Hi all, I have a friend whose wife got some stange symptoms.  She had been investigated by nearly all the tests available in Hong Kong and had been seen by many doctors.  I am still not sure what the disease is and not even whether it is functional or organic. I shall be obliged if any of you can shed any light on this case. (sorry the case presentation is long)         An case of bilateral, progressive numbness and pin-pricking sensation of the tongue, lips, gum, palates and pharynx. To:             All medical colleagues in the world.                 Any bright ideas or suggestions on diagnosis or                 management are welcome. A 45 year old house wife noted  progressive numbness and pin-pricking sensation over                  the tongue, gum, lips, palates and then the pharynx for one year.         The symptoms started one year ago when she noticed soreness                     of the tip of the tongue.  She was seen by a dentist and was                               diagnosed to have repeated minor injury due to an ill-fitting                             dental filling between the lower incisors.  The dental filling was                         removed but symptoms persisted. The soreness and then pin-                              pricking sensation became more severe and these feelings                          spread to the gum, lips and posterior part of the tongue.  Taste                          was said to have diminished, though present.  The patient                                 also noticed more frequent injury by fine fish-bone and she                     attributed it to the diminished sensation of her tongue and buccal               cavity.  Injury to      the buccal mucosa was said to cause less pain                   than before.  In the past 3 - 4 months, she noticed discomfort of the                pharynx ( a numbness feeling which was similar to that due to local             anaesthetic spray ).  She also felt that her speech was a bit more                  clumsy than before.  No difficulty in swallowing was noticed.                 Examination 6 months ago showed that her teeth and mucosal                      surfaces of the gum, tongue, palates, floor of the mouth and cheek                  were normal.    There was bilateral diminished pain and tactile                               sensation over the gum, tongue and palates and lips.  Salty and                         sweet taste was intact over anterior two third and posterior one third              of the tongue.  No _object_ive speech defect was noticed.  Other                       cranial nerves were normal.  No other neruological deficit was                                detected.                   She was seen by a neurologist and M.R.I. of the brain stem with                 angiogram was done which showed  no evidence of brain stem or                   focal intracerebral abnormality.  EMG and light evoked potentials                     were normal.  EB virus antibodies were negative.  Detailed report                    please refer to appendix. She was also seen by a dental surgeon who discovered nothing abnormal in her gums, tongue and buccal cavity.                 She was treated with anxiolytic medications for 2-3 weeks but no                 improvement was noticed.                 The patient said she had experienced similar numbness and                       pin-pricking sensation of her lips and tongue 3 years ago                                       immediately after she had bilateral myringotomy for her                                     Eustachian tube syndrome. The feeling was so distressing that                     she requested to have the myringotomy tubes removed.  The                                 symptoms subsided 2 - 3 weeks after the tubes were removed. Past Health                                         1).     Right hemithyroidectomy in Feb. 1995 because of a thyroid                            adenoma                 2).     One episode of chronic cough from Mar. 96 to Aug. 96 with                       enlarged mediastinal lymph nodes.  Cough and lymph node                                 enlargement subsided later.                 3).     Hypercholesterolaemia on dietary control Physical Examination                 Examination recently showed the same neurological signs as 6                    months ago.  The external appearance of the tongue, gum lips                   palates and buccal mucosa was normal.  Pain and tactile sensation          was diminished over these areas. Salty and sweet sensation was                    intact in the whole tongue.  Other cranial nerves were normal.  No                         other neurological deficit was noticed. M.R.I. of brain in June 94 No focal areas of abnormal signal intensity is noted in the cerebral and the cerebellar hemispheres as well as in the brain stem and the cerebello-pontine angles.  The internal auditory nerves are unremarkable. The ventricular system is normal.  The sulci and the cisterns are unremarkable. The pituitary and the other visible cranial nerves are also normal.  The nasopharynx and the paranasal sinuses are clear.  No lesion is seen in the region of the cavernous sinus.  The 5th cranial nerves are unremarkable. CONCLUSION: No focal intracerebral lesion is seen. M.R.I. of brain on 4th Oct 96 Clinical Information: Chronic cough with hilar L.N. enlargement.  Perioral numbness including tongue.  To rule out hilar lymphadenopathy?  brain stem lesion. FINDINGS: No focal area of abnormal signal intensity is seen in the brain stem, the cerebral and the cerebellar hemispheres.  The temporal lobes are symmetrical and are normal.  The ventricular system is normal.  The sulci and the cisterns are within normal limits.  The visible cranial nerves and the pituitary are also normal.   No abnormality is seen in the nasopharynx.  The paranasal sinurses and the mastoids are clear.  No abnormal enhancing structure is seen after gadolinium injection. Satisfactory flow signal is seen in the anterior, middle and the posterior cerebral arteries.  The internal carotid artery and the basilar artery are normal.  Both vertebral arteries are patent in the neck and are of similar calibre.  The carotid bifurcations are also normal. COMMENTS: No evidence of any brain stem lesions or other focal intracerebral abnormality.  The MR cerebral antiogram is also normal. M.R.I. Thorax with gadolinium on 4th Oct 94 FINDINGS: A tiny nodular soft tissue thickening is seen in the mediastinal fat behind the ascending thoracic aorta, anterior to the trachea and above the right main pulmonary artery.  This is isointense on the T1 weighted images outlined by the hyperintense mediastinal fat.  It is under 1cm size.  It may represent a small lymph node.  There is no enhancement after gudolinium injection.  The rest of the mediastinum is unremarkable.  There is no suspicion of any hilar lymphadenopathy.  No focal areas of abnormal signal intensity is seen in the lungs.  There is no pleural fluid or mass lesion. The rest of the thorax is unremarkable. COMMENTS: The appearance could be due to the presence of a tiny lymph node in the mediastinum but this is probably unchange in size from the previous CT. There is no enhancement after gadolinium injection.  Active pathology is therefore probably unlikely. Thank you, Dr C P Ho, FRCP (Edin)