Wednesday, December 16, 2015

A 37 years old man with troublesome abdominal movements after paralysis of all four limbs

This is a HIPAA de-identified open-online-patient-record with initial information in duty-doctors notes as well as patient's voice, posted here early winter 2015 after collecting informed patient consent (form downloadable here ) by LNMCH research assistant and patient-information-communication-executive for a discussion initiated by patient's primary care physician in-charge: 
A 35 year old man with sudden quadriparesis 3 months back found to be due to cervical spinal tuberculosis, decompressed neuro-surgically with minimal improvement of power but still bed ridden. What is intriguing is a peculiar diaphragmatic involuntary movement reflected in his abdominal muscles. 

 This is the video https://www.youtube.com/watch?v=3odw50reyuU&feature=youtu.be of his involuntary diaphragmatic movement taken. 

More data here: http://hindiudhc15.blogspot.in/2015/09/a-35-years-old-man-with-quadriplegia-oe.html

Conversational Clinical decision support:

Bhavik Shah I'd love to write this one!
If nobody else writes this up, I'll give it a try once I'm done with exams!
UnlikeReply1September 15 at 10:46pm
Amy Price Pyramidal tract upper neuron/lower neuron junction demylineated?? Does TB or surgery do this or could the inflammation from the surgery cause this and it will calm down?
UnlikeReply1September 16 at 2:20am
Rakesh Biswas Thanks Bhavik and Amy. Looks like something i have never come across before and yet all the ingredients for a pot boiler are present (C3,C4 phrenic nerve root lesion etc). Would be good to hear from the experts (Arjun, Abhijit, Satendra any possibility of a diaphragmatic EMG establishing a correlation?) Do also take a look at the MRI of the spine (DrAgamya, Dr Pathak).
LikeReplySeptember 16 at 6:28am
Rakesh Biswas Dr Rajendra, Prof Jain Will appreciate your inputs on this diaphragmatic curiosity.
LikeReplySeptember 16 at 6:29am
Rakesh Biswas Thanks Bhavik, Please go ahead and try to answer the query on correlation between the diaphragmatic movement (seen on video) and his cervical spinal cord lesion. This time we are not making this a global-health case report but a quick 'images in clinical medicine.' smile emoticon
LikeReplySeptember 16 at 6:45am
Rakesh Biswas Found something here:http://casereports.bmj.com/content/2012/bcr-2012-007393.full Can we get a fluoroscopy for this patient today Agamya?
Intermittent bursts of abdominal wall jerky movements: belly dancer's syndrome? -- Amin et al....
A 47-year-old Iraqi Kurdish woman presented with a 1-day history of sudden onset of frequent, intermittent and painful abdominal wall jerky movements, 6 days after undergoing haemorrhoidectmy. During sleep, these movements were absent. The postoperative period was uneventful and the patient was disc…
CASEREPORTS.BMJ.COM
LikeReplyRemove PreviewSeptember 16 at 7:15am
Rakesh Biswas Agamya I guess even USG of the diaphragm would reveal something spectacular here (Pokhraj?)
LikeReplySeptember 16 at 7:18am
Rakesh Biswas One of the chief problems right now with our patient is his inability to swallow the anti-tubercular drugs due to persistent vomiting (possibly related to his diaphragmatic flutter?). He is also retro virus positive. The images in Kuldeep's prepared UDHC blog-record reveals some onychomycosis that will be sent for fungal scrapings today
LikeReplySeptember 16 at 7:26amEdited
Bhavik Shah Yes, it's probably due to irritation to the phrenic nerve due to the abscess. Here are three papers, two of which are nearly 60 years old, and in Polish, if we can access them somehow, we might get another clue. However, they describe paralysis rather than abnormal movements.
UnlikeReply1September 16 at 7:21pm
Rajendra Takhar https://books.google.co.in/books?id=g815isikVSAC&pg=PA962...
Marsden's Book of Movement Disorders
This book represents the final work of the late Professor C. David Marsden, who was the most influential figure…
BOOKS.GOOGLE.CO.IN
LikeReplyRemove PreviewSeptember 16 at 11:26pm
Rakesh Biswas Here's an interesting paper from our Prof Jain that hints at the ECG as a potential tool to detect diaphragmatic signals (Bhavik, Vipul,Shantanu, Arjun,Subroto):http://www.iseindia.org/journal/isecon_2011_August.pdf
LikeReplySeptember 17 at 7:33am
Rakesh Biswas Arohi, Deepika, Kuldeep, Please upload the videos of the diaphragmatic flutter captured yesterday on fluroscopy. The other food for thought provided by Prof Dwiwedi, HOD radiology:Are these movements due to abdominal muscle flutter and not diaphragmatic? (Inputs Prof Bharati,Mahendra, Swagata, Agamya, Satish, Abhijit). We couldn't find anything in this patient's ECG that could hint at a diaphragmatic potential disturbance but there is a lot of uncertainty in this still.
LikeReplySeptember 18 at 6:42am
Rakesh Biswas Kumar Gautam this patient could benefit from an electrical pacing device to stop his diaphragmatic flutter?
LikeReplySeptember 19 at 7:52am
Rakesh Biswas Dr Deepika will be posting the diaphragmatic fluoroscopy videos today after editing.
LikeReplySeptember 19 at 7:53am
Rakesh Biswas Here https://www.youtube.com/watch?v=nx1DO_ab9ss&feature=youtu.be are the edited fluoroscopy videos showing the diaphragmatic flutter. The voice in the background is that of Prof Dwiwedi (HOD radiology).
LikeReplyRemove PreviewSeptember 20 at 4:38pm
Rakesh Biswas Update: His diaphragmatic flutter disappeared over a week and his lower limb power improved on anti-tubercular therapy from grade 0 to grade 2. He is currently on HAART and anti-tuberculars and has been discharged. Hope to keep following him up.
LikeReply1October 3 at 7:29am
Rakesh Biswas His nailshttp://2.bp.blogspot.com/.../O71nhkZg2Uw/s1600/DSCN0475.JPG have grown Aspergillus Niger (as reported from Dr Shashwati's lab). What antifungal would you choose?
LikeReplyRemove PreviewOctober 19 at 12:42pm
Rakesh Biswas Rajat this is the current patient you helped yesterday. Check out his entire record here on the link at the top of this comment thread. If possible upload his current updates here.
LikeReplyOctober 22 at 10:17am
Rakesh Biswas Jemmima this patient is currently admitted with us and i am hoping you may be able to present him this Wednesday or Thursday where we may not just discuss the approach to his neurology but also the approach to his inequity issues. Also, perhaps you can guide Arohi or Nisarg in writing up their first case-study.


Radiological images:


























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