Is this disease functional or organic?
Dr C P HO
cpho at hkma.org
Mon Jul 28 19:21:22 EST 1997
I have a friend whose wife got some stange symptoms. She had been
investigated by nearly all the tests available in Hong Kong and had been
seen by many doctors. I am still not sure what the disease is and not even
whether it is functional or organic.
I shall be obliged if any of you can shed any light on this case. (sorry
the case presentation is long)
An case of bilateral, progressive numbness and pin-pricking sensation of
the tongue, lips, gum, palates and pharynx.
To: All medical colleagues in the world.
Any bright ideas or suggestions on diagnosis or
management are welcome.
A 45 year old house wife noted progressive numbness and pin-pricking
sensation over the tongue, gum, lips, palates and then the pharynx for
The symptoms started one year ago when she noticed soreness of the tip
of the tongue. She was seen by a dentist and was diagnosed to have
repeated minor injury due to an ill-fitting dental filling between the
lower incisors. The dental filling was removed but symptoms persisted.
The soreness and then pin- pricking sensation became more severe and
these feelings spread to the gum, lips and posterior part of the
tongue. Taste was said to have diminished, though present. The patient
also noticed more frequent injury by fine fish-bone and she
attributed it to the diminished sensation of her tongue and buccal
cavity. Injury to the buccal mucosa was said to cause less pain than
before. In the past 3 - 4 months, she noticed discomfort of the pharynx
( a numbness feeling which was similar to that due to local anaesthetic
spray ). She also felt that her speech was a bit more clumsy than
before. No difficulty in swallowing was noticed.
Examination 6 months ago showed that her teeth and mucosal surfaces of
the gum, tongue, palates, floor of the mouth and cheek were normal. There
was bilateral diminished pain and tactile sensation over the gum,
tongue and palates and lips. Salty and sweet taste was intact over
anterior two third and posterior one third of the tongue. No objective
speech defect was noticed. Other cranial nerves were normal. No other
neruological deficit was detected.
She was seen by a neurologist and M.R.I. of the brain stem with
angiogram was done which showed no evidence of brain stem or focal
intracerebral abnormality. EMG and light evoked potentials were normal.
EB virus antibodies were negative. Detailed report please refer to
appendix. She was also seen by a dental surgeon who discovered nothing
abnormal in her gums, tongue and buccal cavity.
She was treated with anxiolytic medications for 2-3 weeks but no
improvement was noticed.
The patient said she had experienced similar numbness and
pin-pricking sensation of her lips and tongue 3 years ago immediately
after she had bilateral myringotomy for her Eustachian tube syndrome.
The feeling was so distressing that she requested to have the
myringotomy tubes removed. The symptoms subsided 2 - 3 weeks after the
tubes were removed.
1). Right hemithyroidectomy in Feb. 1995
because of a thyroid adenoma
2). One episode of chronic cough from Mar. 96 to Aug. 96 with
enlarged mediastinal lymph nodes. Cough and lymph node enlargement
3). Hypercholesterolaemia on dietary control
Examination recently showed the same neurological signs as 6 months
ago. The external appearance of the tongue, gum lips palates and buccal
mucosa was normal. Pain and tactile sensation was diminished over these
areas. Salty and sweet sensation was intact in the whole tongue. Other
cranial nerves were normal. No other neurological deficit was noticed.
M.R.I. of brain in June 94
No focal areas of abnormal signal intensity is noted in the cerebral and
the cerebellar hemispheres as well as in the brain stem and the
cerebello-pontine angles. The internal auditory nerves are unremarkable.
The ventricular system is normal. The sulci and the cisterns are
The pituitary and the other visible cranial nerves are also normal. The
nasopharynx and the paranasal sinuses are clear. No lesion is seen in the
region of the cavernous sinus. The 5th cranial nerves are unremarkable.
No focal intracerebral lesion is seen.
M.R.I. of brain on 4th Oct 96
Chronic cough with hilar L.N. enlargement. Perioral numbness including
tongue. To rule out hilar lymphadenopathy? brain stem lesion.
No focal area of abnormal signal intensity is seen in the brain stem, the
cerebral and the cerebellar hemispheres. The temporal lobes are
symmetrical and are normal. The ventricular system is normal. The sulci
and the cisterns are within normal limits. The visible cranial nerves and
the pituitary are also normal. No abnormality is seen in the nasopharynx.
The paranasal sinurses and the mastoids are clear. No abnormal enhancing
structure is seen after gadolinium injection.
Satisfactory flow signal is seen in the anterior, middle and the posterior
cerebral arteries. The internal carotid artery and the basilar artery are
normal. Both vertebral arteries are patent in the neck and are of similar
calibre. The carotid bifurcations are also normal.
No evidence of any brain stem lesions or other focal intracerebral
abnormality. The MR cerebral antiogram is also normal.
M.R.I. Thorax with gadolinium on 4th Oct 94
A tiny nodular soft tissue thickening is seen in the mediastinal fat behind
the ascending thoracic aorta, anterior to the trachea and above the right
main pulmonary artery. This is isointense on the T1 weighted images
outlined by the hyperintense mediastinal fat. It is under 1cm size. It
may represent a small lymph node. There is no enhancement after gudolinium
injection. The rest of the mediastinum is unremarkable. There is no
suspicion of any hilar lymphadenopathy. No focal areas of abnormal signal
intensity is seen in the lungs. There is no pleural fluid or mass lesion.
The rest of the thorax is unremarkable.
The appearance could be due to the presence of a tiny lymph node in the
mediastinum but this is probably unchange in size from the previous CT.
There is no enhancement after gadolinium injection. Active pathology is
therefore probably unlikely."
Dr C P Ho, FRCP (Edin)
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