40 yo male, previously healthy and fit/athletic with chronic low back pain/no radicular symptoms.

2 months ago, 'tweaked' neck at gym, no radicular symptoms, slowly resolved with rest, NSAIDs, PT.

1 month ago, *sudden* onset over 24-48 hours of widespread paresthesias in 4 extremities, intermittent, variable, mostly described as 'buzzing' or 'hot/cold' as if limbs falling asleep, unclear distribution, not clearly anatomic/dermatomal, seemingly very sensitive to positioning (ie, legs worse when lying down or sitting but better when standing/walking/running; arms worse when flexed). Over several weeks symptoms came and went with some consolidation in a right ulnar distribution (R 4th and 5th digits, forearm, arm to mid-upper arm including at times parts of the shoulder) and left sciatic distribution. right leg and left arm are variable involved. At times one leg will go completely asleep out of nowhere, for example, when driving.

In addition there has been some very mild weakness in the ulnar distribution, right greater than left, not appreciable on exam but quite obvious in day to day activities - reduced grip strength while exercising, cooking, etc; easy fatigue when writing, cooking; clumsiness when typing. Also some slight soreness in the forearms, the brachioradialis muscles in particular.

A couple of times there has been the scary sensation of a numbness or tingling in the back of the throat, on the right hand side, and in the tongue and even a burning sensation on the face, neck, upper back, right worse than left. This is transient.

Pain is mostly non-existent, not the dominant symptom.

I do not have fasciculations or atrophy.

I did have a mild viral illness just prior to this onset.

I am not 'ill-feeling' but I am more fatigued than usual.

Neuro exam by a qualified neurologist is objectively normal.

MRI brain with/without contrast is normal, read by neurologist and qualified neuroradiologist.

MRI neck with/without is normal.

Chemistry with LFT, ANA, ESR, CK all normal.

nerve conduction studies yesterday: left peroneal/sural normal. Right ulnar shows slowed conduction velocity from axilla to elbow; Left ulnar normal though again some relative slowing from axilla to elbow.

In my mind the distinguishing features of this syndrome are:

1. *sudden* onset;
2. normal neuro exam;
3. multiple mononeuropathy;
4. normal MRI of CNS.

My differential of course wants to exclude really bad things like ALS. Does this?

What else is possible? I have considered atypical presentation of GBS, but with minimal weakness seems unlikely. Vasculitis seems unlikely with negative ANA and ESR. Multifocal motor neuropathy seemed plausible but I understand that causes conduction block rather than conduction slowing. Monoclonal gammopathies?

Thought about adding CBC, serum/protein electorphoresis to labs. Any other suggestions? Would like to avoid LP if not necessary, of course.

thank you for your thoughts,

Welcome to NeuroTalk:

I'd have B12 levels run and Vit D.... B12 should be at 400pg/ml as "normal".... Some people get neuro problems below that but are still reported "normal" by the labs:

This is why 400 should be attended to:
http://www.aafp.org/afp/2003/0301/p979.html
This sneaks up on many people today, so should be ruled out.

Also...do you use a statin? New evidence shows statins prevent REPAIR of axons. They inhibit growth factors which use B12, folate, magnesium and Omega-3 fatty acids to remyelinate damage to axons.
If you do use a statin, I will give you links to photos of damage they cause to cells, and also some biochemical links to how they do this damage.
If you use a statin, you could have been coasting along until a damaging event(s) occurred and now you are not remyelinating properly.

Also viruses have been thought to create autoimmune situations and attack the patient's nervous system. There are not yet tests for all these antibodies, but only some of them.
This is Dr. Latov's Neuropathy panel from Quest...He is in NY and considered one of the top neurologists on this subject.
http://www.questdiagnostics.com/test...ripheralNeurop

Viruses can attack the dorsal roots and there is now an improved MRI out there to visualize this if suspected.

It can be a long frustrating time trying to get a diagnosis. Some posters here have been years at it.

Many here keep a log to chart symptoms with daily environmental situations, food eaten, sleep, drugs taken, stress and yes, even sudden weather changes (barometric LOWs).
Sometimes there is a hint in the journal of where to look more closely. It would be a good idea to limit sugar and starchy carbs for a while and alcohol and see if that helps. Many say it does.

Thank you,

I forgot to mention that B12 is normal (550) and D has recently been normal and I supplement daily.

I am not on a statin and don't have high cholesterol. I am in very good shape normally, running, hiking, and some weight lifting.

Given the acute onset my thoughts are also toward an immune-mediated response, whether a gammaglobinopathy, GBS variant, etc., but my neurology knowledge base is pretty well exhausted beyond those thoughts.

And thank you for the Quest link, I am studying it.

Have you figured it out or do you have any updates? thanks

you mention your ulnar I am assuming that is the nerve in the elbow I have constant spasms in my arm in that area both sides have some ulnar issues may not be any help to you but I am leaning on mine way too much so something to be aware of You Tube has some ulnar exercises as well mine has never become real painful...

You have received great input from one of the board' s biggest treasures (MrsD.) I had to reach out when I read concern about ALS. I'm a nurse and have a diagnosis of idiopathic sensimotor polyneuropathy. I have feared ALS from the onset of this five years ago. We medical people really are victims of having too much knowledge.

So, two things...I had widespread and fairly sudden onset of parasthesias much like yourself. I have been reassured by more than one neurologist specializing in MND that ALS doesn't present in this fashion, nor does it carry sensory malfunction with it. The sensory aspects more often than not take it out of the differential.

Secondly, diagnosing the cause as autoimmune in nature is usually not a straight path. Autoimmune diseases run through my mother's side of the family. My neurologist is convinced this is what my "idiopathic" cause will turn out to be. I've had negative ANA's all along. My blood has been rechecked about twice a year for five years. This recent check finally showed a glimmer of a cause: mildly positive neuronal ganglionic acetylcholine receptor antibodies.

I'm sorry you are dealing with this. It is especially frustrating to not know the cause.