A lymphoma survivor presented for reassessment of his long-standing neurological symptoms more than three decades following a diagnosis of systemic T-cell lymphoma. Despite our desire to establish the diagnosis promptly, time is often necessary to reach conclusions based on the patient’s clinical evolution. We recount the chronology of clinical and radiological findings that, until recently, were largely inexplicable. We then report on the challenging diagnosis of neurosarcoidosis and suggest a known, yet rare, continuity linking it with lymphoma. Finally, we emphasize on the clinical evolution as a determining factor in the quest for a complex diagnosis. Insight, judgment, and perseverance are featured as key virtues of a resilient Neurologist.

Background: Noonan syndrome is congenital syndrome that occur sporadically or inherited as an autosomal dominant disorder, and is associated with a wide spectrum of clinical manifestations that vary greatly in range and severity including facial dysmorphism with low set ears, bulbous nose, micrognathia, and thick upper eyelids, mental retardation, nuchal folding, a low posterior hairline, high arched palate and widely space nipples. Cerebral abnormalities have been rarely associated with this syndrome. The aim of this paper is report the rare occurrence of cerebral abnormalities in an Iraqi girl with Noonan syndrome. Methods: A ten month girl with dysmorphic features, growth retardation and psychomotor retardation was studied. Results: The girl had a sporadic form of Noonan with predominant cerebral manifestations and without congenital heart defect. She had growth and psychomotor retardation, hypotonia, craniofacial dysmorphism with low set ears, bulbous nose, thick upper eyelid, high arched palate, and micrognathia. She also had widely space nipples, nuchal folding and a low posterior hairline. CT-scan showed ventriculopathy with evidence of brain atrophy. Conclusion: This paper reported a very rare association of Noonan syndrome with CT-scan evidence of ventriculopathy and brain atrophy in an Iraqi girl.

With the increasing burden of non-communicable diseases in low-income and middle-income countries (LMICs), biological risk factors, such as hyperglycemia, are a major public health concern in Bangladesh. Optimization of diabetes management by positive lifestyle changes is urgently required for prevention of comorbidities and complications, which in turn will reduce the cost. Diabetes had 2 times more days of inpatient treatment, 1.3 times more outpatient visits, and nearly 10 times more medications than non-diabetes patients, as reported by British Medical Journal. And surprisingly, 80% of people with this so called “Rich Man Disease” live in low- and middle-income countries. According to a recent study of American Medical Association, China and India collectively are home of nearly 110 million diabetic patients. The prevalence of diabetes in this region is projected to increase by 71% by 2035. Bangladesh was ranked as the 8th highest diabetic populous country in the time period of 2010-2011. In Bangladesh, the estimated prevalence of diabetes among adults was 9.7% in 2011 and the number is projected to be 13.7 million by 2045. The cost of diabetes care is considerably high in Bangladesh, and it is primarily driven by the medicine and hospitalization costs. According to Bangladesh Bureau of Statistics, in 2017 the annual average cost per T2DM was $864.7, which is 52% of per capita GDP of Bangladesh and 9.8 times higher than the general health care cost. Medicine is the highest source of direct cost (around 85%) for patients without hospitalization. The private and public financing of diabetes treatment will be severely constrained in near future, representing a health threat for the Bangladeshi population.

The strategic theoretical model is mainly based on the patients perceptive-reactive system and its functioning profiles, putting the typical nosographic descriptions of DSM-V in the background-in clinical practice. This methodological choice is aimed at favoring a more integrated and general approach, enhancing the particular individual components, typical of the patient, far from an excessively rigid approachable only to cage the patient in a scheme that does not value all the nuances of his clinical symptomatology. This model is then integrated with other theories able to fully explain the subjective nature of reality and the re-elaboration of it in a perceptive key.