Sarat Kumar Sahu - MSA (India) Posted on October 13, 2014

Name: Sarat Kumar Sahu  
Sex: Male
Country: India
Age:61 years
Diagnosis: 1.Multiple system atrophy (MSA)  2. Hypertension level 1  3.Mild hyperplasia of prostate 4. Hyponatremia 5. Moderate fatty liver
Date: August 30, 2014
Days Admitted to Hospital: 21 days

Before treatment:
            The patient suffered from stiffness of left lower limb for more than 3 years. The disease progressed gradually. He suffered from walking difficulty. His limbs suffered from tremor and needed rest after 5minutes walk. He went to a neurosurgeon and was diagnosed with prolapsed intervertebral disc. The patient suffered from comprehensive bradykinesia 3 years ago. He had difficulty to bath, comb or walk.  About 2 years ago, the patient suffered from frequent falling, trend backward and the falls were more severe when he's up stairs. His left hand suffered from tremor and stiffness. He went to a hospital and was diagnosed with Parkinson disease. He took levodopa , Amantadine and VE, but the effect was not good. At the same time, the patient right limbs suffered tremor and stiffness too. He also suffered more from unstable walking gait and exercise difficulty. He had difficulty with buttoning up or off the buttons, make bed or turn over, getting up. The sensation of patient was abnormal. The patient suffered from urgent urination 1 year ago. He suffered from a constrained laugh 10 months ago. He also suffered from fecal and urine nary urgency of urine incontinence. He went to New Delhi and received by AIIMS. He received FDG brain + whole body PET/CT scan, DAT brain SPECT/CT and autonomic nerve functional examination, he was diagnosed with MSA-P. He took Levodopa, coenzyme Q10 and multivitamin. He also received walking gait training. The effect was not good. The patient's condition aggravated about 4 months ago. He suffered from obvious bradykinesia and poor balance. He was unable to stand, walk, turn over or sit without support. Left limb suffered tremor and paroxysmal and the whole body had burning sensation. He suffered from lumbago and severe frequent urination and urgent urination. The doctor adjusted the dosage of levodopa. The disease progressed gradually.

Admission PE:
            Supine blood pressure: 132/88mmHg; The standing blood pressure:136/90mmHg. Hr: 85/min. The respiratory sounds in both lungs were clear, with no obvious moist rales. The heart sound was strong, with no obvious murmur. The abdomen was flat and soft, with no pressing pain or rebound tenderness. There was no mass in abdomen. There was no edema in the lower limbs. The temperature of both feet was low. The pulse of dorsal artery of foot was strong and symmetrical.

Nervous System Examination:
            Sarat Kumar Sahu was alert. His facial expression was rigid and had inappropriate smiles sometimes. His speech was clear and his vocal speed was normal. He had slow response. The memory, calculation abilities and orientation were normal. Both pupils were equal in size and round. The diameter of both pupils was 2.5 mms and both pupils were sensitive to light stimulus. Both eyeballs could move freely. The forehead wrinkle pattern was symmetrical. He could close eyes with strong muscle. The bilateral nasolabial sulcus was equal in depth. The tongue was centered in the oral cavity and the teeth were shown without deflection. There was no difficulty with opening mouth or swallowing. The movement of mandible was normal. There was no tremor in tongue. The pharyngeal reflex was not elicited. The muscle strength of the upper limbs was at level 5. There was slight static tremor in left limbs and right upper limb. His hand writing presented micrographia sign. The muscle strength of both lower limbs was at level 4. The muscle tone of trunk was higher than normal. The muscle tone of right upper limb was normal. The muscle tone of left upper limb and both lower limbs was slightly higher than normal. The abduction of bilateral hip joints was limited. The tendon reflex of left upper limb was active. The tendon reflex of right upper limb and bilateral patellar tendon reflex were normal. Bilateral ankle reflex of both lower limbs was not elicited. The abdominal reflexes were not elicited. The sucking reflex was negative. Bilateral palm jaw reflex was positive. Left side Hoffmman sign was positive. Right side Hoffmman sign was negative. Bilateral Babinski sign was weakly positive. The examinations of the deep and shallow sensory system were normal. The patient felt paroxysmal burning sensation in whole body. He felt backaches when he maintains a stereotypic posture. He did the finger-to-nose test, the rotation test, fingers coordination test and the heel-knee-shin test in a clumsy manner, the left side was more severe than right side. He had obvious difficulty to start an action. He had difficulty to turn over or sit-up independently. He had difficulty with standing or walking. He always falls down to left side or backward when he walks. He needed two persons assistant when he walks. The neck had no resistance. The kerning sign was negative. The brudzinski sign was negative. Assistant examination: 1. Head MRI(2014- 4 - 4): Diffuse brain atrophy. 2. Brain FDG + whole body PET/CT scan (2014 - 4 -5):  hypometabolism involving the right parietal and posterior frontal cortices, right basal ganglia and thalami S/O cortical dysfunction and this metabolic pattern is consistent with corticobasal syndrome. No evidence of metabolically active primary pathology on whole body survey. 3. Autonomic nerve function ( 2014 - 4 -7): normal parasympathetic reactivity with mild loss of sympathetic reactivity and cardiac autonomic tone. Kindly correlate clinically. 4. DAT brain SPECT/CT(2014 - 4 -9): The findings are consistent with presynaptic dopaminergic dysfunction.

            After the admission, the patient received the relevant examinations and he was diagnosed with multiple system atrophy. The patient received treatment for nerve regeneration and to activate stem cells in vivo. He received treatment to improve the blood circulation, fight free radicals, nourishment for the neurons, and stabilize cellular membrane and blood pressure. This was combined with physical rehabilitation training. The patient's blood pressure was higher than normal at the time of admission. The repeated measure of blood pressure were all over 140/90mmHg. So the patient was diagnosed with Hypertension level 1. The patient received treatment to lower blood pressure. The examination result showed the patient had moderate fatty liver and mild hyperplasia of prostate. He received treatment to adjust blood lipid and also to protect prostate. The blood test showed values of blood natrium was lower than normal. He was diagnosed with hyponatremia.

Post Treatment: 
            The burning sensation and lumbago have reduced about 75%. Left limb's tremor and shaking have been alleviated obviously. The frequent urination has been alleviated obviously. The times of nocturia is reduced and has only one time nocturia each night. He has no urgent micturition. His blood pressure is stable. His facial expression is more natural than before. His response is quicker than before. The muscle strength of left lower limb is at level 4-. The muscle strength of right lower limb is at level 4+. The muscle tone of trunk is alleviated. The ankle reflex of both lower limbs has been restored to normal. The starting difficulty has been alleviated. His left side completed the finger - to - nose test, the rotation test, fingers coordination test and the heel-knee-shin test in a better way than before. Right side did the finger-to-nose test, the rotation test, fingers coordination test and the heel-knee-shin test in an almost normal manner. He can turn over by himself. His balance ability in sitting position is better than before. He can stand with his single hand supported by others. He walks easier with his single hand supported. The tendency to fall down backwards has been alleviated. But the endurance is still poor.


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