Mrs Williams-Amyotrophic Lateral Sclerosis (ALS)-(British)

Patient Name: Mrs. Williams
Gender: Female
Age: 64 years old
Nationality: British
Diagnosis: Amyotrophic Lateral Sclerosis (ALS)

Condition on Admission:
The patient presented with unprovoked falls while walking and slow speech three years ago, which gradually progressed to generalized bradykinesia, accompanied by muscle weakness and mild dysphagia, with relatively normal oral intake and swallowing. Treatment with riluzole and acetylcysteine showed no significant efficacy. She was diagnosed with Sjögren’s syndrome three years ago, and her condition was currently stable under management with azathioprine, hydroxychloroquine, and carbomer eye drops. She had a history of asthma in childhood, with rare exacerbations at present, which were controlled by salbutamol when needed.

Physical Examination on Admission:
The patient’s heart rate was 78 beats per minute, respiratory rate 18 breaths per minute, and blood pressure 104/62 mmHg. She was 160 cm tall and weighed 75 kg. Her development was normal and nutritional status was good. There was no cyanosis around the lips. Thoracic respiratory movement was essentially normal. Breath sounds in both lower lungs were clear, with no obvious dry or moist rales detected. Cardiac rhythm was regular, and no obvious murmurs were heard. The abdomen was flat and soft, with no hepatosplenomegaly found on palpation. Mild edema was noted in the ankles of both lower extremities, and the dorsalis pedis artery pulses were good.

Neurological Examination:
The patient was conscious and alert with mild anxiety. She had dysarthria. Her calculation ability was slightly decreased, while memory and orientation were normal. Both pupils were 3 mm in diameter with brisk light reflexes, and extraocular movements were intact. Tongue protrusion was midline with mild tongue muscle atrophy and slightly slow movement. Cheek puffing was strong and mastication was essentially normal. Soft palate elevation was strong bilaterally and the uvula was in the midline. Neck rotation and shoulder shrugging were slightly weak. Marked muscle atrophy was observed in both upper extremities with visible fasciculations. Muscle strength of the deltoid and triceps brachii was grade 2+ bilaterally, and grade 3 in other muscles of the upper extremities. Left wrist flexion and extension strength was grade 3, and left grip strength was grade 3. Right wrist flexion and extension strength was grade 3+, and right grip strength was grade 3+. Muscle strength of both lower extremities was grade 3+. She rose slowly from the supine position. She could flex and raise both legs for 10 seconds in the supine position. Abduction and adduction strength of both lower extremities was grade 4. She could stand on her right leg for about 1–2 seconds and was unable to stand on her left leg alone. Muscle tone, sensation, and tendon reflexes were essentially normal in all four limbs. Pathological reflexes were positive in both lower extremities. Finger‑to‑nose test and rapid alternating movements were extremely clumsy on the left side and slow on the right side. Finger opposition test showed 1–4 digits on the left and 1–3 digits on the right. Motor dexterity of both hands was poor with marked interosseous muscle atrophy. Heel‑to‑shin test was performed clumsily in both lower extremities. Meningeal irritation signs were negative.

Treatment Course:
The patient was definitely diagnosed with amyotrophic lateral sclerosis (ALS) upon admission. During hospitalization, she received neural stem cell therapy to repair motor nerve damage, and mesenchymal stem cells for neurotrophic, endocrine and immune support. Adjuvant medications included edaravone, riluzole, neurotrophic factors, reduced glutathione and other drugs for CAST therapy, combined with comprehensive rehabilitation treatment.

After Treatment:
The patient’s motor function is improved significantly, and swallowing function is enhanced; she can swallow 3 tablets at one time. Muscle strength of the proximal deltoid and triceps brachii of both upper extremities is grade 3+, and grade 4 in other muscles. Wrist flexion and extension strength of both hands is grade 4+. Grip strength of both hands is almost grade 5 (able to resist considerable resistance).Muscle strength of both lower extremities is grade 4+; she can raise both legs in supine position for more than 15 seconds. She can stand on her left foot for 3 seconds and on her right foot for more than 6 seconds. Motor dexterity of both hands is significantly improved compared with admission; she is able to write a schedule with clearer handwriting. Her motor balance and coordination are markedly enhanced, and her anxiety condition is relieved.