Title: Narketpally syndrome: a triad of toxic etiological overlap addressed through a PaJR workflow
Introduction: The first case of Narketpally syndrome was published this year (reference 1). We present another case here who is an 82 year old man with prolonged exposure to a triad of toxic etiologies common in location Narketpally in Telangana and likely also in certain other parts of India hitherto undescribed.
Methods: (Identification data) The 82 year old man living 10 kms away was first admitted to our medical college in Narketpally in May 2024 and had been on regular "patient journey record" PaJR follow up since then along with two more admissions in November 2024 and April 2025 (PaJR reference 2,3,4).
Presenting complaints: He had a history of Diabetes since 30 years, hypertension and mild chronic kidney disease since 10 years and his chief complaints during first and second admission was for tingling of limbs and giddiness and in his third admission months later he had sudden giddiness with slurring of speech. He had a history of exposure to fluoride water for first 6 decades of his life, regular Alcohol consumption since age of 20 and a diet rich in simple sugars but low in complex carbohydrates and proteins.
Examination findings: On general examination he was found to have an invisible pillow sign due to ossified posterior longitudinal ligament that has been named Narketpally sign (reference 1) to distinguish it from the previously described invisible pillow sign aka imaginary pillow as it was commonly described in catatonic schizophrenia (reference 5). He also had a metabolic syndrome phenotype with trunkal obesity and sarcopenia. On CNS examination during first admission positive findings were a broad based gait with absent lower limb vibration senses along with loss of ankle reflexes. On second admission he had a cerebellar speech with marked gait ataxia that recovered within a day.
Investigations: His blood biochemistry confirmed mild azotemia of CKD and impaired blood sugars that were quickly controlled on insulin and a cervical spine x-ray confirmed his ossified posterior longitudinal ligament and cranial MRI revealed old cerebral lacunar infarcts and fazekas grade 2 leukoariosis suggestive of cerebral small vessel disease.
Differential diagnosis: OPLL due to immune spondyloarthropathy, CNS and peripheral neural vasculopathy due to causes other than alcohol and diabetes.(reference 6,7)
Treatment: His Diabetes, Hypertension, CKD was managed with standard care through regular PaJR follow up and his OPLL was managed with physiotherapy.
Patient is on regular follow up and the triad of toxin exposure to fluoride, alcohol and simple sugars have been minimised by ensuring filtered water, abstinence and balanced diet through PaJR monitoring.
Conclusion: Narketpally syndrome with musculoskeletal OPLL and neural vasculopathy is a result of a triad of toxic outcomes from exposure to Fluoride, C2H5OH and C6H12O6. While the link between metabolic syndrome, fluoride exposure and OPLL has been separately elucidated before, Narketpally syndrome describes the triad of exposure and defines a syndromic workflow through team based learning around a patient's journey record (1,2,6,7).
References:
1: Podder V, Kulkarni R, Samitinjay A, Salam A, Gade S, Agrawal M, Surendran AK, Biswas R. Narketpally Syndrome and the Embedding of Contextual Values in Real-Life Patient Pathways. J Eval Clin Pract. 2025 Aug;31(5)
2: Martin CM, Biswas, R., Joshi, A., & Sturmberg, J. P. (2011). Patient Journey Record Systems (PaJR): The Development of a Conceptual Framework for a Patient Journey System. In R. Biswas & C. Martin (Eds.), User-Driven Healthcare and Narrative Medicine: Utilizing Collaborative Social Networks and Technologies (pp. 75-92). IGI Global Scientific Publishing
3:Podder V, Dhakal B, Shaik GUS, Sundar K, Sivapuram MS, Chattu VK, Biswas R. Developing a Case-Based Blended Learning Ecosystem to Optimize Precision Medicine: Reducing Overdiagnosis and Overtreatment. Healthcare (Basel). 2018 Jul 10;6(3):78
4:Agrawal, Mansi & Bobba, Braahmani & Iftequar, Yousra & Lekhana, Macharla & Gade, Aditya & Podder, Vivek & Kulkarni, Rahul & Biswas, Rakesh. (2025). PaJR as the Foundation for Next Generation Telemedicine. 10.2991/978-94-6463-784-7_4. https://www.atlantis-press.
5: Shukla R, Ahsan M, Pal A, Shaan F. Unraveling the enigma of ‘Psychological Pillow’: A unique catatonicphenomenon. Industrial Psychiatry Journal. 2024 Aug 1;33(Suppl 1):S284-S286
6: Wang, J., Wei, Z., Kong, Q. et al. The relationship between OPLL and metabolic disorders. Bone Res 13, 90 (2025). https://doi.org/10.1038/
7: Ramos-Remus C, Russell AS, Gomez-Vargas A, Hernandez-Chavez A, Maksymowych WP, Gamez-Nava JI, Gonzalez-Lopez L, García-Hernández A, Meoño-Morales E, Burgos-Vargas R, Suarez-Almazor ME. Ossification of the posterior longitudinal ligament in three geographically and genetically different populations of ankylosing spondylitis and other spondyloarthropathies. Ann Rheum Dis. 1998 Jul;57(7):429-33.https://pmc.
Further references to past data on the same from Narketpally