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A 35-year-old male presents with severe burning neuropathic-type pain in both lower limbs for the past 6 months, significantly affecting sleep and daily function. Pain is continuous, resistant to pregabalin/gabapentin/duloxetine, and NCS + EMG + MRI + B12 and autoimmune/heavy metal/metabolic workup are normal.

Initially evaluated as possible small fibre neuropathy (SFN) or even functional pain, as no demonstrable abnormalities were detected. Psychiatry trial also failed.

Important new development:
Patient has been taking proton pump inhibitors (PPI) daily for >1 year due to chronic epigastric burning. Upper GI endoscopy revealed severe gastritis with Helicobacter pylori infection. He was started on standard H. pylori eradication triple therapy — and his epigastric pain resolved within 15 days.

This now brings attention to the recognized but under-discussed association between chronic H. pylori infection and unexplained sensory neuropathic pain, possibly due to:

  • Chronic immune activation → small fibre inflammation
  • Molecular mimicry / autoantibody-driven neuropathy
  • Increased pro-inflammatory cytokines (IL-6/TNF-α) affecting dorsal root ganglia
  • Subtle micronutrient malabsorption despite normal B12 level
  • Central sensitization triggered by chronic gut–brain axis stimulation

This opens the possibility that H. pylori–induced neuroinflammation or immune-mediated small fibre dysfunction could have been a contributor or amplifier of his neuropathic pain.

– Case 12

21 Year young male, went to his physician with compliant DOE and palpitation. Pateint was send to Cardilologist for ECHO. ECHO finding were suggestive of Pulmonary embolism , RA RV Dilated with normal LV function.Immediate CTPA- WAS done which confirmed PE. Pateint was given 18 mg reteplase bolus. At that time ,HR130, BP 130/80, SPO2 85% (RA). blood reports came after reteplase was given which showed platelet count 14,000, and HB 10GM%. REST of the routine reports were normal. Now patient was shifted under my care after these report came. when patient came to me His Heart rate 132, BP 120/70, SPO282%( RA) but patient is breathing comfortably ( RR-24).

This patient fall in category of chronic sub massive ( moderate PE). As he was not in shock, not acidotic, not in perarrest condition, not severe RV Dysfuction. Evidence do not support use of thrombolytics in MODERATE PE( clinicaly stable patient. Thogh thrombocytopenia report came later but retrospectively it look the pateint was just lucky that he did not bleed with such a low platelet count.

As he was shifted to my care immedietely post thromolysis ,there was neither any clinical improvementt or deterioration.

Post thromolytic ECHO showed RA/RV Dilated , PASP (50 ), WITH NORMAL LV function.

when patient came to me His Heart rate 132, BP 120/70, SPO282%( RA) but patient is breathing comfortably ( RR-24).

Patient responded to Oxygen ( 15litre NRVM) ,SPO2 99%, As he was non acidotic , and hemodynamicaly stable , we planned to manage further with LMWH . Workup sarted for thrombocytopenia and thrombophilia. He was found to have (APLA & ACLA) postive with ADsDNA postive . Steroid and HCQs was strtaed for same . His platelet stated improving after 24 hour. He was started on warf after 48 hours. It look 7 days to achieve INR OF 3.5 Then sropped LMWH. Platelets came to normal after 5 days.

With retrospective history ,he gave history of Cough and DOE since last 2 months.

We have discharged this patient on warf ( target INR :3.75-4.5), HCQS, WYSOLONE & Mycophenilate mofetil.

At discahge his HR-90, SPO2 (92%-94% ) on RA, BP 120/80, RR 18. PASP 40.

I am watchful , but it way be possible this Chronic , submassive PE patient may need surgical thrombectomy . I am not sure when I will advise for that . I believe to give 3 month trail of controlling SLE, AND MAITAINING INR of (3.75 to 4.5).

– Case 11

The 74 year, male, tobacco chewer, veterinary Doctor was under treatment for diabetes and hypertension since last 5 years by a diabetologist. Four months ago his sugar control went out of control. 24-hour sugar study was done by diabetologist blood reports. As per the reports has baseline sugar fluctuations has increased, HbA1c 7.5%, ESR 75. As per his diabetologist opinion, he was started on three OHA -(GLICLAZIDE, METFORMIN, SITAGLIPTIN AND ONE DOSE INSULIN TRESIBA 8 UNITS.)

As the patient was known, so came to me with reports for casual second opinion at the same time 4 month ago for getting endorsed that all is well. I wish to get some more reports which his diabetologist said no, saying that all these changes are due to uncontrolled diabetes and once diabetes gets under control all the reports will be ok.

So I wanted to find out the reason for high ESR and fluctuating uncontrolled sugar. TB and malignancy were high in my card so I ask them to get a screening PET -CT has done. The request was turned down by diabetologist and he was very particular in saying that let us wait till sugar in under control and ESR will come down and ESR is a non-specific test.

Then two month ago, on three antidiabetic drugs and tresiba his sugar got under control, HbA1c =6.5 and ESR CAME DOWN TO 45. I was still persistent for PET CT- Request declined.

A week ago a patient came with 5 kg weight loss, SGPT 95, ALK PHOSPHATASE 154, BILIRUBIN 1.8. ESR again rose to 74. ( All these reports patient was getting it done himself -in view of routine checks)

I got his CA-19-9( 38- high normal) MDCT abdomen and MRCP done, which showed an inoperable CA Pancreas. Endoscopic USG biopsy showed high-grade Adenocarcinoma.
Lesson – 1-High ESR in diabetes is not a normal finding.

2-Whenever sugar goes out of control in well-managed diabetes find the treatable causes and precipitating factors rather adding three or four drugs.

– Case 2 – Backache?

This 43 yr female, from affluent class, came to for second opinion 5month ago. She was suffering from bachache since last two month. No fever,no loss of apetite, no weight loss and pain was localised to lower back. She was seen by neurologist, orthopedics, rheumatologist, spine surgeons & OB&G. CBC,CT & MRI were normal. ESR 35.Reason for my opinoin was non relieving pain by all measures and she was advised ovarian cyst surgery for pain. As I was I was not convinced with small folicular cyst and pain relation I asked to go to other OB&G, where he said this may due to LS joint TB. As pateint has local tenderness. He send patient back to me. She had local tenderness. I got her montoux, which was positive (20*20). Usg neck abdomen normal. Repeat ESR-40. CRP 32.

I was of the opinion to start AKT. But patient wanted confirmation, so I advised PET-CT, which showed increased uptake in LS Joint, pancreas and small lesion at Right lung apex area. To get bug and culture it I advised to go LS joint biopsy and cs or navigation-MR guided needle aspiration at clevland USA. Patient went to spine surgeon for biposy where he not only advised against biposy but said it is nothing . Got HLADR27, brucella and ANA profile which was negative. He advised patient to go to ID. As patient was from very affluent class well to lots of supersepecialst ,they took opinion from many concerned superspecialist and everyone advised against AKT.
She was put on NEOCOXIA AND MINOCYCLINE THINKING that it is PID and even PET CT , MONTOUX , ESR AND CRP ALL WERE IGNORED. She GOT SYMPTOMATICALLY BETTER.

After 6 month they came back to me with more sevre pain, fever low grade and incresed CRP ,ESR. This time same ID person advised that she should be given trail. Repeat HRCT -THORAX ,increased lung invlovement, medustinal LN positive. Now last 15 day she is on full AKT.

Though I persued this patient so much and was so confident for dx which I could see well before time, but was not endorsed by other seniors so treatment got delayed for 6 moth only.

– Anasarca – Interesting Case 1

This 33 yr female was referred to me for generalised anasarca for 2 years. She has gained 50 kg weight and now was not able to do routine activity due to breathlessness on exertion. O/E Pulse 70/min, BP 170/100, SPO2 95%(RA), generalised pitting edema ( from face to toe). She was comfortable in lying position. CXR-B/L blunt CP ANGLE . ECHO -WNL, grade -2,diastolic dysfunction. She was being treated for
hypothyroidism (50mcg eltroxin), hypertension ( amlodipine-10 mg), dytor 40 mg tds . Her albumin level was 3.5 gm%.

So as suggested by most of you we did send CBC-N,LFT-N,RFT-N, Na118, K 4.2,URINE-R/M,(Albumin nil,-3-4 cells, No RBCs).Albumin 3.5
gm% total protein 6.5gm%. ECHO-N, USG -Normal kidney- B/L Pleural effusion, free fluid in abdominal wall and 3rd spaces. TSH > 100, FREE
T4- LOW, Random cortisol low. Antithyroid Antibody positive very high. Anti -TPO antibody positive.

Based on above finding our dx was autoimmune thyroiditis with severe hypothyroidism anad hypocortisolism. We 1st gave 100 mg
hydrocortisone and 300 MCG eltroxin. Next day we have started on 200mcg eltroxin, wysolone 10mg ,CILINDAPINE, RAMIRIL AND
TEORSEMIDE . She was send home and came back after 14 days. She has lost 40 kg water in 14 days. We needed to stop antihypertensive
and diruretics. Now she is doing well on 200mcg of eltroxin and 7.5 mg wysolone.

Experienced the Tachycardia Case

It was 14th of January 1997 noon time When I experienced the tachycardia for the first time and was thinking that this is merely some Palpitation but a veterinary Doctor Who was present, there told me the gravity of the situation and suggested to consult the cardiologist at earliest. Which I ignored, thinking that heartbeat can increase for various reasons, and it is not serious.

This kind of attack used to happen some 4 to 5 times every year. Once I was in a hospital for the installation of dialysis unit, I experienced the same. II made fun of this and asked the dialysis technician to put his hand on my chest to experience the feeling of Rail Gadi.

He immediately rushed To the doctor present there and told the situation. The doctor then examined me and sent me for a 2D echo.

After that, I was referred to an electrophysiologist who advised For EPF plus RFA.

But there was a very big requirement before going for RFA that Anyhow, I must be having an ECG done at the time when I was experiencing the SVT attack, because only after the study of that ECG, the experts could be able to find and pinpoint the area to be treated.

As I told that I had many number of attacks, so whenever I felt having an attack are used to rush for getting an ECG as early as possible. Sometimes I was lucky to have someone who could take me but many times I was like started my car and reached Any place where the ECG could be performed and the hilarious part was that almost every time when I reached at the reception of any centre and told that it is a tachycardia situation, and the ECG must be done immediately, The usual response was, they were asking me to bring the patient in, and at the time they were told by me that I am the patient, Their Face expressions, and response were like anything, I still Have smiles when I remember those.

These kind of treatments were very specialised and a very few specialists were there for the same in 2001. After gathering the information from across the India, I went to Escorts hospital, Delhi for the treatment.

Where they tried to stimulate the stroke to pinpoint the area for the Ablation, but it gave no results even after five hours, so they had to terminate the process. I got discharged and advised to come again after sometime.

I had many severe attacks of supraventricular tachycardia in letter years and even had to get admitted And had to be administrated with intravenous use of Isoptin .

In the year 2008, I again undergo for RFA at MAX Delhi and it Was looking like a success, but after 18 hours the AV node Of my heart stopped working, and I became a patient of bradycardia.

Being rigid not to have permanent pacemaker implant I tried to maintain myself with the help of medicines, but after having a very severe attack of bradycardia had to undergo for PPI. Which was done in September 2008.

But this was not the end to my problem. I started experiencing palpitations Even after RFA N PPI Because of high rate Atrial episodes. For which R FA was done again in 2014, which eliminated every natural heartbeat, and I Became dependent Hundred percent on external pacing.

In the year 2016, my pacemaker was replaced and the life was looking a bit smooth

What again this Was not the end of my problems. I was on a lot of medicines, precautions and diet.

In the year 2020. When the Covid wave was at its peak on 14th October, I had multiple MI attacks. ( Three in 8 1/2 minutes ) And almost no, Hospital was ready to admit me without Negative RTPcR. Anyhow, with the help of friends and relatives, I managed to get in a reputed hospital and was advised for emergency Angioplasty, but again I refuse and decided to for Thrombolization process. That Worked, but as it took more than eight hours for me to get any kind of treatment, my heart was damaged too much.

After that, even after being on heavy medicines I started Having unconsciousness attacks, vertigo very often. Again, I started consulting the experts across India, and it was found that due to heavy damage, my heart is not responding properly to the external pacing.

There were two types of opinion that one was to control the situation with the help of medicines and the other was to go for CRT-D Implant replacing the pacemaker.

After a lot of investigations in the hospital with multiple x-ray, echocardiogram, and several days off halter Monitoring it was decided for CRT – D implant. During roughly 3 weeks of time, the investigations done made a very Horrifying picture that there were very few chances of success ( less than 10% )and a very big risk For life. So as always, this was not going to be easy on me.

People Who know about such procedures may understand that such kind of implant take 45 minutes to 80 90 minutes, but once I got into the operation theatre, I came back after more than nine hours and on the ventilator.

Finally, by the grace of God in August 2021 I had my CRT-D Implant successful and with that and a lot of medicines, I started To lead towards almost a normal life.

As the time was passing by, I started experiencing multiple problems in my daily life as decreasing stamina, losing my appetite, weight, loss, lack of concentration, etc. Even the day to day routine, small work became like climbing the mountain for me, like if I used to put on my socks and tie the laces of my shoes, after that, I had to rest for 5 to 10 minutes because of feeling tired and breathlessness. I had to stop driving, climbing stairs , walking more than 100 steps and most of the time I remained on bed.

When it became very much inconvenient For me and my family, again I started search for Remedy for me, but got advised by the Many cardiologists To get registered for the heart Transplant as according to them, I was on the external pacing since a very long time and MI caused a significant damage to my heart.

After consulting N, number of Medical experts ( Cardiologist, physicians, lifestyle consultants ) Of various streams Like Apathy, homeopathy, Ayurved, and naturopathy, was not able to get any proper solution to feel get better.

As I told earlier that I was throughout the India since 2001 to meet cardiac experts, as my case was too much complicated one. I have an experience of nine times being in cath lab at various institutions. I have consulted almost every big name of the cardiac field Across India.

This year, when My brother-in-law visited to Lucknow, after observing my health conditions, he became worried too much. He holds one of the top positions in A leading pharma Company having business in multiple countries, he started looking for Some experts for me and finally he arranged one video meeting with Dr. Rajesh Mishra, Who is world renowned Intensivist and Internist at Ahmedabad. ( which I came to know very later when my sister living in USA searched For him at various platforms and told me that the kind of expert he is are very few in the world )

Hi, asked me about my health issues with extreme details and then suggested some very unusual tests and I was confused that I have problems related to my heart and I am being advised to get My B12, D3 levels check with some other evaluations, which no cardiologist ever asked for, but anyway I decided to follow him and got the tests done.

Once I sent the reports to the doctor, he studied Those and then only asked me to come in person for further checkup and treatment.

I went there and was examined by him, but again got confused that instead of asking about my heart problems, he was searching that what kind of vaccinations I had, or what kind of support medicines Other than Cardiac support, I was having And many other health related issues and symptoms.

He performed a 2-D echo and observed the condition of my heart, which was Having only 20% LVEF.

Only after that, he started describing the real problems I was having due to not giving attention to the rest of the body and by focusing on the heart only.

I was on too much medicines in higher doses to prevent my heart from sudden cardiac death, to control my blood pressure and pulse and maintain my other vitals.

He advised for sleep study and Bipap with saturation monitoring And decided the further course of treatment for me.

For anyone surprise that a severe Cardio patient who is advised for heart transplant is being prescribed for some essential vitamins, adult vaccination, and the medicines for the Cardiac support are reduced to their minimum like one by fourth.

He told me that there is not much to be done with your heart, but we can support that by reducing load on it, and also with the help of Bipap with oxygen, it can be reduced further more during rest Timings.

I had three days trial and testing on Bipap with oxygen at Ahmedabad And then, Dr Mishra finalised the Settings of Bipap / Oxygen , Potency, frequency of the medicines.

There were the miraculous improvements Observed during my Ahmedabad, stay as my energy levels, increased, sleep became better, and I started regaining my appetite.

After coming back to Lucknow on the evening of thirteenth this month only , from fourteenth to eighteenth My deep sleep increased from twenty minutes to seventy minutes just in 4 days Which was never recorded more than 30 minutes Since last many years.

I am advised to get a few tests done after one month of treatment to observe the difference. With such kind of recovery, I am very sure that there will be a lot of improvement can be seen in the reports.

Just 15 days back I was having almost no hope that I could have a normal life during rest of the period ( being bedridden or worse ), I don’t know that how long I will live, but after meeting with Dr. Rajesh Mishra, I feel myself very lucky and Privileged that I will be leading a quality life in future with his guidance and support. He is having a very unique approach that Filled me with very positive attitude towards life.

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