A Case That Refused to Fit the Textbook

⚡Not every disease announces itself clearly. Some whisper, mislead, and dare you to stop thinking.

It began as what appeared to be a routine referral.

A 50-year-old man, treated three months earlier for acute necrotising pancreatitis, returned to the hospital — this time with a 12-kg weight loss over two months and mild hemoptysis. Something was clearly wrong, yet nothing was immediately obvious.

Reviewed the image again - a pancreatic lesion was also found in ct thorax - extended sections of abdomen 

Malignancy/ Infection was the initial consideration, and a CT-guided biopsy was planned

Patient showed no signs of sepsis — no fever, no leukocytosis, no clinical toxicity.

Then came the first twist.

🙀His heart rate was 30 -35 bpm - heart block - which was not present in the last admission 

The biopsy now seemed unsafe.

A pacemaker appeared necessary.

But implanting one without excluding infection felt equally perilous.🤷

Despite the risks, the biopsy was performed.

The report read:

“Acute on chronic inflammation.”

No answers — only more uncertainty.

Patient had scleritis too - had noticed during the initial examination - but overlooked 🙂‍↕️

The clinical picture continued to grow more puzzling:

* A pancreatic lesion

* Pulmonary lesions

* New-onset heart block

* Significant weight loss

* Conjunctival redness

Nothing connected neatly. patient underwent temporary pacemaker.

Yet the case refused to settle.🤔🤔

One question lingered relentlessly:

Could this be autoimmune - IgG4-related disease?

A diagnosis often dismissed as existing only in textbooks.

After repeated discussions — and considerable persuasion of both the team and the patient — serum IgG4 levels were finally sent. ( it was not easy - practice is kinda difficult in 2 tier cities where every small factor matters)

📌 They returned elevated.-374mg/dl 

At last, the missing piece fell into place.

📍The Lesson

IgG4-related disease is a master of disguise — capable of involving multiple organs and even presenting with cardiac conduction abnormalities.

Some diagnoses reveal themselves only to those willing to listen carefully to the whispers — and refuse to stop thinking.

special thanks to Dr. Praveen Kesav R MD (AIIMS, Delhi), EBIR-ES, EDIR, DICR sir for timely input and guiding me and Dr Hitesh sir (med gastro) for giving me the opportunity💫