User driven health care: "Jar of mango pickles" sign: system 2 medical cognition PaJR from 2013 revisited

In this link : http://www.udhc.co.in/INPUT/displayIssueGraphically.jsp?topic_id=218 used to be the patient input record

Please find the output after discussion including the current status here: http://www.udhc.co.in/SOLUTION/viewSolution.jsp?solution_id=40&topic_id=218

Also please find the discussion we had in our forum (including comments from Prof Dilawari):

Rakesh Biswas

Currently we are managing this 23 year old lady suffering from symptoms of malabsorption syndrome since the last 14 years when she was given a diagnosis of gluten sensitive enteropathy at the age of 9.

Presently possibly since the last 2 years she has severe kyphoscoliosis along with severe bowing of her upper limbs as well as a left clavicular fracture with callus (Ela can you upload her clinical pictures?). Her neurological examination suggests paraplegia with increased DTRs and bilateral flexor planters.

We have done a macroscopic examination of the 24 hour stools which looks like a 'jar of pickles' (Ela picture?) with undigested fecal food particles. What are your thoughts on further management of this lady in pain?

Like · · Unfollow Post · February 24 at 4:40pm

Komal Kukreja and DrReedhi Garg like this.
Rakesh Biswas No other neurological manifestations although not all of them may be present in all patients. The diagnosis of Coeliac was made 14 years back in Govt Medical College, Bhopal possibly as an assumption to see if she would respond to a gluten free diet (a...See More
Celiac disease: diagnostic criteria in prog... [Cell Mol Immunol. 2011] - PubMed - NCBI
www.ncbi.nlm.nih.gov
PubMed comprises more than 22 million citations for biomedical literature from M...See More
February 24 at 9:34pm · Like · Remove Preview
Rakesh Biswas Ela http://www.annsaudimed.net/index.php/vol33/vol33iss1/529.html?view=abstract
Annals of Saudi Medicine - Celiac disease presenting as rickets in Saudi children
www.annsaudimed.net
Celiac disease presenting as rickets in Saudi children
February 24 at 9:35pm · Like · Remove Preview
Jang Dilawari Check the following
1 Vit D and Calcium level
2 Bone density(dexa-scan)
3 D-xylose test or faecal fat test.
4 check celiac serology to make sure she is keeping to Gluten free diet....See More
February 26 at 1:01pm via · Unlike · 1
Rakesh Biswas Great to hear from Professor Dilawari (Santanu, Pralay , Vivek Jha, Lakshmi Kant Jha, Tarun Chakrabarti). We inquired and found that many laboratories in India have discontinued the 72 hour Fecal fat test possibly due to the unpleasant logistic issues...See More
February 26 at 4:53pm · Like
Jang Dilawari Is her kidney function normal?
In secondary hyperarathyroidism calcium can be normal.
Get an endocrinologist to comment.
JBD

Sent from my iPad
February 26 at 7:00pm via · Unlike · 1
Jang Dilawari Please comment on:
1 what were her symptoms when she was diagnosed CD.
2. Was there D2 biopsy done.?
3 I understand her jejunal (d2) biopsy 2 years ago was normal. Were she on GF Diet at that time? It is also mentioned that she never responded to GFdi...See More
February 26 at 7:15pm via · Unlike · 1
Rakesh Biswas 1. She was having symptoms of malabsorption (oil and undigested particles in stool) when she was first diagnosed at age of 9 years (14 years ago). It appears to have been a presumptive diagnosis (by the pediatricians in another medical college) at that...See More
February 26 at 9:30pm · Like
Rakesh Biswas Her kidney functions are normal.
February 26 at 9:36pm · Like
Rakesh Biswas Interesting article comparing D2 versus capsule jejunal biopsies http://www.ncbi.nlm.nih.gov/pubmed/15520918 and another one http://ajcp.ascpjournals.org/content/116/1/63.full.pdf on how to recognize gluten sensitivity in biopsies showing normal villi.
Duodenal versus jejunal biopsies in suspected celi... [Endoscopy. 2004] - PubMed - NCBI
www.ncbi.nlm.nih.gov
PubMed comprises more than 22 million citations for biomedical literature from M...See More
February 26 at 9:41pm · Like · 1 · Remove Preview
Rakesh Biswas Our Endocrinologist Dr Jindal saw her today and with his help we managed to send her samples for PTH and TTG at a considerably reduced rate to Lal's pathology lab.
February 27 at 8:11pm · Like
Rakesh Biswas Hope someday we can have a poor-patient-fund at our institute that may enable us to get such tests done more easily in future. During my teaching career in Manipal i found this fund was managed by medical students and appeared to be one modality that effectively integrated medical education and practice.
February 27 at 8:15pm · Like · 1
Rakesh Biswas Prof Dilawari we did a bedside test for pancreatic exocrine dysfunction on this patient today and found the test positive. This bedside test is performed by mixing one part feces with 9 parts of 5% Sodium Bicarbonate solution in a test tube. A strip of x-ray film (one can use developed film) is inserted into the tube and allowed to sit at room temperature for 2 ½ hours. As X-ray film is coated with an emulsion of gelatin the gelatin on the x-ray film can be dissolved after that time (it will turn clear) if there is normal fecal protease activity. We did the test with a normal control (the patient's mother) and this patient's X ray film didn't clear although her mother's did clear very well. Exocrine pancreatic dysfunction seems to be a well known association of coeliac sprue and an often cited cause for treatment failure. http://www.ncbi.nlm.nih.gov/pubmed/7351287, http://www.ncbi.nlm.nih.gov/pubmed/1855688?dopt=Abstract, http://www.wjgnet.com/1007-9327/12/1503.asp I am not sure of the diagnostic sensitivity or specificity of this (what appears to us to be) very useful bedside test for pancreatic exocrine function (the rest are all way to expensive and beyond our patient's reach). Would be good if someone could do a search and inform us.
Exocrine pancreatic insufficiency in celiac... [Gastroenterology. 1980] - PubMed - NCBI
www.ncbi.nlm.nih.gov
PubMed comprises more than 22 million citations for biomedical literature from M...See More
February 28 at 9:45pm · Like · 1 · Remove Preview
Rakesh Biswas Her serum PTH was raised to 155 as against a normal of 72 suggestive of secondary Hyperparathyroidism. Her serum TTG (Tissue transglutaminase) was normal putting the likelihood of Coeliac considerably lower down the list.The CT abdomen done to chase th...See More
23 year old lady with oily stools since 9 years of age and painful skeletal deformities since last 2
care.udhc.co.in
The diagnosis of Coeliac was made 14 years back in Govt Medical College, Bhopal ...See More
March 17 at 10:53pm · Like · 1 · Remove Preview
Manas Ghosh Is there any role of vit B12 and doing MRI of cervical region?
March 24 at 10:53pm via mobile · Unlike · 1
Rakesh Biswas Thanks Manas. She has more of skeletal deformities rather than any neurological debility.
March 24 at 11:11pm · Like
Rakesh Biswas Current update: Patient is on follow up of our physiatrist Dr Joshi and he has shared his own 'user-driven' conversations:From: Ganesh Joshi
Date: Wed, Apr 17, 2013 at 1:13 PM
Sir,
Please peruse this response from my best friend who always hits the bu...See More
April 18 at 10:58pm · Like · 1
Aakriti Pandita would like to see her images and x-rays.
April 18 at 11:45pm · Like
Rakesh Biswas Aakriti they are linked here http://care.udhc.co.in/INPUT/displayIssueGraphically.jsp?topic_id=218 also posted in the conversational thread above.
23 year old lady with oily stools since 9 years of age and painful skeletal deformities since last 2
care.udhc.co.in
The diagnosis of Coeliac was made 14 years back in Govt Medical College, Bhopal ...See More
April 19 at 11:42am · Like · Remove Preview

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As all the content including the actual stool image has been lost on changing the PaJR platform, shared a few google images of actual mango pickles jar from the internet from witch's kitchen and Tarla Dalal

User driven health care

Tuesday, August 22, 2023

"Jar of mango pickles" sign: system 2 medical cognition PaJR from 2013 revisited

Rakesh Biswas

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