The presence of vertebral tuberculosis (TB) in developing countries and Southeast Asia is well known, but developed nations such as the USA and UK also claim a good share because of immigrants and the HIV population. We present a unique case series of two patients with chronic abdominal pain where various differentials and arduous investigation were employed. Finally, after a few months, we could locate the lower thoracic Pott's spine and commenced the treatment with successful resolution of symptoms.Surgeons and gastroenterologists should rule out the spinal cause of abdominal pain and also be aware of other atypical presentations before labeling it functional or irritable bowel syndrome (IBS) or somatoform disorders. Extensive investigation, cost, delay in diagnosis, and emotional disturbances could be the end product commonly encountered in a neuropathic abdominal pain patient if a high level of suspicion is not kept at the initial presentation. Above all, potential bony deformity, neurological deficits, and their irreversible sequelae such as paraparesis can also be thwarted.
Well delineated precipitating factors of migraine or incapacitating headaches are well known in the literature. Few peculiar and under-recognized precipitants are crying, shouting, straining in stools, urination, orgasm, childbirth, powerlifting. We present a case of a young student whose laughing aloud is a potent headache precipitant and is consistently reproducible despite normal brain imaging. It is worth mentioning here that laugh-induced headache has recently been assigned a place in the International Classification of Headache Disorders (ICHD-III) in 2018.The proposed pathophysiology in our case could be loud laugh induced Valsalva maneuver raising intraabdominal and intra-thoracic pressure momentarily causing venous congestion of head presenting as episodic headache. Another plausible explanation related to craniospinal pressure dissociation and the concept of dural elasticity and compliance needs to be explored if the symptoms persist and repeat scans show no pathology. Momentarily rise of intracranial pressure due to vigorous laugh could press the tonsils or distal cerebellar portion to herniate down transiently, causing symptoms and may be back to normal position once the laugh ceases. Social laughter releases enormous endogenous opioids, which is supported using positron emission tomography (PET) and u-opioid-receptor (MOR)-specific ligand carfentanil. A mirthful laugh could trigger a primary laugh headache. The role of modulated opioidergic activity and social mirthful laugh, if connected with such rare headaches requires further study.
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