Work up or stop worrying?

[MissyMe]

So, here's my story.

In the last couple of months, maybe a bit longer, I've had some strange symptoms. Some of them coincide with the start of a new medication in clinical trails for binge eating disorder, specifically a Norepinephrine-Dopamine Reuptake Inhibitor (NDRI). Some of them occurred beforehand. Part of me wants to write these things off as side effects of the drug, but a portion of the symptoms are paradoxical to what would be expected and potentially predate it. Oh yeah... and as full disclosure, I'm a doctor in residency training. This is a second career for me so I'm in my 40's. And I hate going to doctors. Ugh.

Between October and December, I had a couple of weird episodes where I broke out crying at work over the stupidest reasons. It was totally embarrassing, and at the time I chalked it up to stress. (Not likely hormones as I had total hysterectomy long time ago.)

Then January, I started this medicine. Initially, I had a super dry mouth. It's a known side effect of the drug. So, when the hypersalivation started about a month ago, it made no sense. I seem to notice this more in the evening, and especially when I am lying down to go to sleep. However, if I'm not preoccupied with something else, I will notice it during the day, too. As I'm sitting here writing this, I can feel the dang saliva. Super annoying.

Over this same period of time, I started having issues with swallowing. There was actually a day that I thought I might be having an allergic reaction because it felt like the back of my throat was swollen. I was seen in ED and they elected to rule out stroke because I was demonstrating slight weakness of the left leg. CT and MRI were both negative. I'd noticed issues with that leg, but I thought it was my ankle was giving way due to a sprain (break?) I didn't have evaluated a few years ago. Neuro wasn't sure what to make of this... but felt it was not an acute issue needing intervention.

Next I started having the fasciculations. Interesting thing fasciculations. This has been in the last week or so. Again, I noticed them more when I was at rest. It felt like buzzing or overstimulation. The movement was very fine and I could see the tiny wave like patterns on my skin. Again, NDRIs can cause twitching, but fasiculations are less common.

I've also noticed some spasticity. Not sure how long this has been going on. I chalked this up to electrolyte issues. Figured I must be drinking too much coffee, not enough water, not eating well, etc. Noted a lower than normal potassium level (3.3) from the ED visit so this technically supported my theory.

And for now, that's it. As you can see, I can sort of "explain away" these things. And that makes me think I shouldn't worry. But since my medical training is not in neurology and my knowledge of the ALS is only book-based, it makes it difficult to decide whether these symptoms warrant work up anyway.

Let me know what you think. Thanks in advance.

 

[Nikki J]

Did you follow up on the leg weakness? That is the only thing that caught my attention. From an old injury is likely but should be checked beyond the confines of an ED. I am sure you know ALS phobia is very common among med students residents and attendings. All have graced this subforum, none have returned reporting a diagnosis so far in my time here

 

[MissyMe]

Thanks Nikki.

You are very right about the self diagnosis stuff in medical trainees, although I'd not heard about ALS in particular. In my case, I never would have even considered it (and actually didn't think of it) until I was looking up the symptoms in the context of drug side effects. The thing was, the evidence for this to be drug related was kind of crappy. Possible, but then I'd be the weirdo with the bizarre side effects. But ALS did come up repeatedly in context of the salivation, swallowing, fasiculations... and those issues plus the leg weakness made me go "oh crap... do I need to check this out?"

Anyhow, to answer your question, no, I haven't gone to the doctor yet. I think I was assuming if I ignored this long enough, it would just go away. I'm probably the opposite end of the spectrum from your Nervous Nelly, who lies awake all night, convinced that every single twinge of something unusual is proof that he/she has whatever disease he/she has latched onto. (Seriously... I've read some of the "do I have posts" and you all are infinitely more patient than me.) If I was looking for someone to validate a false belief, this clearly is not the place. However, it does seem to be where I can get an opinion on whether I'm likely to be laughed out out someone's office as the idiot resident who thinks they have a problem but doesn't. Bottom line - it sounds like you are saying evaluation isn't unreasonable.

I'm curious though, for those who have been diagnosed, do symptoms really sprout up so quickly? The way we were taught, it always seemed like people had vague complaints for years but were only diagnosed when they became suddenly debilitated.

 

[affected]

Hi missy

Usually if one is truly concerned about a health issue the first thing they do is go and get checked over by a doctor. If something shows as wrong, they can then be tested and checked by the right specialty and a strategy worked out.

I don't read Nikki's reply as saying you need to worry about ALS, but that if you think you have something wrong you should go to a doctor.

ALS doesn't even begin to occur to me as I read your story. That doesn't mean you don't have something going on that can be treated. Most things are best treated early.

Yep PALS find they suddenly have things going on, suddenly things do not work, they don't feel like they are about to not work. If you read our sticky post titled NEW MEMBERS READ BEFORE POSTING you will get lots of answers. We put a lot of effort into creating that post and it is our official position, we don't argue against anything written in there.

 

[Nikki J]

I personally doubt very much this is ALS. I did not mean to imply that. I simply meant that weakness is a symptom to be explored. You surely know that there are many causes of weakness. It is always appropriate to follow up from the ED. Every ED I have ever known of put follow up as part of their plan -aside from anything else their lawyers insist on it.
You might get a smile if you presented yourself directly to the neuromuscular clinic but you should follow up as instructed and take it from there. Remember we are not doctors who have seen you , let alone examined you.
However a couple of episodes of breaking down do not constitute emotional lability/ PBA. The saliva increase does not fit, fasciculations mean nothing. Feeling like your throat was swollen is not what I heard from my family member when their bulbar symptoms began,
Spasticity? Maybe but like weakness non specific. So follow up and please do not worry

 

[lgelb]

I agree w/ explanations like low K+ and the NDRI, which as you note, don't always mesh well with caffeine, dehydration and snack food diets/sleep deprivation (which I'm guessing you have some of in residency). As Nikki says, if the weakness persists or progresses, esp. post-trial, it would be something to explore but horses outnumber zebras, as you know.

Best,
Laurie