From the Guidelines
For Kathleen's complex presentation of progressive facial numbness, loss of taste, and neurological symptoms, I would recommend a comprehensive workup focusing on potential neurological causes, as suggested by the most recent guidelines 1. Initially, I would order a brain and cervical spine MRI with and without contrast to evaluate for structural lesions, demyelinating diseases like multiple sclerosis, or vascular abnormalities. A complete blood count, comprehensive metabolic panel, HbA1c, vitamin B12 level, folate, and thyroid function tests would help identify metabolic causes of neuropathy. Given her history of alcohol use, liver function tests and nutritional deficiency screening would be important. I would also order tests for inflammatory markers including ESR, CRP, and autoimmune panels (ANA, RF, anti-SSA/SSB) to rule out autoimmune conditions. Nerve conduction studies and electromyography would help characterize the neuropathy pattern. A lumbar puncture might be necessary to evaluate for inflammatory or infectious processes. Given the temporal relationship with her dental procedure, I would consider trigeminal neuralgia or a complication of the root canal, possibly warranting maxillofacial imaging. A formal ophthalmologic evaluation would address her visual symptoms. A neurology consultation would be essential for specialized assessment and management of her complex neurological symptoms. This comprehensive approach is necessary because her presentation suggests a progressive neurological disorder that could be related to multiple sclerosis, brainstem pathology, or a systemic condition affecting multiple nerve distributions, and is supported by recent guidelines for the management of immune-related adverse events in patients treated with immune checkpoint inhibitor therapy 1.
Some key points to consider in the workup include:
- Screening for reversible neuropathy causes: diabetic screen, B12, folate, TSH, HIV, consider serum protein electrophoresis, and other vasculitic and autoimmune screen 1
- Consideration of MRI of spine with or without contrast, and MRI of brain if cranial nerve involvement 1
- Consideration of EMG or NCS to characterize the neuropathy pattern 1
- Consideration of a neurology consultation to guide the workup and management of neuropathy 1
- Evaluation of the patient's symptoms and history to determine the best course of treatment, as suggested by recent guidelines for the management of neuropathic pain in diabetes 1.
It is also important to consider the patient's history of alcohol use and potential nutritional deficiencies, as well as her current medications and potential interactions. The patient's symptoms have significantly impacted her daily functioning, affecting her ability to eat, swallow, and maintain balance, and a comprehensive approach is necessary to address these issues and improve her quality of life. Recent guidelines for the management of neuropathic pain in diabetes suggest a stepwise pharmacological strategy with careful attention to relative symptom improvement, medication adherence, and medication side effects 1. In this case, the patient is already taking gabapentin, but it is not effective for her current symptoms, and alternative treatments such as pregabalin, duloxetine, or tapentadol may be considered, as suggested by recent guidelines 1.
Overall, a comprehensive workup and management plan are necessary to address Kathleen's complex neurological symptoms and improve her quality of life, and should be guided by recent guidelines and evidence-based practice 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Initial Assessment
The patient, Kathleen, presents with progressive facial numbness and loss of taste, which began approximately 5 years ago. Her symptoms have significantly impacted her daily functioning, affecting her ability to eat, swallow, and maintain balance.
Potential Diagnoses
- Multiple Sclerosis (MS): The patient's symptoms, such as progressive facial numbness, loss of taste, and vision changes, are consistent with MS 2, 3, 4, 5.
- Peripheral Neuropathy: The patient's history of neuropathy in her feet, extending from her knees down on the left side due to sciatica, and beginning to affect her right side as well, suggests peripheral neuropathy.
- Vitamin D Deficiency: The patient's recent start of vitamin D supplements and the potential link between vitamin D deficiency and MS disease activity 3, 5, 6.
Workup
- Electromyographic (EMG) examination: To assess the patient's muscle function and detect any signs of neurogenic atrophy (NA) 2.
- Magnetic Resonance Imaging (MRI): To evaluate the patient's brain and spinal cord for any lesions or abnormalities consistent with MS 3, 4, 5.
- Vitamin D level check: To assess the patient's vitamin D status and potential deficiency 3, 5, 6.
- Neurological examination: To assess the patient's cognitive function, motor function, and sensory function.
- Laboratory tests: To rule out other potential causes of the patient's symptoms, such as infections or autoimmune disorders.
Management
- Medications: The patient is currently taking gabapentin, which may not be effective for her current symptoms. Other medications, such as disease-modifying therapies for MS, may be considered.
- Supplements: The patient has recently started taking vitamin D supplements, which may be beneficial for her MS symptoms 3, 5, 6.
- Lifestyle modifications: The patient may benefit from lifestyle modifications, such as regular exercise, a balanced diet, and stress management, to help manage her symptoms.
Further Evaluation
- The patient's history of heavy alcohol use and potential withdrawal symptoms should be considered in her management plan.
- The patient's social support system and potential need for counseling or therapy should be assessed.