Update 34yoM

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Oct 10, 2023
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Hello all,

This is my
Previous post
I had a follow up appointment yesterday (4/8/24) with neuroimmunology at MGH. Last appt was approximately 5 months ago on November ‘23.

Despite mild symptom progression, repeat emg listed below of right upper and lower extremity was unremarkable. A mild ulnar neuropathy was found.

R forearm continues to worsen with cramps and stiffness, as neurologist noticed some atrophy on dorsum of hand between 4th and 5th digits. They do not think the ulnar neuropathy is the source of symptoms.

Holding phone is becoming more difficult although not impossible.
He also noticed about 2-3 beats or clonus in R ankle during plantar reflex testing. As I am about to fall asleep I often get this rapid upbeat dorsiflexion only in R ankle.
Additionally they witnessed the R tricep getting ‘stuck’ for a second after contraction, then releasing with a few fasciculations.
They still believe this might be post Covid related and want me to see another neuro immunologist in the department.
It is difficult for me to grasp this as I do have clear symptom progression with no available treatment halting this. They stated that ‘you should just get better’.
I did ask Neuro if this is a presentation of UMN dominant MND, as they said that is very rare. But did not have any explanation for the findings on exam - aside from repeating MRI (which I recently had about 7-8 months ago).
I also questioned the lateralization of symptoms post Covid to R forearm and slightly R leg, to be very odd, vs a more generalized/ global presentation. Furthermore these new symptoms starting 1 year after having long haul symptoms.

My fear is a more UMN dominant presentation, as a matter of time before there are more LMN signs evident.

They want to continue to see me every three months going forward.

Thank you all

Visit Date: 3/27/2024 10:24 AM Patient Age On Visit Date: 34 Years Fellow: Ario Mirian
Attending: Reza Seyedsadjadi

Reason for Study: 34 y.o. male who describes right hemibody greater than left muscle twitches and post-exertional cramping. He has noticed right D4/D5 adduction weakness and is concerned about right intrinsic hand muscle atrophy.

Electrodiagnostic studies were requested for evaluation of possible amyotrophic lateral sclerosis.

Nerve Conduction Studies Right superficial radial-snuff box, median-D2, ulnar-D5, and sural sensory responses are normal. Right ulnar-ADM motor response was normal in amplitude and distal latency with focal slowing of conduction velocity across the elbow. Right median-APB and ulnar-ADM motor responses are normal.

Late Responses Right median-APB and ulnar-ADM minimum onset F wave latencies are normal.

Cramp fasciculation protocol: Repetitive stimulation was performed of the right tibial nerve recording from the abductor hallucis at 1, 3, and 5 Hz. There were no after-discharges and clinical cramps.

Needle Electromyography: Concentric needle examination was carried out of selected muscles in the right arm, thoracic paraspinals, and leg, as tabulated below. There was no abnormal insertional or spontaneous activity. Motor unit potential morphology and recruitment were normal in all muscles examined.

Clinical Correlation: This is an abnormal study. There is no definite electrophysiologic evidence of a generalized neurogenic process affecting the motor nerves or their axons. There was incidental evidence of a right ulnar neuropathy at the elbow. Ario Mirian, MD, MSc MGB Neuromuscular Fellow

All data has been reviewed by me and I agree with the impression above. I certify that I was present for the key portion of the needle electromyography procedure. Reza Seyedsadjadi, MD Neuromuscular Attending

Sensory NCS

Nerve / Sites Distance Peak Lat Amplitude Temp.
cm ms µV °C

R Median - Dig II
Dig II 13 3.5 43.6 33.8
Palm 8 2.3 99.4 32.7
R Ulnar - Dig V
Dig V 11 2.9 25.2 33.6
Palm 8 2.1 60.8 34
R Radial - Snuff box
Forearm 10 2.4 32.1 31.3
R Sural - Lat Mall
Calf 14 3.9 12.4 32.5

Motor NCS
Nerve / Sites Distance Latency Amplitude Velocity Temp. cm ms mV m/s °C

R Median - APB
Wrist 6 3.8 14.0 33.6
Elbow 26 8.2 13.9 58.3 33.9
R Ulnar - ADM
Wrist 6 3.4 13.8 30.1
B.Elbow 21 6.9 13.2 60.7 29.9
A.Elbow 10 9.1 12.8 44.4 29.8
R Tibial - AH
Ankle 10 5.5 8.3 31.5
Pop Fossa 36 12.5 8.1 51.3 31

F Wave

Nerve Fmin Temp. ms °C
R Median 29.0 31.3
R Ulnar 30.8 29.6

EMG Summary Table
Spontaneous MUAP Recruitment
Muscle Fib/PSW Fasc Misc Dur Amp Polyphasic # MUs Rate Effort

R. Deltoid None None None Normal Normal Normal Normal Normal Full
R. Biceps None None None Normal Normal Normal Normal Normal Full
R. Triceps None None None Normal Normal Normal Normal Normal Full
R. Flex Carp Rad None None None Normal Normal Normal Normal Normal Full
R. First D Int None None None Normal Normal Normal Normal Normal Full
R. Abd Dig min None None None Normal Normal Normal Normal Normal Full
R. Thor PSP Mid None None None
R. Vastus Med None None None Normal Normal Normal Normal Normal Full
R. Tib Anterior None None None Normal Normal Normal Normal Normal Full
R. Gastroc Med None None None Normal Normal Normal Normal Normal Full
You know 2-3 beats of clonus can be normal. Long covid is still an evolving condition. I don’t think anyone knows enough to say definitively this can’t be long covid since you don’t meet criteria for any other illness.

I do realize that living in limbo is hard but you have great doctors and I think you need to trust them
Thank you Nikki,
I agree, it is. I just don't seem to fit the picture of any known Long Covid presentations.

Could you have some sort of neuromuscular pathology with absolutely no EMG findings?
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