HrutvikJ

| DNB General Medicine | MBBS | Work in Progress |

[Dr Sudhir Kumar MD DM @hyderabaddoctor]

Clinical Quiz
🔸45 year old man presented with muscle weakness and pain for 6 months. He had difficulty in getting up from squatting position, climbing up stairs and while reaching for objects above shoulder height.
🔸On examination, he had enlarged tongue (macroglossia) and hypertrophied calf muscles (see the image below).
🔸Serum CPK was 9600 U/L (normal range: 85-170). EMG was myopathic.

What is the most likely diagnosis?

[Dr Aditya Gudheniya @Gastronaut___]

If you have fatty liver (MASLD/MAFLD), you’ve probably been told that Just do BRISK WALKING

But most people don’t know what “brisk” actually means physiologically.
A short thread 🧵

[Nirmal Pandey MD DM Neurologist @nirmalregency]

62♂.
No significant PMH.
~18 months h/o progressive decline in language abilities: speech, comprehension & recently writing.

We neurologists should know where to look👀
T2 MRI 👇

[WalidoNeuroPedia @NeuroWalid]

Dyken's Criteria to diagnose Subacute Sclerosing Panencephalitis (SSPE), AKA Dawson disease.
#neurotip #neuropathology #neuroinfection

[JAMA Neurology @JAMANeuro]

A 62-year-old man presented with progressive limb weakness and involuntary movements. Take the Clinical Challenge.

What is your diagnosis?

https://t.co/kAcekr61dM

[CME INDIA @CMEINDIA1]

A 36-year-old male presents with intermittent dull right-sided abdominal pain for 2 months, associated with progressive abdominal distension and gradual vision impairment. There is no fever, vomiting, or urinary symptoms.

A positive family history reveals similar illness in multiple siblings.

Examination Findings

BP: 160/95 mm Hg

Hepatosplenomegaly

Ophthalmology: Peripheral corneal opacities

Laboratory Clues

↑ Serum creatinine

Normocytic anemia

↑ Total cholesterol & triglycerides

Very low HDL-C

🧠 Most Likely Diagnosis

Lecithin–Cholesterol Acyltransferase (LCAT) Deficiency

What is the mode of inheritance of this disorder?
✅ Autosomal recessive

🔍 Clinical Reasoning

Multisystem involvement (eye, liver, kidney, lipids) suggests a metabolic enzyme defect

Corneal opacities + low HDL + renal dysfunction are classic for LCAT deficiency

Affected siblings with unaffected parents strongly indicate autosomal recessive inheritance

📌 Clinical Pearl

Think LCAT deficiency in young adults with corneal clouding, hepatosplenomegaly, renal dysfunction, and very low HDL, especially with sibling involvement.

🩺 Management Snapshot

Supportive care & CV risk reduction

BP and lipid control

Monitor for progressive renal disease

Future directions: enzyme / gene replacement therapies

🔹 CME INDIA | Rare Dyslipidemia Awareness | Genetics in Clinical Practice

[EndoCollab™ | GI Endoscopy Community @EndoCollabcom]

Quick Tip: Iron Pill Gastritis

60yo M w/ anemia on oral iron. EGD: diffuse gastritis + enlarged fold in proximal stomach greater curvature.

Biopsies: Iron deposits.
1/6

[Ravi Kumar @RheumattDoc]

📘 2022 ACR Glucocorticoid-Induced Osteoporosis (GIOP) Guidelines

👥 Who Should Be Assessed?

👤 Adults ≥40 years
💊 Glucocorticoids ≥2.5 mg/day (prednisone equivalent)
⏳ Duration ≥3 months

🧮 Fracture Risk Assessment

🧠 FRAX (GC-adjusted)
🦴 DXA BMD (hip & spine)
📸 VFA / spine X-ray
⚠️ Look for:
•🩹 Prior fragility fracture
•📈 Cumulative GC dose
•🚶 Fall risk

🚦 Risk stratification (adults ≥40 years)

��� Low risk: FRAX major osteoporotic fracture (MOF) <10%.

🟡 Moderate risk: FRAX MOF 10–19%.

🟠 High risk: FRAX MOF ≥20% or hip fracture risk ≥3%.

🔴 Very high risk: prior osteoporotic fracture, T-score ≤ –3.5, FRAX MOF ≥30% or hip ≥4.5%, or high glucocorticoid exposure (≥30 mg/day prednisone equivalent or ≥5 g/year).

💊 Pharmacologic Treatment

🟢 Low Risk

🥗 Lifestyle measures
🧂 Calcium + 🌞 Vitamin D
❌ No drug therapy

🟡 Moderate Risk

🥇 Oral Bisphosphonate (Preferred)
💊 Alendronate / Risedronate
🔄 Alternatives:
•💉 IV Zoledronic acid
•🧬 Denosumab
•🧠 Teriparatide

🟠 High Risk

✅ Strong treatment recommendation
Options:
•💊 Oral / 💉 IV Bisphosphonates
•🧬 Denosumab
•🧠 Teriparatide / Abaloparatide

🔴 Very High Risk

⭐ Anabolic therapy preferred
•🧠 Teriparatide / Abaloparatide
Alternatives:
•🧬 Denosumab
•💉 IV Bisphosphonate

🧒 Special Populations

👶 Age <40 years

🦴 Treat only if:
•Prior fragility fracture OR
•🔥 Very high GC exposure
🥇 Preferred: 💊 Oral bisphosphonate

🧑‍⚕️ CKD / Transplant Patients

🚫 Avoid bisphosphonates if eGFR <30 ml/min
✅ Consider:
•🧬 Denosumab
•🧠 Teriparatide

🧂 Calcium & Vitamin D (All Patients)

🧂 Calcium 1000–1200 mg/day
🌞 Vitamin D 800–1000 IU/day
🎯 Target 25-OH Vit D ≥30 ng/mL

🔁 Monitoring

📅 DXA every 1–2 years
🔄 Reassess if:
•💊 GC dose changes
•🦴 New fracture
•⏳ Long-term GC therapy

🧠 Summary

⏰ Assess early
🥇 Bisphosphonates = first line
⭐ Anabolic agents for very high risk
🛡️ Prevent fractures before they occur

#RheumattDoc #MedTwitter #RheumTwitter #rheumatology @DrAkhilX @IhabFathiSulima @CelestinoGutirr @DurgaPrasannaM1 @Urchilla01

[Ravi Kumar @RheumattDoc]

🔥 Disease Activity in Rheumatoid Arthritis (RA)

🧩 Core Components
•🤕 Tender joint count (TJC)
•🔴 Swollen joint count (SJC)
•🧑‍🦱 Patient global assessment
•👨‍⚕️ Physician global assessment
•🧪 ESR / CRP

📊 Disease Activity Indices

1. 🟢 DAS28 (28-joint Disease Activity Score)
Components: TJC28 + SJC28 + PtGA + ESR/CRP
•🟢 Remission: < 2.6
•🟡 Low: 2.6 – 3.2
•🟠 Moderate: 3.2 – 5.1
•🔴 High: > 5.1

2. 🟢 SDAI (Simplified Disease Activity Index)
Components: TJC28 + SJC28 + PtGA + PhGA + CRP
•🟢 Remission: ≤ 3.3
•🟡 Low: 3.4 – 11
•🟠 Moderate: 11.1 – 26
•🔴 High: > 26

3. 🟢 CDAI (Clinical Disease Activity Index)
Components: TJC28 + SJC28 + PtGA + PhGA
❌ No lab values
•🟢 Remission: ≤ 2.8
•🟡 Low: 2.9 – 10
•🟠 Moderate: 10.1 – 22
•🔴 High: > 22

🏆 ACR/EULAR Boolean Remission

All must be met:
•🤕 TJC ≤ 1
•🔴 SJC ≤ 1
•🧪 CRP ≤ 1 mg/dL
•🧑‍🦱 PtGA ≤ 1 (0–10 scale)

🎯 Treatment Target
•🎯 Primary goal: Remission
•✅ Acceptable: Low disease activity
•🔁 Reassess every 1–3 months

⚠️ Key Points
•👣 DAS28 excludes feet and ankles
•🤕 Fibromyalgia may falsely elevate scores
•⚖️ Obesity can increase patient global scores

🧠 Take-home Message

📏 RA disease activity should be measured regularly, not estimated, to guide optimal treatment decisions.

Image : 📘 Kelly and Firestein’s Textbook of Rheumatology

#RheumattDoc #MedTwitter #RheumTwitter #rheumatology @DrAkhilX @IhabFathiSulima @CelestinoGutirr @DurgaPrasannaM1 @Urchilla01

[Dr Abhilasha Manwatkar (AIIMS Nagpur) @Abhilasha21822]

New joint pain + clubbing = search for cancer.

Why ..let’s decode👮🏾🕵🏽‍♀️

A 60-year-old man came with history of 8 weeks of joint pain.
Also mentions breathlessness + dry cough. Hands show clubbing.

X-ray shows periosteal new bone formation and tram-line sign.

But CT chest changes everything...

👉 Diagnosis is easy : Hypertrophic osteoarthropathy (HOA)

How do you diagnose HOA? 🦴🫁
🔹 Arthralgia/synovitis
🔹 Bone pain (tibia & femur classic)
🔹 Digital clubbing
🔹 X-ray: periostitis / tram lines
🔹 Always image the chest

Till here it’s easy twist is…
Why we did chest xray and ct thorax …

⚠️ New-onset HOA = think malignancy until proven otherwise

Key pearl 💡
📊 new onset means secondary HOA can be due to an underlying malignancy
📍 Most commonly lung cancer (NSCLC)..

Take-home
Rarely Joint pain may be the first sign of cancer.
Always 👀 beyond joints…

[Swati Garekar @swatigar]

Older Child, preadolescent, unable to even walk in the house, so severely cyanotic....
...so sad to see these kids in OPD day after day ...
...yes we are able to help out.
But they should have been detected and made to undergo surgery long time ago....

What do u think is the diagnosis. Even the ecg is classic.
@DrRajeshG1 @nihar_nayak2

[Braydon Dymm, MD @BraydonDymm]

2025 was a landmark year for stroke neurology.

From the MeVO trials to news of AI-driven systems of care and Factor XIa inhibitors on the horizon, the landscape of vascular neurology has shifted.

Here's a month-by-month recap of the year! 🧵

[Ravi Kumar @RheumattDoc]

🦴📸 Kellgren–Lawrence Scale: OA at a Glance

Grading Osteoarthritis on X-ray (0–4)

Grade 0 – Normal 🦴✨
•Normal joint
•No OA changes

Grade 1 – Doubtful OA ❓🦴
•Possible tiny osteophytes
•Doubtful joint space narrowing

Grade 2 – Mild OA 🌱🦴
•Definite osteophytes
•Possible joint space narrowing

Grade 3 – Moderate OA ⚠️🦴
•Multiple osteophytes
•Definite joint space narrowing
•Subchondral sclerosis
•Possible bony deformity

Grade 4 – Severe OA 🔥🦴
•Large osteophytes
•Marked joint space narrowing
•Severe subchondral sclerosis
•Definite bony deformity

Key points
•Based only on radiographs (not symptoms)
•Widely used in clinical practice, trials, and epidemiology
•Pain severity may not correlate with KL grade

#RheumattDoc #MedTwitter #RheumTwitter #rheumatology @DrAkhilX @IhabFathiSulima @CelestinoGutirr @DurgaPrasannaM1

[European Society of Cardiology Journals @ESC_Journals]

Does mavacamten improve mid ventricular obstruction in hypertrophic cardiomyopathy? Find out in this case series: https://t.co/7W7nx0bXAW

#EHJCaseReports @Phiso_de @TJ_Yeo @aayshacader @BoldiKovacsMD @SukritiBanthiya @ANazmiCalik @O_Azizy_MD @saramoscatelli7 @EHJCREiC #CardioX #echofirst

[European Society of Cardiology Journals @ESC_Journals]

A detailed explanation of how high flow arteriovenous fistulas leads to high output cardiac failure https://t.co/2nu9JPNkzN

#EHJCaseReports @Phiso_de @TJ_Yeo @aayshacader @BoldiKovacsMD @SukritiBanthiya @ANazmiCalik @O_Azizy_MD @saramoscatelli7 @EHJCREiC #CardioX #echofirst

[Mohith reddy @DrMohithreddy]

Palindromic rheumatism is fascinating—best viewed as a two-axis overlap (autoimmunity + autoinflammatory ‘attack’ biology).
Ref: doi:10.1038/s41584-019-0308-5

How often do you encounter this autoinflammatory-leaning presentations ? @DurgaPrasannaM1 @sarath_rheum @IlliasulK @Rheumat_Aravind

[ILLIASUL IBAD @IlliasulK]

Does giving the SAME drug, at the SAME dose, but at a DIFFERENT time of day change its effect in rheumatology?

Short answer: YES.

Long answer 👇🧵

@DrAkhilX @IhabFathiSulima @CelestinoGutirr @Janetbirdope @Urchilla01 #medtwitter #rheumtwitter

[Nirmal Pandey MD DM Neurologist @nirmalregency]

12♀
One month h/o of subacute parkinsonism syndrome
Low volume difficult speech
Staring look
Sialorrhea
Open mouth
Extreme hypokinesia
Fever 20 days before onset
MRI 👇

[Gastronomer @Middle_class_xo]

Classifications of Crohn’s Disease 📚
🧵 Vienna ➡️ Montreal ➡️ Paris — let’s compare!
#MedTwitter #Gastrotwitter #GastroX #IBD

[Ravi Kumar @RheumattDoc]

🧩🧬 Anti-RNP: A Piece of the Puzzle

🚨��� Honest question: how often is MCTD labeled just because RNP is positive?

🎯 Anti-U1 RNP is necessary but not sufficient for MCTD (Mixed Connective Tissue Disease)

⬇️ Here are the classification criteria

🧬✨ MCTD Classification Criteria

1️⃣ Alarcón-Segovia Criteria

🧪 Serology (Mandatory)
•🔬 Anti-U1 RNP ≥ 1:1600

🏥 Clinical (≥ 3 required)
•🤲 Swollen hands
•🦴 Synovitis
•💪 Myositis
•✋ Sclerodactyly
•❄️ Raynaud’s phenomenon

📊 Diagnostic Performance
•🎯 Sensitivity: ~ 60–70%
•🛡️ Specificity: ~ 90–95%

2️⃣ Kahn Criteria

🧪 Serology (Mandatory)
•🔬 Anti-U1 RNP ≥ 1:1200

🏥 Clinical
•❄️ Raynaud’s phenomenon
➕ ≥ 2 of:
•🤲 Swollen fingers
•🦴 Synovitis
•💪 Myositis

📊 Diagnostic Performance
•🎯 Sensitivity: ~ 70–75%
•🛡️ Specificity: ~ 85–90%

3️⃣ Kasukawa Criteria

🧪 Serology (Mandatory)
•🔬 Anti-U1 RNP positive

🏥 Clinical Requirement
•✅ ≥ 1 Common feature
•➕ ≥ 1 feature from ≥ 2 overlap diseases

🔹 Common Findings
•❄️ Raynaud’s phenomenon
•🤲 Swollen fingers / hands

🟣 SLE-like Features
•🦴 Polyarthritis
•🧠 Lymphadenopathy
•😊 Facial erythema
•🫀 Pericarditis / 🫁 Pleuritis
•🧪 Leukopenia / Thrombocytopenia

🔵 Systemic Sclerosis-like
•✋ Sclerodactyly
•🫁 Pulmonary fibrosis / ↓ DLCO / restrictive PFT
•🍽️ Esophageal hypomotility / dilatation

🟠 Polymyositis-like
•💪 Muscle weakness
•📈 Elevated CK
•⚡ Myogenic EMG

📊 Diagnostic Performance
•🎯 Sensitivity: ~ 80–90% ⭐ (highest)
•🛡️ Specificity: ~ 70–80%

🧠 Take home
•🛡️ Most specific → Alarcón-Segovia
•🎯 Most sensitive → Kasukawa

#RheumattDoc #MedTwitter #RheumTwitter #rheumatology @DrAkhilX @IhabFathiSulima @CelestinoGutirr @DurgaPrasannaM1