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 BASD INPUTS.
[11-09-2025] PPM 1: 
[12-09-2025 15.12] PPM 1: Paroxysmal atrial fibrillation noted on 9th and 12th morning
[12-09-2025 15.22] PPM 1: Clinically during this cross sectional observation at 3:14 PM appears to be still in atrial fibrillation.
[12-09-2025 15.24] PPM 1: Echocardiography an hour ago:
[11-09-2025 16:25] PPM 1: @PPM5 see if you can get the temperature charting done by an intern
[11-09-2025 16:25] PPM 5: Okay sir
[11-09-2025 16:27] PPM 1: What is the evidence of UTI in this man? @PPM4
[11-09-2025 16:29] PPM 1: Initially had oluguria on day of admission with 600 ml from 8-9/9/25
From next day input output was balanced everyday at 2-2 lts
[11-09-2025 16:31] PPM 4: patient had history of burning micturition sir and also cue showed pus cells and color of urine on first day was a bit different on presentation
[11-09-2025 16:32] PPM 1: Urine culture?
[11-09-2025 16:32] PPM 4: He was dehydrated on first day sir
[11-09-2025 16:32] PPM 4: It was supposed to come today
but the micro dept said they will dispatch tomorrow.
[11-09-2025 16:37] PPM 1: @PPM 3 the current diagnostic uncertainty is around the quadriparesis heralded by fever and a past history of quadri/paraparesis in 2016 when he was operated with a lumbar spinal laminectomy following which he gradually recovered with normal walking abilities till ten days back when he again developed weakness of lower limbs and has been bedridden since last 3 days
[11-09-2025 16:39] PPM 1: Unfortunately, we don't have the 2016 MRI (although done in our hospital) to compare with the current MRI changes visible because if the same changes were there even in 2016 when he reportedly fell from a height of 12 feet when plastering the wall, then spinal surgical intervention at this point of time may not be useful
[11-09-2025 18:30] PPM 3: Based on the MRI images you've shared—particularly the sagittal and axial views of the cervical and thoracic spine—here’s a professional radiological impression tailored to the clinical context of quadriparesis following fever and a prior history of lumbar laminectomy:
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🧠 Radiological Impression: Cervical and Thoracic Spine MRI
1. Cervical Cord Signal Changes
- There appears to be intramedullary T2 hyperintensity within the cervical spinal cord, possibly spanning multiple levels.
- This suggests myelopathy, which could be inflammatory, infectious, ischemic, or compressive in nature.
- No overt syrinx or cavitation is seen, but the cord contour may be slightly swollen.
2. Disc and Vertebral Findings
- Mild to moderate degenerative disc disease is evident, with some posterior disc bulges—particularly at C4–C5 and C5–C6.
- These may contribute to ventral cord indentation, though not severe enough alone to explain the acute quadriparesis.
3. Spinal Canal and Cord Compression
- No frank spinal canal stenosis or cord compression is seen at a level that would explain sudden deterioration.
- However, dynamic instability or missed subtle compressive lesions (e.g., ligamentous hypertrophy or epidural pathology) should be considered if symptoms are disproportionate.
4. Thoracic Cord
- The thoracic cord appears relatively preserved, with no significant signal abnormality or compressive lesion noted in the sagittal view.
5. Post-Surgical Lumbar Changes
- Although not the focus of these scans, prior lumbar laminectomy changes may be visible in the lower slices.
- No acute pathology is evident in the lumbar region on these views.
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🔬 Differential Radiologic Considerations
Given the clinical context of fever and subacute neurological decline:
- Transverse myelitis or infectious myelopathy (e.g., TB, viral) should be high on the list.
- Autoimmune demyelination (e.g., NMOSD, MOGAD) is plausible, especially with longitudinal cord involvement.
- Spinal cord infarct is less likely without a clear vascular pattern but not excluded.
- Spinal epidural abscess is not evident on these images, but contrast-enhanced MRI would be essential to rule it out definitively.
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Would you like help drafting a radiology report or correlating these findings with CSF and lab results for a multidisciplinary discussion?
[11-09-2025 18:33] +964 750 136 1306: Given the clinical history of prior lumbar laminectomy for paraparesis in 2016, full recovery, and now a subacute onset of quadriparesis preceded by fever, alongside the MRI findings of cervical cord T2 hyperintensity without significant compressive lesions, the most likely diagnosis is:
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🧠 Longitudinally Extensive Transverse Myelitis (LETM)
Possibly due to Neuromyelitis Optica Spectrum Disorder (NMOSD) or post-infectious/inflammatory myelitis
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🔍 Why This Fits:
- Cord signal changes on MRI span multiple vertebral levels, typical of LETM.
- No significant mechanical compression to explain the severity of symptoms.
- Fever preceding neurological decline suggests an inflammatory or infectious trigger.
- History of prior spinal cord involvement raises the possibility of a relapsing demyelinating disorder.
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🧪 Next Diagnostic Steps:
To confirm and subtype the myelitis:
- Serum AQP4-IgG and MOG-IgG antibodies
- CSF analysis: Cell count, protein, glucose, oligoclonal bands, viral PCRs
- Spinal MRI with contrast: To assess enhancement patterns
- Brain MRI: To rule out MS or ADEM
- Autoimmune and infectious panel: ANA, ESR, CRP, TB, brucella, HIV, syphilis
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🩺 Differential Diagnoses to Keep in Play:
| Diagnosis | Supporting Features | Contradictory Features |
|-----------|---------------------|-------------------------|
| NMOSD | LETM, relapsing course, post-infectious trigger | Needs AQP4 confirmation |
| Post-infectious myelitis | Fever, subacute onset | Usually monophasic |
| Spinal cord infarct | Sudden onset, focal signs | Less likely with fever |
| MS | Prior episode, young age | Lesions not typical for MS |
| Spinal epidural abscess | Fever, weakness | No compressive lesion seen |
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Would you like help drafting a diagnostic memo or a structured clinical pathway for your team to follow? I can also help you prepare a teaching slide or CME case summary if you're presenting this.
[11-09-2025 18:34] PPM 3: Thank you for laying out the clinical trajectory so clearly—this case indeed presents a layered diagnostic challenge. Here's a structured breakdown of the key elements and possible considerations to help clarify the picture:
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🧠 Clinical Timeline Summary
- 2016: Episode of quadri/paraparesis → lumbar laminectomy → gradual recovery to normal ambulation.
- 10 days ago: Fever followed by progressive lower limb weakness.
- Last 3 days: Bedridden due to worsening quadriparesis.
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🔍 Key Diagnostic Considerations
Given the history and current presentation, several possibilities merit close attention:
1. Spinal Cord Pathology
- Cervical myelopathy: Supported by current MRI findings showing cervical cord compression or signal changes.
- Reactivation or progression of prior spinal disease: Especially if there was incomplete resolution post-laminectomy.
- Spinal epidural abscess or transverse myelitis: Fever preceding neurological decline raises concern for infectious or inflammatory etiology.
2. Infectious/Inflammatory Etiologies
- Post-infectious demyelination (e.g., ADEM) or viral myelitis (e.g., HSV, EBV, CMV).
- Tuberculosis or brucellosis: Endemic considerations, especially with fever and spinal involvement.
- Autoimmune: Neuromyelitis optica spectrum disorder (NMOSD), MS, or connective tissue disease-related myelopathy.
3. Vascular Causes
- Spinal cord infarction: Sudden onset weakness, especially if vascular risk factors are present.
- Spinal dural AV fistula: Can cause progressive myelopathy and mimic inflammatory conditions.
4. Metabolic/Paraneoplastic
- Paraneoplastic myelopathy: Especially if systemic symptoms or malignancy risk factors exist.
- B12 deficiency or copper deficiency: Rare but can cause subacute combined degeneration.
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🧪 Recommended Next Steps
To narrow the differential, consider:
- MRI with contrast (if not already done): Look for enhancement patterns, abscess, or demyelination.
- CSF analysis: Cell count, protein, glucose, cultures, oligoclonal bands, viral PCRs.
- Serologies: TB, brucella, HIV, syphilis, autoimmune panel (ANA, anti-AQP4, anti-MOG).
- Spinal cord function tests: EMG/NCS if peripheral involvement suspected.
- Repeat lumbar imaging: To rule out recurrence or missed pathology.
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Would you like help drafting a structured diagnostic algorithm or checklist for your team? Or perhaps a memo summarizing the case for multidisciplinary input?
[11-09-2025 19:54] PPM 1: 👆 which LLM is this one? Probably it doesn't have computer vision and just guessed on textual cues?
[11-09-2025 19:55] PPM 1: 👆 Which LLM?
[11-09-2025 20:46] PPM 3: Copilot
[11-09-2025 21:14] PPM 1: 👆
[11-09-2025 22:07] PPM 3: When I start sharing with one LLM I usually contuie the whole process with that LLM
[11-09-2025 22:41] PPM 1: They appeared to be different texts
[12-09-2025 14.51] PPM 1: Orthopedic plan
Planned to start iv amiodarone infusion in the morning but as of now couldn't be administered as it's not available
[12-09-2025 15.39] PPM 1: Fever since admission
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