07-03-2025
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
Afternoon ward:
Bedside: 74M with neck pains since one week. Hypoglycemic coma one episode this morning followed
by recovery and then again sudden altered sensorium since two hours!
On examination severe neck stiffness and positive kernigs and brudzinskis signs
Bench: radiology of the spine attached. @PPM2 we need to build a cervical spine OPLL image database
ASAP!
[07-03-2025 15:56] PPM 1: @PPM3 share his chest X-ray PA view and CT head
[07-03-2025 16:13] PPM 2: OMG why Hypoglycemia?
[07-03-2025 16:14] PPM 1: @PPM3 please share his history.
Past diabetes? Any oral hypoglycemics?
[07-03-2025 18:45] PPM 2: What's the diagnosis for this?
[07-03-2025 19:20] PPM 3: Patient initially went to a doctor outside for general checkup and for back
& neck pain, where he was found to have gross hydrouretronephrosis. Then he was referred to KIMS
hospital for urologist opinion.
There he was advised for CT Kub, which the patient did not get it done right then.
He also had neck pain for which he was referred to ortho, where he was admitted for? Cervical
spondylosis.
During his stay in ortho wards, he developed sudden onset of fever spike with respiratory distress. After
shifting to sicu, his grbs was found to be ~30 mg/dl with seizure like activity -? hypoglycemic seizures
with altered sensorium. After correction with IV dextrose, patient sensorium improved and he could
perform his routine activities.
But after a while his blood glucose levels started dropping again, and was transferred to GM dept.
Here dextrose maintenance fluids were started, but patient had recurrent hypoglycemic episodes.
In the afternoon patient sensorium turned to worse as he became irritable, altered with was making
incomprehensible sounds. On examination kernigs sign seemed positive with neck rigidity+ (?
meningitis,? cervical fluorosis)
On Auscultation - right sided coarse crepts +.
No previously known T2dm, htn, tb, epilepsy,cad, cva sir.
Haven't used any OHAs or injectibles.
[07-03-2025 19:21] PPM 3: Community acquired pneumonia
?Hypoglycemic seizures
Post renal aki with gross hydrouretronephrosis 2° to right upper ureteric calculi, sir.
https://youtube.com/shorts/ig1HZlv-FDY?si=P8Q5k2ypjyAw6SJP
CT Head sir.👆
[07-03-2025 19:39] PPM 2: What is the diagnosis for that Hypoglycemia?
Is there an endocrinological cause for sudden onset Hypoglycemia (for patients not known to have
diabetes or on insulin)?
[07-03-2025 19:40] PPM 2: What is the cause of sudden onset Hypoglycemia? Everything else is
secondary now.
[07-03-2025 19:41] PPM 2: All of these are post blood or imaging diagnoses. None correlate with the
clinical history you gave.
Does a CAP come in with such an xray at all?
PPM 1 -👍
[07-03-2025 19:43] PPM 2: I wish I could see the pituitary gland here!
[07-03-2025 19:46] PPM 4: Fluorosis Or DISH
[08-03-2025 12.11] PPM 1: Today's Update on this same 74M patient:
So to summarise from what we have known about him till now:
Bedside: 74M presents with neck pain and get's admitted with orthopaedic but eventually because of his
altered sensorium gets transferred to General Medicine where he is found to have hypoglycemia and
while he recovers after dextrose, he again slips into altered sensorium, shows meningeal signs along
with a large right lobar consolidation and CSF turns out to be normal suggesting meningism as an
explanation of his meningeal signs.
Bench: Radiology shared above
Interesting presentation of atypical pneumonia presenting with atypical symptoms that hides pneumonia
as the underlying cause. We still don't know what precipitated his pneumonia.
We know that he already has OPLL due to our endemic fluorosis but is it possible that his neck pain
presentation was due to inflammatory signals from the lung parenchyma getting transcribed through his
enthesis? Just wondering out loud.
[08-03-2025 12:19] PPM 2: Is TB being considered? Is that a Tubercular Empyema?
[08-03-2025 12:19] PPM 2: Ultrasound of the Lungs?
[08-03-2025 12:20] PPM 2: Surely a C-peptide and ketones would have told us if this is Insulin
mediated or non-insulin mediated. Possible?
[08-03-2025 12:26] PPM 1: Yesterday done. Confirmed the loculated effusion both anteriorly and
posteriorly however the fluid appeared to less to tap.
[08-03-2025 15.14] PPM 1: Afternoon Update of 74M in acute care ward:
Again we are seeing the same recurrent pattern of potential TBM in CSF by noticing hypoglycorrhaecia
and increased proteins! Now we need to think if the pulmonary consolidation is actually a tubercular
pneumonia! @PPM5 do we have his sputum AFB?
[08-03-2025 15.17] PPM 5: No sir.
[08-03-2025 16.15] PPM 1: Let's also get his pleural tap
[08-03-2025 16.16] PPM 5: 👍
[08-03-2025 16.22] PPM 1: This is the image of his clear CSF taken out yesterday! Could the gram
positive cocci visible in the CSF be contaminant from the culture vial?
Again we are seeing the same recurrent pattern of normal CSF cell count (reported by pathology as just
5 cells) and potential TBM in CSF by noticing hypoglycorrhaecia
and increased proteins!
[08-03-2025 16.44] PPM 1: The microscopic images of the gram positive cocci shared by our
microbiology with the observation that the Gram positive cocci are scattered here and there.
Uniform size (unlikely stained particle artifact).
10-03-2025
PPM 1 - PMR Update for 74M
His hypoglycemia appears to be a one time event and not sustained due to ongoing sepsis or likely that
it recovered as sepsis recovered? Complex questions for our sepsis project @PPM2?
Compare the make shift fever chart shared on Saturday with this one. 👆
[10-03-2025 15.27] PPM 1: 74M Afternoon PMR update:
[12-03-2025 09.45] PPM 1: Today's update on our meningitis patient:
Bedside: comatose with difficult to elicit dolls eye movements because of cervical OPLL
Bench: CSF smear pneumococci
Culture and CBNAAT awaited.
[12-03-2025 09.47] PPM 1: During attempt at dolls eye reflex elicitation he appears to be having a
strong conjugate eye deviation to the right.
This CT showing his pneumonia and abdomen 👆
[12-03-2025 15.40] PPM 1: Ward 74M afternoon update:
Patient appears conscious in stark contrast with today morning's sensorium
[12-03-2025 15.42] PPM 1: Captured his imaginary pillow sign (unpublished) @PPM4 @PPM3
[12-03-2025 22:18] PPM 2: Hmmm is it the same chap with acute hypoglycemia sir?
[12-03-2025 22:18] PPM 2: Pneumococcal Waterhouse-friedrichson? 😁
[13-03-2025 06:41] PPM 1: Yes https://pajrcasereporter.blogspot.com/2025/03/74m-with-neck-pain-
hypoglycemic-coma.html?m=1
Morning twist in 74M's internal medicine data!
Check out his previous chest X-ray and Hrct lung video shared here:
And compare those with today's chest X-ray attached here!
Does this suggest that it was a phantom tumor and primarily due to heart failure including the so called
pneumonia explaining his normal blood white cell counts!
Actual pneumonia would not resolve this quickly on chest X-ray? @PPM2
Check out two similar patients from our hospital logged by our elective students in 2019 and 2022 who
also had the physical imaginary pillow sign just like this patient here 👇@~PPM7
Conversations to be mixed in the upcoming commentary: @~PPM7 @~PPM4
[17/03, 10:00]ms: Yes sir ne had a raised jvp
But we have not treated his heart failure
How will it reduce?
Without treating?
[17/03, 10:02]cm: What is the best treatment for heart failure?
Bed rest!
[17/03, 10:03]ms: Is it possible with good lv function?
[17/03, 10:05]cm: Yes Hfpef can easily do that as we keep seeing from time to time!
Need to see his echo video to check out the magnitude of LVH and LA diameter over Aortic root to put
more weight to Hfpef as a cause
ms: medical student
cm: CBBLE moderator
[18-03-2025 16.06] PPM 1: Hospital timeline graphical update on 74M with altered sensorium with
multiple causes and effects!
Today we found more leads in his history from his daughter into his altered sensorium!
[19-03-2025 11.35] PPM 1: Medical cognition rethink Update of 74M:
Revisited the patient's history with the daughter now in our quest for causes and effects:
Patient was having forgetfulness since two months. He takes 90 ml of alcohol everyday and stopped 20 days back (before admission) as he was unable to earn enough from his tailoring work to maintain his regular drink!
After 18 days of this event of his stopping alcohol, he developed fever and vertigo and was taken to a local doctor who gave injections and while his fever subsided, he started having hallucinations imagining he was running the sewing machine when he was lying on his bed!
On the day he got admitted, he was brought to our psychiatry OPD for the hallucinations , although soon after, the daughter noticed that he was also having slurred speech and ataxia and hence brought him to our general medicine OPD where he was asked to get a chest X-ray and shown directions to radiology OPD mentioning that it's next to Orthopedic OPD and when they inquired in Orthopedics OPD they admitted him in orthopedics ward!! What a wild story! Patient stories can be the wildest truths stranger than fiction! @~PPM3 @~~PPM4
Then in the Orthopedic ward he developed an episode of diarrhoea with fecal incontinence and severe sweating following which he became comatose and was found to have hypoglycemia which was promptly corrected and he regained consciousness but by afternoon had slipped again into coma following which we noticed meningeal signs and removed his CSF and got his chest X-ray suggestive of right lobar consolidation along with loculated pleural effusion and treated him for pneumococcal pneumonia and meningitis!
After a few days the patient suddenly recovered his sensorium and his chest X-ray also normalised suddenly which sowed the first doubt of our diagnosis! On reviewing his phenotype, he appears to have a metabolic syn phenotype with severe sarcopenia and substantial visceral fat which the daughter claimed was much more earlier!
In the light of the data above we are currently thinking this was more of a viral vestibulitis, cerebellitis that eventually progressed to encephalitis and then recovered.
The clinical meningeal signs that we thought were meningeal are still present after recovery @ PG Kims 2022 and are part of his fluorotic enthesopathy! The pneumonia and loculated effusion was actually a phantom tumor (classic medicine exam short note) that recovered as his heart failure recovered!
So eventually, as reported by us here in the past, a viral fever not only precipitated heart failure but this time also progressed to encephalitis but recovered.
The heart failure and even his potential cerebral neurodegenerative disorder going by his history of recent progressive dementia are all a part of his metabolic syn and NCD!
@CR
@PPM5 @PPM2
[19-03-2025 13.18] PPM 1: 👆74M's current mini mental score! @PPM4 @CR
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