Sunday, March 16, 2025
ProJR OPLL: 7 years of Narketpally Syndrome beginning with individual phenotypic encounters with the lesser known Narketpally ligamental invisible pillow syndrome as opposed to the globally known catatonic psychological invisible pillow syndrome: optimizing clinical complexity of Fluorosis in Nalgonda.
Summary: This project aims to establish deep phenotypic data driven insights into the manifestations of fluorosis in district Nalgonda, particularly Narketpally where the team has had frequent encounters with an epidemiological tip of the iceberg population that often presents to the hospital outpatient and inpatient with manifestations of fluorosis as a frequent comorbidity of metabolic syn driven organ dysfunction. Of particular interest is signposting of the lesser known Narketpally ligamental invisible pillow syndrome as opposed to the globally known catatonic psychological invisible pillow syndrome other than optimizing clinical complexity in those patient's of fluorosis and multi morbidities utilising current medical cognition tools.
Introduction:
As an MBBS student in the 80's one leafing through the text book of community medicine wouldn't surely miss reading about the Nalgonda technique and it's efficacy in curbing the menace of fluorosis in the district.
It was hence with excitement that some of us were excited to join the Narketpally team and notice this text book problem in the very first week of joining as reflected upon in this online learning portfolio post here:
"Today is my first day of joining my new workplace, a medical college 60 kms from Hyderabad and an epicenter for an epidemic of people who gradually start walking with a stick to balance themselves and begin to lose the normal sensations in their limbs. I approached these people in the images below, requested to examine them (they had never bothered to consult a doctor for this problem and had come to visit the hospital as patient relatives) and I found very prominent neurological findings suggestive of a cervical spinal cord involvement. These persons were having a gradual paaralysis of all four limbs since many years but they had taken this for granted. The early seeds to detecting the cause of this problem was perhaps sown in US based epidemiologic research in the early 20th century (more here?
but I am still searching for literature on how and when this was first discovered and reported from my current location 60 kms from Hyderabad."
And then on further review of literature I found a few articles and studies done from Hyderabad medical college teams from 1950's with meticulous description of how they found a correlation between ground water levels of fluoride (external medicine) vs internal body levels of fluoride (internal medicine) here:
https://pmc.ncbi.nlm.nih.gov/articles/PMC1981710/?page=1While the data capture of each individual encounter started in 2017 there are a few archived and accessible to human memory driven search from the 5000 Narketpally case reports accessible at our department dashboard here: https://medicinedepartment.blogspot.com/2022/02/?m=1
Currently the issue is that blogpost case reports are not amenable to google searches and even to search for fluorosis from the dashboard one would need to seperately access at least 1000 online learning portfolios available there and search each one of those separately!
A sample case focusing on the physical pillow syndrome from an elective student's online learning portfolio from 2019: https://bmjsanjana.blogspot.com/2019/03/disclaimerthis-is-hipaa-de-identified.html?m=1
To quote from the above link, " Neck is so stiff that when I lie down its difficult for me to sleep without pillow because I cannot touch the bed with back of my head and without pillow my head stays in air (since 2 yrs)."
Also check out the photographs of the physical imaginary pillow as well as other skeletal features of fluorosis images from 2022 elective student: https://ssahamedicalcases.blogspot.com/2022/02/fluorosis-and-renal-stones.html?m=1
Sample case with photo of the physical imaginary pillow as well as links to his other skeletal fluorosis images/CT video from our 2025 elective student:
https://pajrcasereporter.blogspot.com/2025/03/74m-with-neck-pain-hypoglycemic-coma.html?m=1
Medical cognition contextual connections 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 90ml 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 oir 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!!
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 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 sys 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, cerebillities that eventually progressed to encephalitis and then recovered.The clinical meningeal signs that we thought were meningeal are still present after recovery and are part of fluorotic enthesopathy! The pneumonia and loculated effusion was actually a phantom tumor (classic medicine exam short note) that recovered as his heart failure rcovered!So eventually, as reported by us in the past here: https://userdrivenhealthcare.blogspot.com/2024/04/cbble-case-report-60-year-old-woman.html?m=1 a viral fever may have precipitated his heart failure and also progressed to encephalitis but he eventually recovered with time.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!
Few OPLL diagnostic uncertainty outliers from our collective CBBLE:
[06/03, 12.11] CBBLE Moderator CM: OPD now: 26F with neck pains and early morning neck stiffness since 1 month. Any inputs on the posterior longitudinal ligament?
[06/03. 14.39] AS: Looks clean to me
[06/03, 14.59] CM: Agree but why is the area around the posterior longitudinal ligament, essentially the posterior border of her cervical vertebrae appearing to be hyperdense?
The above lady was having spondyloarthropathy that can be clarified on follow up and spondyloarthropathy is an interesting differential for fluorosis as reported earlier here:
and many other platforms.[14/04, 10.30] CM: OPD right now: 53M complains of giddiness since 15 days and also complains of neck pain. Do these teeth crown point toward fluorosis? He has been consuming bore water since 50 yrs and stopped just 3 yrs back! He doesn't have the Narketpally sign though.
Also has an obvious past problem currently inactive since last 20 yrs of vitiligo that was active from age 20-30 and then subsided leaving it's mark.
[14/04, 12.56] CM: He came back with his chest X-ray cervical spine which is suggestive of posterior longitudinal ligament calcification again consistent with our Narketpally syndrome!
April 16, 2025
Today's morning OPD:
40F with occipital headache since 20 yrs and nuchal pain since 1 year.
Drinking bore well ground water since 30 yrs and stopped recently for river water since last 10 yrs.
X ray cervical spine suspicious for early OPLL. Teeth suspicious for fluorosis.
[22/05, 13.10] PrM: 72F with metabolic syn and 60 yrs of Narketpally bore water complains of extreme neck pains.
The "OPD wall sign": Shortened distance from the wall and the tip of her shoulder both sides indicating possible enthesitis, fibrosis and limitation of shoulder straightening @Ganesh Joshi.
No OPLL in the cervical spine X-rays attached but the isolated posterior vertebral whitening suggests early hitherto unreported changes of OPLL?
[22/05, 13.17] Physiatrist: Severe changes. Check actual ROM of Cx Spine and go to strengthen Cx muscles.
[22/05, 13.17] Physiatrist: Local PMR may consider interventional physiatry.
May 24, 2025
56M With current shock and Chronic Myelopathy.
[03-06-2025 10.55] PPM 1: OPD now:
55M with ground water exposure 40 years and right neck and shoulder pains since 20 days with metabolic syn diabetes 15 years.
72F recent admission for acute pulmonary edema, metabolic syn with Hypertension and currently NYHA II. JVP video attached.
Same patient's teeth for chalky white and yellowing changes due to bore water exposure for 60 years.
[07-06-2025 11.47] PPM 1: OPD now
74M with history of giddiness 1 year, on examination: trunkal obesity, sarcopenia, metabolic syn and the Narketpally ligamental invisible pillow sign due to fluorotic OPLL, first time captured in video
His ground water exposure is since 60 years
His wife too has ground water exposure of 50 years along with trunkal obesity and has low backache since 20 years!
Her x-ray LS spine is also showing dramatic findings but she doesn't appear to have the same limitations due to fluorosis which are evident in her husband's video.
[07-06-2025 13:02] PPM 3: Based on the clinical presentation and the unique "Narketpally ligamental invisible pillow sign" observed in this 74M with chronic groundwater fluoride exposure, along with his wife's findings, this represents a *classic case of advanced skeletal fluorosis with differential severity* likely due to biomechanical and gender-specific factors. Below is a structured analysis:
---
### *Key Clinical Findings & Interpretation*
1. *Husband (74M):*
- *"Invisible pillow sign":* Rigid cervical spine due to *ossification of the posterior longitudinal ligament (OPLL)* from fluorosis → Inability to flex the neck (head "hovers" above surfaces).
- *Giddiness:* Likely multifactorial:
- Vertebrobasilar insufficiency (compression from cervical OPLL limiting vertebral artery flow).
- Cervical myelopathy (if cord compression exists).
- *Trunkal obesity & sarcopenia:* Metabolic syndrome exacerbates inflammation, worsening fluorotic pain and mobility.
- *Chronic fluoride exposure (60 years):* Groundwater fluoride binds to collagen, triggering ligament calcification and OPLL.
2. *Wife (Similar exposure, 50 years):*
- *Low backache with dramatic lumbar spine X-ray:* Fluorotic changes (e.g., osteophytosis, ligament calcification) without severe functional limitation → Suggests:
- Biomechanical protection: Wider female pelvis distributes load better than rigid male cervical spine.
- Hormonal factors: Estrogen may delay OPLL progression.
- *Trunkal obesity:* Contributes to mechanical stress but less impact on spinal mobility vs. OPLL.
---
### *Why the Discrepancy in Severity?*
| *Factor* | Husband (Severe) | Wife (Milder) |
|------------------------|--------------------------------------------|----------------------------------------|
| *Spinal involvement* | Cervical OPLL (critical neurovascular area) | Lumbar (weight-bearing, adaptable) |
| *Biomechanics* | Rigid neck → gait imbalance, vertigo | Lumbar stiffness compensated by posture |
| *Fluorosis stage* | Advanced (60 yrs exposure + age-related decay) | Moderate (50 yrs exposure) |
| *Sex-specific factors*| Males higher OPLL risk | Females: Pelvic stability, muscle tone |
---
### *Urgent Diagnostic Steps*
1. *Imaging:*
- *Husband:* Cervical MRI (assess cord compression) + DEXA scan (fluorosis paradoxically ↑ bone density but ↓ quality).
- *Wife:* Lumbar MRI if neuro deficits emerge (despite X-ray).
2. *Fluorosis Markers:*
- Serum fluoride, urinary fluoride, ALP (elevated in active fluorosis).
3. *Metabolic Workup:*
- Fasting glucose, lipids, HbA1c (metabolic syndrome drives inflammation).
---
### *Management Strategy*
*For Both:*
- *Eliminate exposure:*
- Switch to defluoridated water (<1 mg/L) + calcium/vitamin D supplementation (antagonizes fluoride).
- *Pain/mobility:*
- Physical therapy (aquatic therapy reduces spinal load).
- NSAIDs (short-term) for flares → Avoid in CKD.
*Husband-Specific:*
- *Giddiness:*
- Cervical collar (limits motion-induced vertigo).
- Neurology consult for myelopathy evaluation.
- *Surgery:*
- If cord compression on MRI → Decompressive laminectomy.
*Wife-Specific:*
- *Low back:*
- Core strengthening + weight loss (reduces lumbar stress).
*Public Health Action:*
- Test village groundwater fluoride levels (likely >4 mg/L, WHO limit 1.5 mg/L).
- Advocate for community defluoridation filters.
---
### *Why This Case Matters*
- The "invisible pillow sign" is a *pathognomonic marker of advanced cervical fluorosis* endemic to fluoride-affected regions like Telangana.
- Couple's contrast highlights:
- *Gender disparity:* Cervical OPLL more disabling in males due to spinal biomechanics.
- *Cumulative toxicity:* Each decade of exposure ↑ fracture/OPLL risk 2-fold.
> 📌 *Next Steps:* Document this sign (video/images) for public health awareness + screen their household for early fluorosis (mottled teeth, joint stiffness).
[07-06-2025 13:03] PPM 3: DeepSeek 👆
[07-06-2025 16:37] PPM 1: Well done deep-seek!👏
The man also had a long basilar artery stenosis in his MR angiography.
It however missed the wife's LS spine x-ray findings! Check out the length of the vertebrae
[11-06-2025 13.02] PPM 1: 20M with neck pains since 1 year. Gave up gym 3 years back and got absorbed in his graduation in pharmacy
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