THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER 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.
[16-06-2025 13.23] PPM 1: OPD now
52F with anger issues since 2021. Got operated for thyrotoxicosis in 2023 and currently having progressively worsening gait noticed by family members since May 2025.
[18-06-2025 07:25] PPM 1: Morning CBBLE session around this patient:
[17/06, 22:51] +91 pan India clinical discussion fora: What was the cause here
[18/06, 07:17]cm: The video shows a broad based ataxic gait that on further examination revealed more cerebellar signs in the form of intention tremors and dysdiadochokinesia.
Her anger issues since 2021 got resolved on psycho pharmacological Mx even as she got operated for thyrotoxicosis in 2023 and it's intriguing as to why she's currently having progressively worsening gait noticed by family members since May 2025 although her cranial MRI is normal suggesting that her cerebellar abnormalities could be early and possibly due to a demyelinating cause.
Is there a connection between thyrotoxicosis and cerebellar involvement? @PPM3 @PPM6
[18/06, 07:18] cm : @Meta AI any studies showing a connection between thyrotoxicosis and progressive cerebellar signs and symptoms?
[18/06, 07:18] Meta AI: Thyrotoxicosis can indeed cause cerebellar symptoms, including ataxia, due to the impact of excessive thyroid hormones on the nervous system. Research suggests that thyroid disorders, such as hypothyroidism and hyperthyroidism, are linked to cerebellar dysfunction.
Key Findings:
- Cerebellar Syndrome: Thyroid disorders are considered a common cause of cerebellar dysfunction due to hormonal imbalance. Cerebellar impairment often occurs in hypothyroidism and Hashimoto encephalopathy.
- Symptoms: Patients may exhibit ataxic gait, intention tremors, dysdiadochokinesia, and other cerebellar signs.
- Reversibility: Some studies suggest that cerebellar symptoms may improve with normalization of thyroid hormone levels, but persistent or progressive symptoms can occur, raising questions about long-term effects or co-existing conditions.¹ ²
Possible Causes and Associations:
- Thyroid Hormone Imbalance: Excessive thyroid hormones can affect the cerebellum, leading to impaired coordination and balance.
- Autoimmune Conditions: Conditions like Graves' disease and Hashimoto encephalopathy may contribute to cerebellar dysfunction.
- Other Factors: Certain medications, infections, and systemic conditions can also play a role in cerebellar symptoms.³
Further Investigation:
Given the complex relationship between thyrotoxicosis and cerebellar involvement, further evaluation is necessary to determine the underlying cause of progressive cerebellar symptoms. This may include⁴:
- Genetic Testing: To rule out genetic ataxias or other conditions.
- Imaging Studies: Such as MRI to assess cerebellar structure and function.
- Laboratory Tests: To evaluate thyroid function and other potential contributing factors.
In conclusion, while the exact relationship between thyrotoxicosis and cerebellar involvement is not fully understood, research suggests a link between thyroid disorders and cerebellar dysfunction. Further investigation is necessary to determine the underlying cause of progressive cerebellar symptoms in individual cases.
[18-06-2025 07:25] PPM 1: @PPM5 please share her current thyroid function tests
[18-06-2025 07:27] PPM 3: Will do a literature review today and share my findings sir
[18-06-2025 07:28] PPM 5: By afternoon the report will come sir
[18-06-2025 07:47] PPM 1: Also share the patient's full history timeline so that @CR can archive it in the case report
[18-06-2025 08:06] PPM 1: CBBLE discussion continued:
[18/06, 07:56] +91 hu2: What I am thinking is it is not due to cerebellar lesion but due to drug causing EPS, won't be appropriate to check patient for cerebellar signs, what I suggest stop olanzapine and evaluate.
[18/06, 07:58] +91 hu2: We can tapper olanzapine and shift her on Fluoxetine.....
[18/06, 07:58] +91 hu2: Than evaluate....
[18/06, 08:00]cm: @PPM3 please share what psychiatric medications she's taking.
One of the reasons for calling her again to OPD from her wards yesterday was to review these but couldn't be done as they didn't bring the papers
[18/06, 08:02] +91pan india clinical discussion fora hu2: Or what else we can do if is it demylenating disorder as seen in along with autoimmune hyperthyroidism, than we can also have trial of IV steroid to see the effects.
[18/06, 08:03]cm: EPS was an important first possibility cognitive bias we had while evaluating her but then her cerebellar signs were too dominant to be able to ignore
[18/06, 08:04]cm: Yes one of the reasons for her admission is to go ahead with the iv steroid trial
[18-06-2025 14:45] PPM 1: Update from @PPM3's evaluation yesterday:
She was on Olanzapine 7.5mg taken at night, with Clonazepam 0.25mg SOS.
However, her most recent psychiatry review notes (dated 22/4/2025) say that she was not compiant with medication for a while due to financial issues.
In 2021, when her psychosis diagnosis was made, she was also on Fluoxetine. It was slowly tapered from 40mg to 20mg, and then stopped after some time.
[18-06-2025 14:46] PPM 4: •Any previous MRI of Brain
•Any ischemia? (post operative thyroid sx)
•Does she have any unhealed trauma?
[18-06-2025 14:47] PPM 1: MRI normal
[18-06-2025 14:47] PPM 4:? Psychiatric h/o sir
Today's thyroid report
[18-06-2025 15:14] PPM 4: What kind of thyroid surgery sir, any Discharge summary after surgery.
[18-06-2025 15.15] PPM 1: Total thyroidectomy
[18-06-2025 16.12] PPM 1: This is where her history begins on 3/3/21👆
On Olanzepine since then
[18-06-2025 16:17] PPM 4: Sir did psychiatric symptoms start before surgery?
i think thyroid harmonal imbalance caused her psychosis
[18-06-2025 16:17] PPM 1: Yes
[18-06-2025 16.18] PPM 1: This is her first OPD visit after the surgery
[18-06-2025 16:18] PPM 4: Sir I think we just need to balance those harmones
and maintain them in normal levels gradually
[18-06-2025 16:19] PPM 4: And also give her psychiatric medication for current symptoms.
[18-06-2025 16.20] PPM 1: So to balance the hormones the entire thyroid gland was removed and thyroxine replacement was started since post surgery May 2023
[18-06-2025 16:20] PPM 1: And what about her gait? Did you see the video in the case report?
[18-06-2025 16:23] PPM 4: Can psychiatric medications dose might have caused it (cerebellar gait as said in video) adjust the dose of psychiatric medications and also psychotherapy is needed.
[18-06-2025 16:34] PPM 1: No such olanzepine induced cerebellar disturbances reported in the past globally but it's possibly due to immune mediated cerebellar dysfunction as you will find in the case report archived link in the description box. Even queries have been archived there!
[18-06-2025 16:40] PPM 4: I think i need more knowledge to read these images 😅
[18-06-2025 16:40] PPM 4: I haven't revised my radiology yet
will try to find it
[18-06-2025 16:43] PPM 1: Just normal anatomy
Nowadays LLMs can read better @PPM 7
[18-06-2025 16:45]PPM 4: 😅😅
i just don't want to make a mistake
on my input
[18-06-2025 16:46] PPM 1: No problem there are many team members who will correct and most importantly we have LLMs here
[18-06-2025 16:48] PPM 4: LLMs means 😅
[18-06-2025 16:50] PPM 1: @Meta AI what does LLM mean? What are you?
[18-06-2025 16:50] Meta AI: LLM stands for Large Language Model. I'm Meta AI, powered by Llama 4. Think of me like a super-smart computer program that can understand and respond to human language. I'm here to help with whatever you need, whether it's answering questions, generating text, or just chatting 🤖💻. What's on your mind?
[18-06-2025 16:50] PPM 4: I'm just a MBBS graduate sir
[18-06-2025 16:51] PPM 1: School students can do what we are doing. Very near future alk these will be practiced in school by citizen astronauts
[18-06-2025 16:51] PPM 4: Yeah
[18-06-2025 17:40] PPM 4: All? 😅
[18-06-2025 17:46] PPM 1: All
[18-06-2025 17:47] PPM 4: Got it
[18-06-2025 17:47] PPM 4: U tested me a lot 😅😅
whether I'm using ai or not.
genuinely haven't used AI to answer or raise questions
[18-06-2025 17:48] PPM 4: Just using my ongoing Neet pg prep knowledge 😅
[18-06-2025 17:49] PPM 4: Im trying to see the patient beyond their labels
and where the imbalance is and what might have caused it
[18-06-2025 17:49] PPM 4: Where can we adjust it
[18-06-2025 17:50] PPM 4: I don't know exact doses and all the minute details..
but yeah i tried to genuinely answer ur Tests
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