn't affect my foot problems. The first 1 Mg of Clonazepam that I took, immediately relived toes sensation.
2. Is there any conclusion or diagnostic meaning we can take from effect of Clonazepam?
3. I haven't visited Orthopaed or any other specialist. Is it possible that orthopaedic disease could cause these symptoms?
4. Also, is there any conclusion or diagnostic meaning from the fact that symptoms disappear when I have infection or other acute pain?
5. Which EMNG device could note or register such a small nerve damages, if that is possible cause?
Answered by Dr. Olsi Taka 44 minutes later
Brief Answer:
Read below.

Detailed Answer:
Thank you for your feedback.

1. Regarding the "serotonin dysbalance"....I didn't want to dwell too much on that, because I would have to guess the thoughts of my colleagues. But yes, that term indicates a psychological origin of the manifestation. The medication you were given (Cipralex and Cymbalta as well) are medication commonly used for anxiety and depression, their effect results from raising serotonin levels.
Dysautonomia is another issue and I do not think is related to your problem.
Whether such a symptom can be psychosomatic....any symptom can be psychosomatic, anxiety can mimick virtually any symptom, some more commonly some more rarely. I wouldn't put it as the most likely diagnosis in your case, but all us doctors when we fail to find an identifiable explanation, do consider a psychosomatic origin, at times we are right at times perhaps it is just due to our or modern medicine limitations in understanding every manifestation. In a way I myself am not offering a definitive explanation either.
As for the fact that Clonazepam worked and Xanax not, that logic applies in both directions, they belong to the same benzodiazepine class and Xanax or Diazepam so whatever the cause they should all work or not. But it may happen that some patients are more responsive to one representative of a particular class than the other.
2. The above being said Clonazepam is more used than other benzodiazepines for movement disorders like dystonia, which is why I made that remark. But its applications are many though, it acts as a muscle relaxer in general, is used also in epilepsy (not that I am saying that is your case).
3. Local issues like cysts, benign tumors, thickening of connective tissue may cause local symptoms, but pain would be more prominent and contractures persistent not fluctuating, so I do not think that very likely, I believe your doctors must already have considered that.
4. The disappearing when you have other medical issues is puzzling. Actually it would go towards the psychosomatic hypothesis rather than other conditions, the fact that symptoms improve when your mind is busy with other stuff and you're not thinking about that.
5. There isn't a device which can prove that unfortunately, in fact there are many neuropathies involving the small fibers which can not be electrically measured.

As for the exclusion of dystonia due to lack of other symptoms, I wouldn't be that sure as there are so many different types of dystonia, a manifestation often not well understood. That is why I XXXXXXX I would have made a botulinum toxin trial. The fact symptoms have remained limited though are anyway reassuring in terms of prognosis, in the sense that any progressive neurodegenerative movement (of which dystonia or muscle cramps, twitches could be a part) is excluded by lack of progression over these years.

Let me know if I can further assist you.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Olsi Taka 10 days later
The neurologist who gave me Dg. of serotonin imbalance was the first and the last doctor I have visited regarding my leg problem. I was so scared thinking I am having MS or I would get Dystonia disease that I was so relieved when she said it’s nothing wrong with you, that is just serotonin imbalance, i will give you antidepressants-not because I think you are depressed, it’s because those are the only pills who affecting serotonin that is going up and down in your brain and causing your pulsation feelings of the foot. She has never asked me did I have injury and I have never mentioned that. She said serotonin imbalance affects many young people, it is caused by stress. Take this pills for a while and everything will go away. That sounds so logical for me. She gave me Deanxit, Escitalopram 10 mg and 0.5 mg Clonazepam. First evening when I took Clonazepam that immediately reduced sensation in the foot. I thought, OMG what a clever doctor. Next year she increased antidepressants to 2 Deanxit + 20 mg Escitalopram-DAILY! That didn’t effect my foot sensations, I was taking more and more Clonazepam (1-2 mg XXXXXXX ) to reduced sensation. She was keeping telling me Clonazepam is just symptomatic therapy, you have to take more antidepressants to stabilize your serotonin. She has never suggested any other diagnostic tests, it was enough for her that one EMNG (with superficial electrodes) and MRI of the brain/spine were ok. I didn’t have any blood tests, I didn’t have EEG not to mention anything else. That is just small part of that neurologists work.
1.     Can you explain me, does even that Dysfunction of autonomic nerve system exist –can it be caused with serotonin imbalance?
2.     Can you suggested me what other diagnosis should be rule out
3.     Is there any way I could prove that my symptoms are caused with that injury of the foot I had (skin biopsy? nerve biopsy? some other advantage diagnostic tests anywhere in the world?)
4.     My symptoms have started 4 years ago, if I damaged any of that small nerves is there any possibility for recovering them or this is now permanent state?
5.     I don’t know why sometimes when I had high fever that little decreased symptoms, but what I know is, that has absolutely nothing with my attention. When I have noticed that (maybe is just coincidence I don’t know) me, my husband and family were make all attention to my foot, because we couldn’t believe why now were symptoms decreased
6.     The most similar to my symptoms that I could researched would be „PAINFUL LEG AND MOVING TOES SYNDROM“. Can you tell me more about it? I know it’s treated with Botox.
7.     Let me do feedback to my symptoms: during „injury” of the plantar part of the foot and skin between toes I felt pulsation feelings of the left foot. Later I have developed pain in whole left leg especially posterior and lateral part of the leg, (from gluteus). Symptoms are going to the roof when I am in sitting position. I am having feeling that long sittings „decreasing oxygen to my leg nerves“, and after long sitting small, little jerks of toes would happened. Those are very small jerks of the toes and its happening every few minutes or, few of them/per hour. But that jerks are happening rarely, in days that I spend in sitting position, especially in car, in car is the worst, or long sitting at work. Immediately when I stretch my leg symptoms decrease. Pain in leg completely disappear when I start walking, but different sensation in forefoot stays all the time, especially in last 3 toes that are more bend then toes on other foot. The worst of all is constant tension and oversensitivity in that toes when I am standing still (sitting, or lie in bed). Tension that feels like every second some of the toes will jerk. I had to compress those toes to reduce that tension. My neurological exam is completely ok, no dermatome change in feels, vibration feel is the same on both foot (8/8), no color change.

Thank you in advance
Answered by Dr. Olsi Taka 4 hours later
Brief Answer:
Read below.

Detailed Answer:
Hello again!

1. Dysfunction of the autonomic nervous system is a diagnosis, but I don't really see what does it have to do with your case. Autonomic nervous system controls blood pressure, heart rate, sweating, digestion etc, functions our body does autonomously without us thinking about it. Most commonly its dysfunction manifests with orthostatic hypotension. May be other manifestations but won't go in depth as it doesn't seem to be related to your symptom really. As for serotonin imbalance it is not a separate diagnosis, but serotonin imbalance is thought to be part of issues such as anxiety or depression, hence drugs which raise serotonin levels like Escitalopram are often used for anxiety apart from depression.

2. The other diagnosis is dystonia. Would have been also nerve compression, but with normal ENG unlikely.

3. Skin biopsy may provide some more information, there are no other tests.

4. Unfortunately no, if there is nerve damage most recovery happens during first year, afterwards further recovery unlikely.

5. As I said I was puzzled about the disappearance with fever and can not offer an explanation apart from the symptoms being due to anxiety and fever episodes removing your focus.

6. As for "painful legs and moving toes" it is a sensible hypothesis. The pain is more severe than what you describe it though, usually described as "deep, burning, throbbing, cramping" etc, while you speak more of oversensitivity or pain on pressure. It is a valid hypothesis though. It remains a mysterious disorder (as the name which is merely a description might suggest) it is not well understood, its cause not well known. It has been linked with nerve root or peripheral nerve damage, but your lumbar MRI and nerve conduction studies do not support that. One thing that might interest you is that among factors linked with it is listed also local trauma (which could be your skin injury). As for treatment until recent years many treatments have been tried with not that much success, but as you have read botulinum toxin seems promising. Since botulinum toxin is used for dystonia I would consider a therapeutic trial if available.

7. The additional info, the exacerbation by sitting would have pointed towards a nerve compression. Normally nerve conduction studies should have evidenced something in that case though as well as lumbar MRI if there was compression in the lumbar spine, so considering those normal tests it's unlikely.

I hope to have been of help.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Olsi Taka 14 hours later
Thank you, only 2 questions more 1. Could I caused some kind of general systemic neurological reaction with that small nerve injury? ( example somebody when even don't remember the injury develop CRPS-algodystrophy, I know I don't have typical CRPS) 2. On what mechanism small nerve injury of foot can cause pain in whole leg?
Thank you
Answered by Dr. Olsi Taka 3 hours later
Brief Answer:
Read below.

Detailed Answer:
My apologies for answering a little late.

Regarding the first question about CRPS, I do not think it to be the case. CRPS is accompanied with skin changes in temperature, color, abnormal sweating, swelling, muscle atrophy etc. Also the pain is more severe usually, so it doesn't look to be your case.
As for the second question on how does the pain invlove the whole leg, pain is not necessarily perceived only in the area of the trauma, there can manifest what is called referred pain. That happens because when a spinal segment is stimulated from pain signals coming from a certain area may lead to sensitization of adjacent segments responisble for other area. So that is a possible explanation. However while I am saying that I must admit that the whole leg is somewhat uncommon to have referred pain due to that type of trauma. When you initially presented your case it seemed the symptoms involved mainly the foot and lower leg. As I said before when symptoms go from that high, from the gluteus, my first hypothesis on that alone would have been nerve root compression. But since the reports of the MRI and ENG are normal that is excluded. There is also the possibility of nerve compression more downwards than the lumbar spine, like from the piriformis muscle, but still some changes are usually seen by a correctly performed nerve conduction study.
Perhaps to make sure nerve conduction studies could be repeated, but this time not only with superficial measurements as you mention them to have been done, but also with a full electromyography (inserting recording needles in the muscles to evaluate their activity.

Wishing you good health.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Olsi Taka 11 minutes later
yes,my whole leg hurts on strong mechanical pressure,especially posterior upper part of the leg, part where I sitt, posterior part of knee, and above explained sensations of forefoot, jerks of toes and bending position of last three toes- I will attach a picture
Answered by Dr. Olsi Taka 36 minutes later
Brief Answer:
Read below.

Detailed Answer:
Thank you for the pic, I can see what you mean.

Now that I understand the pain to be a continuum from up downwards, combined with the information of the pain triggered by sitting position, it does make the possibility of nerve compression, if not the nerve root the sciatic nerve more distally in the limb (wouldn't be detected by the lumbar spine MRI). Most commonly the site of compression is at the piriformis muscle level.
So to confirm or rule that out, the electromyography which I mentioned should be done to check for abnormal patterns in the gluteus and piriformis muscles. Electromyography of more distal muscles might also give information regarding other possibilities like dystonia.

Looking forward to hearing from you again

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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