[This is a scanned copy of the the report from Daragh Heitzman, M.D. dated 28 August 2000, addressed to Dr. Jenevein and copied to Dr. Henderson and Mike Firth.]
Mr. Firth is a pleasant 57 year old, ambidextrous, white male, with a history of hypertension and chronic low back pain, with a surgical history including left hand surgery and right eye cryosurgery, with allergies to griseofulvin (hayfever), on atenolol, Naprosyn and Neurontin 1800 mg p.o. q.d. in divided dosages, who has come for an evaluation of a peripheral neuropathy. The patient has been evaluated by Bruce Jenevein, M.D. of Neurology who requested a second neurologic opinion.
The patient reports that one to one and one half years ago, he began experiencing numbness and tingling in the balls and toes of his feet bilaterally. Since that time, it has gradually moved up to areas just below his knees bilaterally. His left foot appears to be somewhat more affected. There is no weakness, but he does admit to chronic low back pain. There are no problems with his bowel or bladder though he says that sometimes in the morning he cannot increase the pressure of his urinary stream. There is no focal weakness, erection difficulties, radicular numbness, tingling or pain. He said that he does have some heel pain when he gets up in the morning and walks, but says that the Neurontin has relieved this. There is no family history of any peripheral nerve problems. He said that he was never a very good athlete but he did do synchronized swimming and played volleyball at a younger age. He has no history of high arches or hammertoes. There is no numbness, tingling, pain or weakness in his arms.
The patient has injured his left knee on multiple bicycle accidents. He was seen by John Coon, M.D. of Neurosurgery who did not feel that he had a surgical problem in the lumbar spine to explain his lower extremity complaints. He had an MRI of the lumbar spine which demonstrated degenerative changes with mild stenosis at the L4 through Si levels as well as left L5-S I nerve root encroachment. You have performed extensive blood tests including urine for heavy metals, serum protein electrophoresis, hepatitis panel, TSH, RPR, rheumatoid factor, vitamin B12 level, C-reactive protein, ANA, cryoglobulins, glycosylated hemoglobin, anti-MAO antibodies, antiGM antibodies, anti-RI antibodies, and anti-HU antibodies; all have been negative. You have commended that an ANCA has been slightly positive at 1:20. A lumbar puncture demonstrated 1 WBC, 1 RBC, glucose of 61 and protein of 36. The cultures were all negative. The IgG indices were also unremarkable.
The patient says he has not had any sexual activity [since] prior to the outbreak of HIV. He does not feel this is a factor. There is no family history of amyloidosis. You have discussed with him a nerve/muscle biopsy in the past by his account. He [sometimes] rides a bike to work. He never tried any other medications besides Neurontin for his lower extremity complaints. You had performed an EMG examination which suggested a peripheral neuropathy. The patient wonders if his prior antifungal treatments in 1966 and 1997 with Sporanox or Lamisil could be the cause of his neuropathy? He said that he has done searches on the internet but could not find any association. He denies any weight loss.
He also denies any neck pain, visual problems, speech problems, or swallowing difficulties, though he does say that he has a blind spot in the right eye related to an eye injury. He says that his short-term memory may be somewhat off in regards to his thinking, but he denies any other problems. There is no vertigo, diplopia, nausea or vomiting. He infrequently drinks alcohol.
The review of systems was otherwise negative. The social and family histories were noncontributory. He denies having any sexually transmitted diseases or tick bites.
On exam, he was 6' 2-1/2" tall and weighed 270 pounds. Pulse was 60 and regular. There were good dorsal pedal pulses withojxt obvious pedal edema. There was a negative straight leg raising test bilaterally. There was no tenderness on palpation of the extremities, vertebral column, sinuses or scalp. The neck was supple without lymphadenopathy, or thyromegaly. Heart and lung sounds were normal. There were no obvious cranial or carotid bruits. There were scars on his left fifth finger.
On neurologic exam, the patient had normal mental status and speech exams. There was no evidence of dysarthria or aphasia. On cranial nerve exam, he was wearing glasses. The remainder of the ocular and cranial nerve exam (lI-XII) was normal. The extraocular movements were intact. There were normal fundi with no evidence of papiliedema or ptosis. There were no field cuts or nystagmus. On motor exam, there was 5/5 strength throughout with normal bulk and tone. There was no pronator drift. There was good fine motor skills in the upper extremities and toe tapping in the lower extremities. There was no spasticity, cogwheel rigidity or rest tremor. On sensory exam, there was decreased light touch, pinprick, position sense and vibration appreciation distally in both lower extremities. There was a negative Romberg sign. On cerebellar exam, finger-to-nose and heel-to-shin were normal. On gait exam, there was no ataxia with good toe, heel, and routine walking, though he was slightly unsteady with tandem walking. Reflexes were 1/4 throughout except for trace at the anldes. The toes were downgoing bilaterally.
I am suspicious that he has a peripheral neuropathy, probably idiopathic in nature. I cannot exclude the remote possibility that he has some neuropathy of an etiology not determined by some other unlikely cause. I would also be skeptical that he has concomitant problems such as in his brain, cervical or thoracic spine producing his abnormalities. We cannot exclude the possibility that some of his lumbar spine abnormalities are contributing to his leg complaints. I also see from your notes that you are concerned that he may have some degree of plantar fasciitis.
I discussed proceeding with a nerve/muscle biopsy and how this test was performed. I told him about the search either vasculitis or amyloidosis with this test. I also raised the possibility of doing additional blood work including CBC, CMP, HIV, serum immunofixation, urine immunofixation, ESR, Lyme's titer, lipid profile and amyioidosis.
He states that HIV is out of the question. I will defer to you whether you want to order the additional blood tests listed above. Another possibility could be doing an MRI spine survey, getting an orthopedic evaluation to evaluate for possible plantar fasciitis and doing Doppler studies of the lower extremities. I will look to see if there was any information about either Lamisil or Sporanox causing nerve injury.
Please do not hesitate to call me if you have any questions.
Daragh Heitzman, M.D.
DH/prn.lh cc: Robert 1. Henderson, M.D