Svetlana Blitshteyn, MD



Dysautonomia Clinic

Svetlana Blitshteyn, MD

Neurologist and Autonomic specialist

PO Box 441, Getzville, NY 14068

Phone: 716-531-4598 Fax: 716-478-6917

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Neurology Consult

Date: January 10th, 2017

Re: Beverly Thomassian

DOB: 6/4/1963 Fax:

I had the pleasure of speaking with Beverly Thomassian in a 60-min phone consultation that she requested on January 10th, 2017. she is a 53-year-old woman who was essentially healthy until March of 2016 when she experienced a sudden onset of expressive aphasia due to acute ischemic left parietal stroke. Fortunately, her speech recovered, but the etiology of stroke was never identified. Importantly, she has a family history of early stroke and myocardial infarction in her father. Following the stroke, she experienced a milder similar episode of aphasia, but also presyncope and chest pain; workup at that time was unremarkable for stroke or heart disease. Shortly thereafter she developed burning pain in the right foot and leg below the knee, which was attributed to post-stroke central pain syndrome. She was doing well, despite the burning pain ranging 4-10/10 in severity, and continued to work full-time at her business, teaching courses and walking on a desk treadmill for 5 hrs per day. On 12/26/16, she experienced presyncope, rapid heart rate and burning pain in the chest and presented to the ER; workup for stroke and cardiac disease was negative. She does report having an active herpes simples type I infection at the time and was taking Acyclovir; she reports having recurrent herpes episodes every few weeks. Following this incident, she noticed daily symptoms of orthostatic tachycardia with heart rate up to 160 bpm, fatigue and exercise intolerance. She is able to walk or stand for about 2 hours daily. Workup was only remarkable for elevated anti-TPO antibodies; she did try Synthroid, but felt that it may have caused tachycardia and chest pain previously so she discontinued taking it.

For neuropathic pain, she tried Cymbalta for 2 days, which caused side effects, Pamelor, which caused mood disturbance and gabapentin 300 mg BID, which was ineffective at that dose; the dose was never increased further. Her episodes of presyncope and orthostatic tachycardia predominantly occur in the morning, around 9 am. She sleeps between 7-9 hrs per night, she continues to have menstrual cycles without signs of irregularities or hot flashes, and she does report increased urination, likely as a result of increased fluid intake.

PAST MEDICAL HISTORY

Chronic herpes type I, ischemic stroke 3/16, hypothyroidism, chronic foot pain (post stroke synderome), IBS, migraine with aura once a month (less in the past few years)

MEDICATIONS

Pravachol 20 mg qd, Zyrtec 10 mg qd, Metamucil qd, progesterone cream for 6 days, aspirin 81 mg qd, Valtrex 1000mg as needed for outbreaks.

SOCIAL HISTORY

She lives with her husband and 2 teenagers; she is a full-time business owner who walked on treadmill 4-5 hrs each day. She denies tobacco use; she drinks 3-4 alcoholic beverages per week, no caffeine for 10 days. Currently, she walks 2-3 miles per day. She does supine exercise and consumes a high sodium diet of about 2 gm with fluid intake of 2-3L daily.

FAMILY HISTORY

Father had MI at 39 and a stroke at 40; he was a smoker. Mother had depression/anxiety and has a form of autoimmune diabetes. One brother has HTN.

PERTINENT DIAGNOSTIC STUDIES

Cardiac monitoring showed no evidence of AFIB. Cardiac echo was negative for PFO. MRI of the brain from 12/26/16 showed a residual FLAIR hyperintesity at the left parietal region. Per the patient, her supine HR is in the 60s, then increases to greater than 100 bpm on standing. Per the patient, EMG of the left leg showed no evidence of large fiber neuropathy.

IMPRESSION

1. POSSIBLE POTS

2. POST-STROKE CENTRAL PAIN SYNDROME

3. SUBCLINICAL HYPOTHYROIDITIS

4. PERIMENOPAUSE

RECOMMENDATIONS

Clinical features in conjunction with reported increase of heart rate from supine to standing suggest a possibility of Postural Tachycardia Syndrome (POTS), although the duration of symptoms (since 12/26/16) has not been long enough to satisfy the diagnostic criteria for POTS. Possible etiologies may include post-stroke central dysautonomia, in addition to post-stroke central pain syndrome, but may also be secondary to subclinical Hashimoto’s thyroiditis, immune-mediated due to recurrent Herpes simplex type I infection or associated with perimenopausal state.

For completeness, I recommend obtaining the following diagnostic tests to rule out secondary causes if these have not been obtained already:

These labs have already been obtained:

ANA, anti-TPO Ab, anti-thyroglobulin antibodies, TSH, free T4, free T3, Ab, ESR, RF, CRP, -vitamin B12, magnesium, homocysteine, and other antibodies to rule out APS

- morning cortisol, -24-hr urine sodium test as an indirect measure of blood volume

- 24-hr blood pressure monitor before atenolol is initiated to rule out orthostatic BP spikes

These labs need to be ordered:

- anti-SSA and anti-SSB antibodies

- anti-DS DNA

- tissue transglutaminase Ab, anti-gliadin Ab.

- vitamin B1 whole blood, vitamin B6, vitamin E, vitamin D 25-OH, ferritin, copper

- anti-cardiolipin antibodies

- CK, lactic acid

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Therapeutically, the patient would benefit from a trial of atenolol 12.5 mg qam for the orthostatic tachycardia. For chronic neuropathic pain, I recommend using Lidoderm patches or Lidoderm cream, TENS unit, and whirlpool therapy, which is also good for the orthostatic intolerance.

Non-pharmacologic management should include increased salt intake of about 2 gm per day with a combination of dietary salt and salt tablets. Fluid intake should be at least 2L per day with a combination of Gatorade and water. Importantly, I recommend a graded exercise program using a recumbent bike, rowing machine, swimming or floor exercise. She should continue walking daily, but over-exertion from walking on treadmill for hours is not recommended at this time due to the ongoing autonomic symptoms.

I will speak with the patient in 4 weeks to discuss her progress. Please feel free to contact me should you have any further questions or concerns.

Sincerely,

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Svetlana Blitshteyn, MD

Director and Founder of Dysautonomia Clinic

Clinical Assistant Professor of Neurology

University at Buffalo School of Medicine and Biomedical Sciences

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