Sunday, April 22, 2012


     I saw him in the office fof  the abnormal chest x-ray and some weight loss. He was referred to me by a family doctor , who was following him for last about a year. In that time he had lost some weight, may be 8 lbs. He was not a smoker and family doctor did blood tests , and chest x-ray. The blood tests did not show the reason for his weight loss, he was not diabetic , nor did he have anemia or thyroid problem.  He also did a nonspecific blood test called CEA , which is a tumour marker. This was also normal . The chest x-ray however did show abnormality, which was reported as " scaring , may be related to granulamatous disease, as in old tuberculosis. "So he was referred to me .
    He was 69 years old black male , came with his wife . He had no cough, no fever, no night sweats, to suggest TB. His examination was unremarkable . He was ex smoker, had quit smoking 8 years. . He did not have poor appetite. He did not have much cough, some left from his chronic bronchitis. When I asked him about history of TB , he told me that he was told about abnormal x-ray  in New York few years ago.He was told that it residual scaring from TB.
     I did the usual work up ,did cat scan of the chest and even though it showed 'scaring may be related to old TB , but also did a endoscopy--bronchoscopy , as I could not rule out 'scar cancer' i.e the cancer that develops in old scar. It came back negative. I was waiting for the TB cultures , so I told him to get me  old x-ray reports from New York. When I saw the old x-ray and compared them to the one which were done here, they looked unchanged .So the possibility of active TB was low and when I got the TB cultures negative , it was completely ruled out. He however continued to loos weight So I started to look for occult cancer,as it can cause weight loss. I did cat scan of the belly and send him to a gastroeterologist, to do colonoscopy. His work up came OK , No cancer was detected.
     When he came for the follow up, he looked weak and had  further lost weight , now almost 30 lbs. He had no other complaints , but he was not doing any exercise and when I saw him walk , he looked like an old   man walking with some difficulty. When I examined him , he had lost some fat , but what struck me most was the loss of muscle mass. It is not uncommon to loose muscles when one loose that much weight.But with his other symptoms, I thought of something. He was loosing MUSCLES. and so I thought of some kind of neuropathy(inflammation of nerves, which can lead to muscle loss ) or the myopathy , the muscle disease. The weight loss van be explained on the basis of loss of the muscle tissue.
     I ordered the muscle enzymes and send him to a neurologist . I had explained him and his wife about my thinking. I also called the neurologist and told him my concerns.
    Next week I got the call from the neurologist. He had done the investigation and had the diagnosis. He had ALS---amyotropic Lateral sclerosis, also known as Lu Garick' disease. So I was party correct , He had lost weight due to loss of the muscle mass, and it was due to ALS . In this disease patients get degeneration of neuronal cells in the spinal cord (anterior horn cells ). The unfortunate problem is that even though I now knew the cause of his weight I had NO TREATMENT, and prognosis was very poor , with the patients needing respiratory support and feeding etc .   

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