Ibrahim Rashid-Amyotrophic Lateral Sclerosis-(Maldives)

Name: Ibrahim Rashid
Sex: Male
Nationality: Maldivian
Age: 50Y
Diagnosis: Amyotrophic Lateral Sclerosis (ALS)    
Discharge Date: 2018/07/09

Before treatment:
The patient felt weak in his left arm in 2012, he couldn’t raise it over shoulder height and it was hard for him to grasp with his left hand. As the disease progressed his right arm became the same so he went to a local hospital and was diagnosed with ALS. He took Riluzole 50mg twice a day but his condition still got worse. He felt weak in his legs in 2013, it was hard for him to go up and down stairs and he also had facsiculation. In 2014 he spoke lower and his speech was unclear, it was hard for him to chew food and sometimes he choked when he drank. It was hard for him to breathe in a lying position. At present his muscle power in the four limbs is weak, he has high muscle tension, he can’t sit up, stand or walk by himself. It is hard for him to chew or swallow food, he chokes when he is drinking and he cannot speak clearly.
His spirit is normal, he eats small pieces of food and he sleeps well. His urination function is normal, he defecates once in 2 days.

Admission PE:
Bp: 122/87mmHg, Hr: 71/min, breathing rate: 19/min, body temperature: 36.6 degrees. weight: 63.2Kg. The patient has normal physical development and the nutrition status is good. There is no injury or bleeding spots of his skin and mucosa, no congestion of the throat and no tonsil swelling. Chest development is normal with decreased chest movement when he is breathing. The lungs breathing sounds were low with no rales. The heart beat was powerful with regular cardiac rhythm and no murmurs. The abdomen was soft with no masses or tenderness. His liver and spleen were normal, shifting dullness is negative, he has a normal spinal column, no edema of the legs, skin temperature was lower than normal and the dorsalis pedis pulse was normal.

Nervous System Examination:
Patient was alert, mental status was good, he had a slur in  his speech. His memory, calculation and orientation abilities are normal. Both pupils were equal in size and round, diameter of 3 mm, react well to light, with no nystagmus and the eyeballs can move freely. The bilateral forehead wrinkle and nasolabial groove are symmetrical, he can make his tongue extend out as normal to the lip side and there was tongue muscle atrophy. Showing teeth was normal, his tongue movement was limited, his tongue could not push against the cheek powerfully. He could bulge his cheek with air leakage, chewing ability was weak, his bilateral soft palate could not lift powerfully and the uvula was turned to the left side. There was muscle atrophy of his shoulder girdles, arms, thenar muscles and hands interosseus muscle. His neck was soft and he could not turn his neck or shrug powerfully. The right arm adductor muscle power was 2 degrees, he could not do abduction. Left arm adductor muscle power was 2 degrees, the abduction muscle power was 1+ degree. His right hand fingers can move but he can only move his left thumb and his hands could not grasp. The leg muscle power was 3- degrees, his arm muscle tone was low, the leg muscle tone was increased. The bilateral biceps reflex and radial periosteal reflex were decreased. The  patellar tendon reflex of the legs was active, Achilles tendon reflex was hyperactive. The bilateral palm-jaw reflex was positive, the left side Hoffmann sign was negative, the right side Hoffmann sign was positive. The bilateral Babinski sign was neutral. Patient could not perform the finger to nose test, the fast alternate movement and finger opposite movement because of weakness and abnormal muscle tone. He could not perform the heel-knee-tibia test and the meningeal irritation sign was negative.

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

Post-treatment:
After 14 days treatment his breathing function got better, the blood oxygen concentration was maintained at 98-99%. His speech was louder and clearer. The movement of his tongue was more flexible, his chewing and swallowing function was better and choking was reduced. He could eat more than before and in a shorter eating time. His neck control ability improved, he could lift up his head and turn his neck more flexibly. The muscle strength of both arms was increased，the adduction is faster and larger than before and his elbow joints could now move. His forearm could lift up from the bed，his left thumb，middle finger and index finger could move. The leg muscle power increased also and he could lift his legs from the bed higher than before and against some force. Both legs could now be bent by himself and the feet could now bend backwards. In a  standing position he now required  less power from others  helping him, he could lift his legs with more flexibility and his  movement endurance improved.