Summary: This project aims to establish deep phenotypic data driven insights into the manifestations of fluorosis in district Nalgonda, particularly Narketpally where the team has had frequent encounters with an epidemiological tip of the iceberg population that often presents to the hospital outpatient and inpatient with manifestations of fluorosis as a frequent comorbidity of metabolic syn driven organ dysfunction. Of particular interest is signposting of the lesser known Narketpally ligamental invisible pillow syndrome as opposed to the globally known catatonic psychological invisible pillow syndrome other than optimizing clinical complexity in those patients of fluorosis and multimorbidities utilising current medical cognition tools.

Introduction:

As an MBBS student in the 80s, one leafing through the text book of community medicine wouldn't surely miss reading about the Nalgonda technique and it's efficacy in curbing the menace of fluorosis in the district.

More about it here in rare and generously preserved documents published by NEERI, Nagpur and archived by a Netherlands based global organisation here: https://www.ircwash.org/biblio/author/105

It was hence with excitement that some of us were excited to join the Narketpally team and notice this text book problem in the very first week of joining as reflected upon in this online learning portfolio post here:

"Today is my first day of joining my new workplace, a medical college 60 kms from Hyderabad and an epicenter for an epidemic of people who gradually start walking with a stick to balance themselves and begin to lose the normal sensations in their limbs. I approached these people in the images below, requested to examine them (they had never bothered to consult a doctor for this problem and had come to visit the hospital as patient relatives) and I found very prominent neurological findings suggestive of a cervical spinal cord involvement. These persons were having a gradual paralysis of all four limbs since many years but they had taken this for granted. The early seeds to detecting the cause of this problem was perhaps sown in US based epidemiologic research in the early 20th century (more here? https://www.nidcr.nih.gov/OralHealth/Topics/Fluoride/TheStoryofFluoridation.htm but I am still searching for literature on how and when this was first discovered and reported from my current location 60 kms from Hyderabad."

Unquote: https://www.facebook.com/share/p/1EJ4JvKPGE/?mibextid=oFDknk

And then on further review of literature I found a few articles and studies done from Hyderabad medical college teams from 1950s with meticulous description of how they found a correlation between ground water levels of fluoride (external medicine) vs internal body levels of fluoride (internal medicine) here:

https://pmc.ncbi.nlm.nih.gov/articles/PMC1981710/?page=1

While the data capture of each individual encounter started in 2017 there are a few archived and accessible to human memory driven search from the 5000 Narketpally case reports accessible at our department dashboard here: https://medicinedepartment.blogspot.com/2022/02/?m=1

Currently the issue is that blogspot case reports are not amenable to google searches and even to search for fluorosis from the dashboard one would need to separately access at least 1000 online learning portfolios available there and search each one of those separately!

A sample case focusing on the physical pillow syndrome from an elective student's online learning portfolio from 2019:

https://bmjsanjana.blogspot.com/2019/03/disclaimerthis-is-hipaa-de-identified.html?m=1

To quote from the above link, "neck is so stiff that when I lie down its difficult for me to sleep without pillow because i cannot touch the bed with back of my head and without pillow my head stays in air(since 2yrs)."

Also check out the photographs of the physical imaginary pillow as well as other skeletal features of fluorosis in the link above.

Sample case with photo of the physical imaginary pillow as well as other skeletal fluorosis images from 2022 elective student:

https://ssahamedicalcases.blogspot.com/2022/02/fluorosis-and-renal-stones.html?m=1

Sample case with photo of the physical imaginary pillow as well as links to his other skeletal fluorosis images/CT video

from our 2025 elective student:

https://pajrcasereporter.blogspot.com/2025/03/74m-with-neck-pain-hypoglycemic-coma.html?m=1

Medical cognition contextual connections rethink Update of 74M:

Revisited the patient's history with the daughter now in our quest for causes and effects:

Patient was having forgetfulness since two months. He takes 90 ml of alcohol everyday and stopped 20 days back (before admission) as he was unable to earn enough from his tailoring work to maintain his regular drink!

After 18 days of this event of his stopping alcohol, he developed fever and vertigo and was taken to a local doctor who gave injections and while his fever subsided, he started having hallucinations imagining he was running the sewing machine when he was lying on his bed!

On the day he got admitted, he was brought to our psychiatry OPD for the hallucinations , although soon after, the daughter noticed that he was also having slurred speech and ataxia and hence brought him to our general medicine OPD where he was asked to get a chest X-ray and shown directions to radiology OPD mentioning that it's next to Orthopedic OPD and when they inquired in Orthopedics OPD they admitted him in orthopedics ward!!

Then in the Orthopedic ward he developed an episode of diarrhoea with fecal incontinence and severe sweating following which he became comatose and was found to have hypoglycemia which was promptly corrected and he regained consciousness but by afternoon had slipped again into coma following which we noticed meningeal signs and removed his CSF and got his chest X-ray suggestive of right lobar consolidation along with loculated pleural effusion and treated him for pneumococcal pneumonia and meningitis!

After a few days the patient suddenly recovered his sensorium and his chest X-ray also normalised suddenly which sowed the first doubt of our diagnosis! On reviewing his phenotype, he appears to have a metabolic syn phenotype with severe sarcopenia and substantial visceral fat which the daughter claimed was much more earlier!

In the light of the data above we are currently thinking this was more of a viral vestibulitis, cerebellitis that eventually progressed to encephalitis and then recovered.

The clinical meningeal signs that we thought were meningeal are still present after recovery and are part of his fluorotic enthesopathy! The pneumonia and loculated effusion was actually a phantom tumor (classic medicine exam short note) that recovered as his heart failure recovered!

So eventually, as reported by us in the past here : https://userdrivenhealthcare.blogspot.com/2024/04/cbble-case-report-60-year-old-woman.html?m=1

, a viral fever may have precipitated his heart failure and also progressed to encephalitis but he eventually recovered with time.

The heart failure and even his potential cerebral neurodegenerative disorder going by his history of recent progressive dementia are all a part of his metabolic syn and NCD!

Few OPLL diagnostic uncertainty outliers from our collective CBBLE:

[06/03, 12:11] CBBLE moderator CM: OPD now : 26F with neck pains and early morning neck stiffness since 1 month. Any inputs on the posterior longitudinal ligament?

[06/03, 14:39]AS: Looks clean to me

[06/03, 14:59]CM: Agree but why is the area around the posterior longitudinal ligament , essentially the posterior border of her cervical vertebrae appearing to be hyperdense?

The above lady was likely having spondyloarthropathy that can be clarified on follow up and spondyloarthropathy is an interesting differential for fluorosis as reported earlier here: https://pmc.ncbi.nlm.nih.gov/articles/PMC9450208/#:~:text=Skeletal%20fluorosis%20can%20mimic%20various,rheumatoid%20arthritis%2C%20osteoarthritis%20or%20spondyloarthropathy.&text=The%20early%20stages%20of%20the,tendinitis%2C%20and%20early%20morning%20stiffness. and many other platforms.

[14/04, 10:30] cm: OPD right now: 53M complains of giddiness since 15 days and also complains of neck pain. Do these teeth crown point toward fluorosis? He has been consuming bore water since 50 years and stopped just 3 years back! He doesn't have the Narketpally sign though

Also has an obvious past problem currently inactive since last 20 years of vitiligo that was active from age 20-30 and then subsided leaving it's mark

[14/04, 12:56] cm : He came back with his x-ray cervical spine which is suggestive of posterior longitudinal ligament calcification again consistent with our Narketpally syndrome!