When you get toxicity, when you get those myelin sheaths that are having problems with their synthesis, what do you see in terms of patient presentation?

So for this, we really have to go back to our first year of medical school, and once again, whenever I hear the term decussation or upper or m- lower motor neuron symptoms, I inherently cringe like a lot of other ER docs.

But these patients will have a combination of both upper and lower motor neuron symptoms due to demyelination of, one, the dorsal columns, two, the lateral corticospinal tracts, and three, peripheral nerves.

So let's take this super slowly.

Effects on the dorsal column will lead to diminished sense of proprioception, your, your sense of space and self, vibration and fine touch.

Effects on the lateral corticospinal tracts lead to upgoing plantars, hyperreflexia, weakness of the voluntary distal muscle control, and then effects on the peripheral nerves will lead to numbness and tingling and weakness in a glove and stocking pattern.

And if you recall, those are symptoms that start initially in the feet and hands that progressively spread proximally towards the ankles and wrists.

So how do you actually make this diagnosis? Is it just based on the patient having those type of symptoms, or is there more here?