Diagnostic Conundrums - Neurology

A 56 year old male presented on 27 Dec 2006 with c/o vague pains all over the body. He gave h/o fever with chills about a week before onset of these symptoms. Clinically there was no significant abnormality and an initial diagnosis of Viral Fever (? Chikungunya) was made. He was treated with Tab paracetamol (acetaminophen) 500 mg tid with Tab B Complex daily.

He came back to us on 16 Jan 2007 with (i) Pain and swelling in the small and medium sized joints, with early morning stiffness (ii) Parasthesiae in the lower limbs (iii) Mild breathlessness.
Clinically: Vitals were within normal limits. There was marked swelling of the Interphalangeal and ankle joints.
Investigations: Hb 12.5 gm%, ESR 10 mm, Total Count: 5000/cumm, P 70, L 27, E 02, M 01, Random Blood Sugar 90 mg%, VDRL - Non Reactor, RA Factor - non reactor
The diagnosis now looked like Sero Negative Polyarthritis.
He was started on Tab Diclofenac 50 mg bid, Tab Folic Acid 5 mg od.

0n 22 Jan 2007 he was reviewed and his condition had worsened - (i) increased pain all over (ii) Unable to walk or lift hands above the head (iii) increasing tremulousness.
Clinically - All joints were swollen and movements of all limbs were sluggish. This prompted me to do a CNS exam:
Power UL - Grade IV, Lower limbs Gd III - IV, Deep Tendon Jerks Bilaterally diminished, absent ankle jerks. Plantars were flexors.
Sensory - Fine touch was absent till mid chest. There was patchy loss of pain and vibration sense over the legs and upper arms.
This got my suspicion up and I thought of an Acute Cervical Cord Lesion.
NIMHANS being the closest and most affordable we sent him there. By the time he reached NIMHANS, about 150 km over bad roads, he had developed acute retention of Urine and needed to be catheterised.
MRI showed:
1. Extruded disc material and superior migration/ Extradural lesion at C5 C6 levels causing focal compression and thinning of cord.
2. Cervical Spondylosis with myelomalacial changes.

Just putting up this as a reminder that what is apparent may not be the actual facet of the illness. We need to keep our eyes and ears open for the most unexpected. After this I did a search using both PubMed and Google Scholar, but really found no such progression described.
Any comments from the Neurologists/Physicians/Neurosurgeons??

Diagnostic Conundrum - ? Budd Chiari

A 24 year old lady presented to our centre with c/o vague abdominal pain, acid eructations and poor apetite. She was seen by doctors in Madanapalle and treated with PPIs as well as Antacids.
A G3 P3, 1st child born through LSCS.
O/E: General Exam - was normal.
Abdomen: Tortuous dilated superficial abdominal veins, with hepatic flow. (The pictures below show you the location and size of the veins)

There was a 2 cm soft hepatomegaly, no splenomegaly or free fluid.

USG: Mild to moderate hepatomegaly, abdominal varices, prominent mid hepatic vein with absence of right and left hepatic veins.

Whats the Diagnosis and how will you proceed? Please help????

Our First TB Culture

Hi all
In this not so clear photograph, you can see the yellowish cream colonies of Mycobacterium Tuberculosis, grown in our Microbiology Laboratory.
The patient is in all likelihood a case of MDR TB, due to multiple, ill advised, irregular Anti TB Therapy instituted at various times.

Diagnostic Conundrum (1)

A 26year old male presened to the RHC with a 6 month h/o

(i) Progressive inability to lift both hands baove shoulder

• (ii) Weakness and wasting of shoulder muscles

He denied any h/o substance abuse, trauma, fevers, convulsions, or exposure.

Clinically: Pulse 78/min, BP 110/70 mm Hg. No lymphadenopathy, icterus or pallor.

CNS: Higher mental functions were within normal limits. There were no cranial nerve anomalies. Spine was normal - no deformity, tenderness or gibbus.

Bilateral symmetrical wasting of shoulder muscles (see photo) with clearly defined bony prominences.

Power at shoulder joint: Shoulder shrug V/V, Abduction O/V, Adduction III/V, Extension III/V, Flexion III/V, Ext Rotation III/V. Unable to lift hand over the head but when he moves his upper limb at a rapid pace he is able to lift his hands over the head.

All other muscle groups power was V/V. Deep tendon jerks unaffected.

There was no sensory deficit.

Investigations: Hb 10 gm%, Total and Differential Counts: WNL, ESR 20 mm 1 st hour, Urine analysis : WNL, HIV (Tridot) - ve.

We could not do CPK due to lack of facilities.

SO WHAT's THE DIAGNOSIS? I put it as FASCIO SCAPULO HUMORAL DYSTROPHY or some other Muscular Dystrophy.

The biggest problem is that this young man is the sole earning member of his family, ekeing out a living on daily wages, and as he can not work, or rather no one is willing to give him work because of his disability, he has been reduced to abject poverty. I am trying to raise funds to send him to Bangalore to at least get a diagnosis. Even with a diagnosis, there is really nothing one can do for him, I suppose and that is the saddest part of it all.

January 2007

The New Year opened with a bang in many ways - what with festivals and patients our cup was rather full.
January is also the month of festivals, with Pongal/ Sankranti being celeberated with great enthusiasm here in the south by one and all, irrespective of caste, creed or religion. This is the harvest festival and it is a very important one. Traditionally a pot of rice, milk and jaggery are cooked together and the pot has to boil over signifying a year full of cheer and bounty ahead. The cattle are all bedecked as they are the ones who actuually provide the work force around here. Tractors still being too expensive and the fact that tractors can not provide milk(!).
So also ID was also celeberated with great fervour. We had to refuse any number of invitations to partake in the feasts as both of us are vegetarian.
Just to see the spirit of the people celeberating these festivals is, as always, an eye opener to me about how people live together in peace and harmony.
January also ushered in the new year and the republic day. We decided to close for these days and fortunately/unfortunately these days happened to fall onour OPD days. Not that any one was cribbing.
Well, started on 03Januray our first working day with a 184 patients. Whew ! at the end of the day Vidya and I were staggering. The relentless pressure kept on and in spite of only 9 OPD days we ended up seeing 1571 patients. January ended with 188 patients and we are desperately hoping for a respite or someone to help us.
We finally also started work on an extension to the building, a waiting room for patients and a water point. I will be publishing these photos soon along with what we plan to do with the extra spaces we have created.
Watch out for Diagnostic Conundrums being published soon.

October to December 2006

Hey Guys forgot to put up the statistics for these months - rather amiss of me. The patient load is never ending and we have had trouble in keeping up with the load.
So here goes:
October 2006: 1036 patients, 63 eye patients, 23 cataracts done at Madanaplle. We worked only three weeks this month before pushing off for a break.
November 2006: Repoened the Health Centre on the 10th of November and in the first week, we did refresher traing for all our staff on basics of health care and management of emergencies. It really paid off because soon after reopening we had a lady who had a convulsion at our door step and the staff were able to handle it without resorting to "nails" etc.
We saw 518 patients, 54 eye patients of which 7 of them were operated for cataracts.
December 2006: Boy, this has been a tough month. 1776 patients blew us away, 82 eye patients and 16 operated. We could have operated more but for a shortage of funds. We raelly are struggling to make both ends meet and are hoping that some of who read this would contribute to our Health Centre.