Puzzling case....

[Guest guest]

Dear Colleagues,

I was hoping you could help me with a complex case I have at the moment which is

puzzling me, I will try and keep it summarized and concise.

35Yo male:

June 2008 diagnosed with Type 1 diabetes and congenital aortic bicuspid valve

defect – surgery very successful for value defect (2009- ionx mechanical valve

replacement). On warfarin to prevent coagulation, no warfarin related issues to

date INR in range.

No history of autoimmune or diabetes in family. Father died young @ 45yo, uncle

the same, other uncle alcoholic also died young. Other family issues valve

defects presenting in nieces and nephews at birth – siblings all well.

Pre- diabetes diagnosis (2008) pt had viral Sx, tonsillitis rapid onset of

septic symptoms (12 hours) remitting and relapsing, critical symptoms before

diagnosis were blurred vision and faintness while playing soccer - Dr suggested

the Diabetes was virally activated ( ???). Only other relevant info here is that

he had spent the previous 6 months on Australia travelling around – no xs

Alcohol, drugs, bites, infections, gastritis etc.

Pt is on a low dose of insulin (10um am 6 um pm ) says occasionally he has

missed some evening dosages and blood sugar did not increase.

GIT: duodenal inflammation Dx at junior cert, pt still feels tenderness over

this point on a daily basis but reports no digestive issues at all, bowel moving

regularly. Diet good and well rounded – informed

Lifestyle: pt very fit walks 8-10 km daily will play football , swim, cycle –

only drinks once a week, work stress manageable.

HERE IS MAIN PC

March 2012, pt was at a friends house started to feel ill

Went and lay down within 30- mins pt felt he was having heart attack, could hear

heart beating and felt he was losing consciousness- difficulty breathing.

Ambulance called pt admitted to St Dublin, all CVS investigations – NAD

In summary the pt had 3 more trips to hospital all bloods and CVS checks normal,

Dr suggested `viral' cause. Pt has also attended a very reputable Cranio –

Osteopath and physio to address and physical immobility in the shoulders and

chest area.

Sx's the patient experiences: pt reports a sensation of his entire ribcage

shaking inside and a sensation of pressure on his lungs so that he feels like he

is suffocating, he also gets a feeling that he could actually die, the cranio

osteopath has been able to reduce the severity of the sensation of the ribcage

shaking inside, but there is an almost constant sensation of the pt chest having

such an intense amount of pressure on it that he can't breathe ( this can happen

up to 30 times a day).

I have to stress that this man seemed to me to be intelligent and rational,

very self aware, no hint of any anxious tendencies or history of any depression

or psychiatric episodes. He is genuinely distraught with his current symptoms.

Only other Sx of note is a Hb reading of 15.7 (13-17.5), all other blood liver

etc fine. Have no reading of serum ferritin etc.. (?)( Haemochromatosis did

cross my mind as the pt says he eats little red meat yet iron is still in upper

range, BUT his liver is fine and he has no fatigue as such).

Further tests to consider:

EBV, H.Pylori, Haemochromatosis, vit D3?

Would really love some collective wisdom on this one anything jumping out apart

from the Viral hypothesis..? Has anyone seen similar Sx in clinic of late,

Have also considered dodgy batch of either warfarin or insulin but pt works as

computer engineer in Pharma and has already checked out this theory.

Really appreciate you taking the time to read this ...

Ciara