Nirmal Pandey MD DM Neurologist Profile picture
Dec 11, 2022 11 tweets 11 min read Read on X
Like to present a case seen in 2017. We were not aware of the entity then. 17F, 15D vomiting, headache. No deficit. Evaluated at institute. Extensive blood/CSF/tropical diseases workup -ve. CSF: P81, G57, cell 30 (all L). IVMPS x 5gm. Discharged with Dx of ADEM. 1st CEMR. (1/8)
8D later readmitted there w/ headache x 3D w/ mild rt ptosis. Again IVMPS x 3gm. Better. Again recurrence of headaches. Both times followup oral steroids not given. Came to us.
2nd CEMR. Similar findings. Slight increase in lesion burden. (2/8)
MR looked odd. We had never seen before. Googled. This paper surfaced. (3/8) pubmed.ncbi.nlm.nih.gov/20639547/
It talked about biopsy to confirm the Dx. Pt did not agree. We followed the suggestion of this article. Oral steroids + AZT. Developed steroids s/e, tapered to 10mg OD. 3rd CEMR (month4): lesions almost same. We had lost it we thought. (4/8)
We remembered @sjauhar quote. (5/8)
We mailed the lead author of the paper seeking help. He replied in 48 hrs. (6/8)
We followed his advice. IVMPS x 5gm. 1gm IVMPS x week. 20 mg MTX weekly. Continued 5mg oral prednisolone. 4th CEMR after 3 months: NORMAL. We tapered weekly IVMPS gradually, continued MTX & 5mg OD steroids. 5th CEMR also normal done after another 3 months (M10). (7/8)
Later after we had been through this came this paper where he stressed about MTX in the Rx of CLIPPERS. Had we not sought help at that point of time, we would not have gained this knowledge ahead of times. (8/8)
academic.oup.com/brain/article/…
courtesy @drharunyildiz that is too good

• • •

Missing some Tweet in this thread? You can try to force a refresh
 

Keep Current with Nirmal Pandey MD DM Neurologist

Nirmal Pandey MD DM Neurologist Profile picture

Stay in touch and get notified when new unrolls are available from this author!

Read all threads

This Thread may be Removed Anytime!

PDF

Twitter may remove this content at anytime! Save it as PDF for later use!

Try unrolling a thread yourself!

how to unroll video
  1. Follow @ThreadReaderApp to mention us!

  2. From a Twitter thread mention us with a keyword "unroll"
@threadreaderapp unroll

Practice here first or read more on our help page!

More from @nirmalregency

Apr 20
Sunday case presentation again
(A daunting case from our archives)
👇

🍒 picked

"We learn through our mistakes"

🧵 coming

#neurotwitter #NeuroX #MedTwitter #MedX #Neurology #FOAMmed

1/15Image
38♀. 90kg.
No PMH.
Fever x 3-4D ☞ body pains.
D6: frequent seizures.
Put on multiple ASMs.
D7: CT head + CSF = WNL.
D11: MR brain WNL (not shown).
D13: Repeat CSF WNL.

D16: Repeat MR Brain faint b/l medial temporal hyperintensities. 👇

Acyclovir ✅

2/15Image
D19: shifted here.

Seizures ++, mostly over both face w/ partial preserved consciousness.
Intubated.
On 4 ASMs.

Added ☞ Ketamine bolus ☞ infusion.
IVIG + IV MPS also started.
Twice daily 1hr EEG monitoring.
(24hr monitoring NA)

Repeat CSF: routine normal.
CSF BioFire -ve, including HSV.
Acyclovir 🚫

3/15Image
Read 16 tweets
Mar 30
Another Learning Sunday Case Presentation.

One does see this often.
We saw it for the 1st time.
A 🧵Ahead.

Having all the classical features in☝️single patient.
That too in a ♀24yrs.

This patient was referred for routine #MRI cervical spine from elsewhere to our hospital.
Majority of our MR studies are from in-house referrals.
#neurotwitter #NeuroX #MedTwitter #MedX #Neurology #FOAMmed

1/🧵Image
These thoughts usually jump to the mind.

What is Your best guess?

1. Past case of transverse myelitis ?
2. Past h/o cervical trauma (whiplash) ?
3. Chronic progressive MS ?
4. Something is amiss !

2/🧵
Additional MR Sag images (T2/STIR/T1).
👇

3/🧵 Image
Read 17 tweets
May 12, 2024
Blink & miss.
57♀. T2DM. Referred for evaluation of possible partial right 3rd cranial nerve palsy of 2 days.
Can we pick up the culprit?
MR brain☞ DWI/ADC👇.
T2/T1 in 🧵
(1/13) Image
MR brain T2/T1 👇
(2/13) Image
What do we see?
(3/13)
Read 15 tweets
Mar 31, 2024
45♀. 45Kg.
1Y. Gradually↑: Unable to get up from ground. B/L hand tremors.
LE weaker > UE.
Lost a few kilos.
Darkening of skin, ↑ from her previous color👇
?clubbing.
Flushing of palms.
DTRs ↓
#neurotwitter #NeuroX #MedTwitter #MedX #Neurology #FOAMmed
A 🧵 Image
She had come w/ some investigations done over past 6M.
HIV/HCV/HBsAg -ve.
CBC/LFT/KFT N (multiple).
TSH 7.4 (Ref: 1-5).
ANA -ve.
NCS: 👇 Image
CXR: 🆗
She also had an USG abdomen done 👇
Abdominal lymph node CT guided biopsy: non-specific, TB GeneXpert -ve. (We are TB predominant in our part).
Ascitic fluid was transudative. Image
Read 13 tweets
Feb 18, 2024
15 ♀
Very peculiar.
Late December. She was taking ↑ than usual time to come out of bathroom. Knocked. No response. Door broken. Unconscious, drooling, naked. This scenario is not so uncommon for us clinicians of North India.
#neurotwitter #NeuroX #MedTwitter #MedX #FOAMed
🧵 Image
Taken to a nearby hospital. ↑ restless & agitation.
“I cannot see” repeating like a parrot.
Came to us in this state ☞ 8 hours.
Restrained. Sedated.
CEMR brain < 24 hrs from onset.
Faint b/l occipital cortical DWI brightness w/ no definite restriction. No enhancement. DWI👇 Image
Faint T2 (not shown) & Flair b/l occipital gyral swelling👇
No Gad enhancement (not shown). Image
Read 16 tweets
Sep 24, 2023
Interesting #Neurology #Pediatrics cases. 🧵
When uncommon cases come, they come in pairs.
Case 1: 8♂. AFI X 5D. Scrub typhus +ve.
AKI. RRT X 3 sessions.
Developed seizures on D8.
MR 👇 #neurotwitter #NeuroX #MedTwitter #MedX #neuroradiology #MRI Image
Case 1: There was no Gad enhancement or restricted diffusion.
Possibilities?
Case 2: 2♀. AFI X 6D. AMS.
MR brain on arrival NORMAL (not shown).
AKI. RRT X 3 sessions.
Developed seizures on D12. MR (D12) 👇 Image
Read 12 tweets

Did Thread Reader help you today?

Support us! We are indie developers!


This site is made by just two indie developers on a laptop doing marketing, support and development! Read more about the story.

Become a Premium Member ($3/month or $30/year) and get exclusive features!

Become Premium

Don't want to be a Premium member but still want to support us?

Make a small donation by buying us coffee ($5) or help with server cost ($10)

Donate via Paypal

Or Donate anonymously using crypto!

Ethereum

0xfe58350B80634f60Fa6Dc149a72b4DFbc17D341E copy

Bitcoin

3ATGMxNzCUFzxpMCHL5sWSt4DVtS8UqXpi copy

Thank you for your support!

Follow Us!

:(