He set aside this docunt and searched for a few related articles. One review stated that hypertrophic pachyningitis presents with a variety of symptoms, including headache, blurred vision, diplopia, hearing loss, cranial nerve palsy, cerebellar ataxia, and limb weakness. Due to its atypical symptoms, it is often misdiagnosed. The key to diagnosis is performing an enhanced cranial MRI scan.
Zhaxi printed these articles and gathered materials about the etiology, pathology, diagnostic criteria, and treatnt plans for hypertrophic pachyningitis. He organized all the information into a folder and then drew a mind map in his notebook, placing the patient’s symptoms at the center and listing all possible diagnoses. He used the exclusion thod to rule them out one by one. In the end, only a few possibilities remained—hypertrophic pachyningitis, intracranial venous sinus thrombosis, low cranial pressure syndro, autoimmune ningitis. Intracranial venous sinus thrombosis can be ruled out by performing magnetic resonance venography. Low cranial pressure syndro can be excluded because the patient’s intracranial pressure is elevated rather than reduced. Autoimmune ningitis, normally presents with increased cell count or protein in cerebrospinal fluid, but the patient’s cerebrospinal fluid was normal, making it less likely. Therefore, the most probable diagnosis is hypertrophic pachyningitis.
He closed his notebook, checked the clock, and realized it was already noon. He stood up, grabbed the docunts, and headed to Yang Ping’s office.
Yang Ping was eating in his office. Seeing Zhaxi enter, he put down his chopsticks: "Any findings?"
Zhaxi placed the docunts on the desk and began his report. He discussed all the information he gathered, his analysis process, and the reasons for excluding other diagnoses, explaining them one by one. Finally, he stated his conclusion: "Professor Yang, I suspect this patient has hypertrophic pachyningitis and recomnd performing an enhanced cranial MRI scan for confirmation."
Yang Ping listened quietly before speaking. He flipped through the docunts, studying them page by page. After about ten minutes, he looked up at Zhaxi: "I generally agree with your reasoning process, but there’s one issue: the articles you found are all from foreign case reports. Hypertrophic pachyningitis is very rare dostically. Have you considered other, more common diagnoses?"
Zhaxi thought for a mont and replied: "Yes, intracranial venous sinus thrombosis can be ruled out with MRV. Autoimmune ningitis is unlikely since the patient’s cerebrospinal fluid is normal. Low cranial pressure syndro is excluded due to elevated intracranial pressure. Tuberculous ningitis, the patient’s cerebrospinal fluid normal, no symptoms of tuberculosis poisoning, can be ruled out. Tumorous ningitis can also be excluded, as the patient’s cerebrospinal fluid normal, no dical history of primary tumor."
He paused, then said: "There’s also the possibility of neurofibromatosis. But neurofibromatosis often presents with other systemic symptoms like lung issues, skin, and joints. The patient doesn’t have these symptoms. Moreover, neurofibromatosis in cerebrospinal fluid usually presents with increased cells or proteins, but the patient’s cerebrospinal fluid is normal, making it unlikely."
Yang Ping nodded and said: "Your analysis is comprehensive, but there’s one diagnosis you haven’t considered."
Zhaxi was startled: "What?"
Yang Ping replied: "Paraneoplastic syndro."
Zhaxi opened his mouth but couldn’t speak. Paraneoplastic syndro, immune-diated neurological damage caused by tumors, can appear before the tumor is discovered. It has a variety of manifestations, including cerebellar degeneration, limbic encephalitis, and peripheral neuropathy. The patient’s subacute cerebellar ataxia indeed matches the manifestations of paraneoplastic cerebellar degeneration, but paraneoplastic syndro typically doesn’t elevate intracranial pressure. Zhaxi expressed his thoughts.
Yang Ping nodded: "You’re right, paraneoplastic syndro typically doesn’t cause increased intracranial pressure. But this patient has elevated intracranial pressure, making paraneoplastic syndro unlikely. However, in your analysis, you should ntion this differential diagnosis and explain why it’s ruled out. This is complete clinical reasoning, considering all possibilities, which requires strong knowledge base, from textbooks, literature, teachers’ instructions, clinical experience..."
Zhaxi lowered his head and added a line in his notebook: Differential diagnosis: Paraneoplastic syndro ruled out due to increased intracranial pressure.
Yang Ping stood up and picked up the phone on the desk: "Neurology Departnt? It’s Yang Ping, the patient in ward seven. I suggest performing an enhanced cranial MRI along with MRV to rule out venous sinus thrombosis. Okay, thank you."
After hanging up the phone, he turned to Zhaxi: "Do the MRI tomorrow morning. Once the results are out, you analyze them."
Zhaxi nodded, feeling both nervous and excited.
The next morning, Zhaxi arrived early at the MRI room. The patient, guided by the technician, entered the scanning area, while Zhaxi stood at the glass window of the control room, watching the images gradually appear on the screen. The technician first did a plain scan, T1-weighted, T2-weighted, FLAIR, layer by layer. Zhaxi stared at the screen, his heartbeat quickening, next to him was Dr. Fang Chuan from the imaging departnt.
In the plain scan images, no significant abnormalities were seen in the brain parenchyma. No tumor, infarction, or bleeding. Then the technician began the enhanced scan, injecting the contrast agent, waiting for a few minutes, then starting the scan. The enhanced images displayed layer by layer.
Currently, Professor Yang is training him on reading various images, including MRIs, but he doesn’t have that level of skill yet. He needs to rely on Dr. Fang for the results.
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