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Rogelio Enriquez De Anda-Amyotrophic Lateral Sclerosis-(USA)

Author Zhangqi Views Posted at 2020/04/16

Name: Rogelio Enriquez De Anda
Sex: Male
Nationality: USA
Age: 63Y
Diagnosis: Amyotrophic Lateral Sclerosis (ALS)
Discharge Date: 2019/09/17

Before treatment:
There was progressive weakness of both legs with muscle atrophy for 3 years and respiratory dysfunction for more than 6 months. The patient had no obvious cause of left foot drop 3 years ago and it gradually developed to weakness of the left leg and the disease progressed slowly. Muscle tremor began to occur 2 years ago and there were more on the left side than on the right side. It was diagnosed as "ALS" 1 year ago. Four treatments of stem cell therapy (intramuscular injection) were given 10 months ago but his condition did not improve. Weakness of the right leg began to appear 8 months ago and respiratory dysfunction began 6 months ago with feelings of chest tightness and dyspnea from time to time. At present the patient's arms are basically normal, he is unable to stand or walk, the respiratory function is impaired, the language and swallowing function are basically normal and there is no choking.
He has normal sleep and spirit, urinary incontinence, takes regular oral oxybutynin and his defecation function is basically normal.

Admission PE:
Bp: 133/87mmHg, pulse rate: 87/min, breathing rate: 22/min, body temperature: 36.3 degrees. The patient has normal physical development and good nutrition. There is no damage or bleeding spots of the skin or mucosa, no cyanosis of lips, a symmetrical chest, poor chest mobility, reduced respiratory sound of the right lung, unremarkable respiratory sound of the left lung and no dry or moist rales heard. Blood oxygen saturation 94-95%, strong heart sound, regular heart rhythm, no obvious murmur heard in the valves, a flat abdomen, normal liver and spleen, mild pitting edema of both legs and dorsal artery pulsation of the feet palpated.

Nervous System Examination:
The patient was alert, in good spirit, had clear speech, normal memory,  calculation and orientation abilities. The diameter of both pupils was 3 mm, reacting sensitively to light with free eyeball movement. He had a symmetrical forehead wrinkle and nasolabial fold. There was unremarkable soft palate-lifting bilaterally, the uvula was in the middle, tongue was in  the middle when extended,  no skew when showing the teeth, mild air leakage on the left side  when puffing the cheeks. Muscle atrophy was observed of both shoulder girdles and the legs. He had a soft neck, normal neck-turning and shrug. There was grade 5  muscle power of both arms, limited extension and flexion of the left elbow, limited flexion of the right elbow. Grip power was grade 5 on both sides, with grade 2+ power of the right leg and grade 1 of the left leg. There was normal muscle tone of the 4 limbs and reduced tendon reflexes of the 4 limbs. A negative Hoffmann sign, Rossolimo sign, and Babinski sign bilaterally, normal finger to nose and fast alternate movement. The bilateral heel-knee-tibia test cannot be done due to muscle power issues. There was a negative meningeal irritation sign.

Treatment:
After the admission he was diagnosed with ALS and received 3 nerve regeneration treatments (neural stem cells and mesenchymal stem cells) to repair his damaged nerves, replace dead nerves, nourish nerves (Edaravone, ganglioside, neurotrophic factors, nerve growth factor), improve body environment, regulate his immune system and improve blood circulation. This was combined with rehabilitation training and a non-invasive ventilator.  

Post-treatment:
After 14 days treatment his respiratory function got stronger with blood oxygen saturation maintained between 97-99%. Both legs got stronger, especially the left side, with the left leg's distal muscle power getting to grade 3, and proximal muscle power getting to grade 2. He could bend his feet easier and his legs became more flexible. His waist and back got stronger remarkably and he was now able to stand up with some assistance from others.


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