Colin F. Stoll, BA
Medical Student
UMass Chan Medical School
Worcester, Massachusetts, United States
Faren H. Williams, MD, MS
Physiatrist, Professor
UMass Chan Medical School
Worcester, Massachusetts, United States
A 68-year-old right-handed male presented for electrodiagnostic consultation with left-hand numbness and decreased grip strength. Electrodiagnostic studies (EDX) were positive for left carpal tunnel syndrome, but imaging revealed multiple enhancing lesions of the brain and cervical spine.
Case Description:
The patient presented with left-hand numbness in the 2nd and 3rd digits and decreased grip strength. Orthopedics noted left upper extremity neurological findings and referred him to physiatry for electrodiagnostic studies (EDX). A detailed history and exam revealed upper motor neuron changes, including left facial droop, suggesting a central nervous system issue. EDX revealed mild left carpal tunnel syndrome and mild ulnar neuropathy at the elbow, which did not fully explain the patient's clinical exam. A brain MRI was then ordered, revealing multiple enhancing lesions. A previous cervical CT showed degenerative changes.
After referral to neurology, a cervical MRI identified a left-sided enhancing lesion at C3-4. The patient was hospitalized for a lumbar puncture, which revealed elevated protein, normal glucose, and elevated RBCs. Pertinent labs showed positive oligoclonal bands, decreased immunoglobulin G subclass 2, and a negative infectious work-up. The exact etiology of the CNS lesions remains unclear.
Discussions:
This case demonstrates the value of a detailed physiatry evaluation before electrodiagnostic testing, particularly in cases where peripheral nerve findings do not correlate entirely with the clinical presentation. A comprehensive physiatry assessment ensured that this patient’s condition was not misdiagnosed as it correctly attributed his presentation to a CNS etiology.
Conclusions:
The physiatry consultation, together with EDX studies is essential to determine what type of work-up is needed when presentation does not align completely with electrodiagnostic data. Early identification of discrepancies between clinical examination and objective data can guide future diagnostic studies and early intervention.
