Hari - Amyotrophic lateral sclerosis (Nepal) Posted on July 4, 2012

Name: Hari Krishna Ghimire             
Sex: Male
Country: Nepal
Age:60
Diagnoses: 1. ALS (Amyotrophic lateral sclerosis) 2. Hypothyroidism   3. Fatty liver (mild) 4. Left renal cysts  5. Benign Prostatic Hyperplasia
Admission Date: 2012-05-14
Days Admitted to Hospital: 28

Hari has had myasthenia in both legs, as well as speech problems for the past 1 and a half years. Initially the symptoms were not serious enough to impact his daily life, but about 1 year ago, the muscle strength rapidly decreased and the speech problems got worse. About 6 months ago, Hari decided to go to the orthopedics department at his local hospital for treatment. Despite taking vitamins for 3 months, the weakness in the legs remained. Three months ago, Hari went to the neurology department for treatment and was prescribed unknown medication for 1 and a half months. About 45 days ago(2012-03-24), Hari underwent an MRI examination of the cranium, as well as an MRI examination of the cervical vertebra, and an EMG. He was diagnosed with Amyotrophic Lateral Sclerosis. Hari was given idebenone and VB12 intramuscularly, but there were no changes in his condition. At present, he can walk and drive a car, but his overall endurance is poor and he spends most of his time sitting and continues to have problems with his speaking ability.

Nervous System Examination:
Hari was alert and his mood was good. The speech was unclear and he spoke slowly. The examination of the memory, calculation abilities and orientation were normal. Both pupils were equal in size and round, the diameter was 3.0mms. Both eyeballs had normal movement and the pupils had normal reactions to light stimuli. The eye positioning was normal. The eye closing ability was strong. The tongue could move to the left side and right side freely, but the tongue had difficulty with vertical movements. There was no atrophy or fibrillation in the tongue muscle. The teeth were shown without deflection. There was no air leakage when the cheeks were expanded. The muscle strength of the center of the soft palate was strong, but the bilateral was weak. The muscle strength of both upper limbs was level 5. The muscle strength of both lower limbs was level 5-. When the patient walked, the distance between both feet was the same width as the shoulders. The patient had poor balance ability when he stood on one leg. The muscle tone of all four limbs was normal. There was no obvious muscle atrophy in the lower limbs. There were no obvious muscle tremors anywhere in the body. The bilateral abdominal reflexes and tendon reflexes in all four limbs were elicited normally. The bilateral palm jaw reflex was negative. The bilateral Hoffmann's sign and Rossolimo's sign were weak positive. The bilateral Babinski's sign was negative. The deep, shallow, and composite cortex sensations were normal through the bigness scale. The patient was able to finish the finger-to-nose test, the rapid rotation test and the Heel-knee-shin test in a stable manner. There were no signs of meningeal irritation. While at rest: Peripheral blood oxygen saturation: 95-98%. EMG (2012.3.24 In India): there were pathological changes in the anterior horn of the spinal cord. Head MRI results: (2012.3.24 In India): There were no obvious abnormalities. Cervical vertebra: (2012.3.24 In India): cervical vertebra had intervertebral disc degeneration. VB12: 226pg/ml. After admission, the patient received the relevant examinations and was found to have: 1. Hypothyroidism, 2. Fatty liver (mild), 3. Left renal cysts, 4. Benign Prostatic Hyperplasia. After the supplements of Euthyrox, the thyroid functioning improved obviously.

Treatment:
Hari received treatment to improve the blood circulation in order to increase the blood supply to the damaged nerves and to nourish the neurons. He also received treatment to promote nerve regeneration. He has been using a BiPAP ventilator to assist his breathing. The patient participated in daily physical rehabilitation training to promote the recovery of the motor functioning.
          
Post-treatment
The soft palate can now be raised slightly. The vertical range of motion of the tongue has increased. The muscle strength of all four limbs is almost normal. The balance ability while standing on one leg has improved. Peripheral blood oxygen saturation: 97-99%.