Clinical Synthesis

Multi-System Diagnostic Review

Patient: K.C.

Age: 40 | Male

Generated: March 2, 2026

📋 Executive Summary

Symptoms began after a May 2024 exertional vestibular event; persistent 24/7 lightheadedness became established by ~Fall 2024. Current symptoms include non-positional lightheadedness (worse upright but present seated/supine), cognitive ‘lag,’ bilateral non-pulsatile tinnitus, and orthostatic tachycardia physiology with elevated standing norepinephrine measured at 15 minutes.

Autonomic Profile

Objective testing demonstrates a hyperadrenergic pattern with tilt heart rate surge >40 bpm without orthostatic hypotension and standing norepinephrine of 630 pg/mL (measured at 15 minutes standing).

🫀 1. Autonomic & Peripheral Nerve Screen

Norepinephrine (pg/mL)

Orthostatic norepinephrine elevation (15-min stand) consistent with hyperadrenergic physiology.

Tilt Table Data

Values plotted represent approximate timepoint readings from the tilt table flowsheet; peak BP values varied across readings.

Skin Biopsy (12/4/2025)

IENFD Distal Leg 7.3 fibers/mm
(Normal: >5.4)
IENFD Thigh 9.8 fibers/mm
(Normal: >7.0)
SGNFD Distal 38.5%
(Cutoff: 38.2%)
Congo Red (Amyloid) Negative

👁️ 2. Sensory Hardware Status

Spontaneous Nystagmus

Caloric Results (Sum)

Total caloric slow-phase velocity (SCV) sum = 7°/sec.

Vision Progress

Binocular metrics improved; persistent symptoms suggest central integration component.

Clinical Observation

Vertical phoria normalized to 0Δ. Jump vergence accuracy 100%. Total caloric SCV sum 7°/sec. Binocular mechanics improved; persistent non-positional symptoms suggest evaluation of central sensory integration.

🦠 3. Immune, Gut & Vascular Axis

sCD40L (Platelet Activation Marker)

Platelet activation marker decreased over time.

Cytokines (Mar 2025 → Oct 2025)

Radiance Cytokine-14; pg/mL.

GPCRs (U/mL)

Gut Barrier (Functional Markers)

CellTrend GPCR Positive Thresholds (U/mL): AT1R ≥17, ETAR ≥17, α1 ≥11, β1 ≥15, β2 ≥14, M3 ≥10.0, M4 ≥10.7

Immune Cell Trend (cells/µL)

Month / Year CD3 (/µL) CD4 (/µL) CD8 (/µL) NK (/µL) CD19 (/µL)
Mar 2025* 1618 1234 327
May 2025 1728 1334 409 360
Aug 2025 1302 960 319 274 291
Oct 2025 1083 813 275 224
Jan 2026 1205 923 292 230 241
Ref Range 622–2402 359–1519 109–897 24–406 12–645

*April 2025 COVID reinfection noted. NK and CD19 data missing for Mar 2025.

Takeaway Counts declined after Apr 2025 reinfection (nadir Oct 2025) with partial recovery by Jan 2026.

🧠 4. Neurologic & Metabolic Axis

ASL Perfusion Analysis

Relative perfusion pattern based on ASL radiology interpretation.

Radiologist Note (ASL MRI)

"ASL map shows patchy hypoperfusion frontal toward the vertex, deep temporal and occipital lobes bilaterally, with somewhat diminished basal ganglia activity. No focal infarct or structural lesion reported."

MitoSwab Summary

High Citrate Synthase (306%) suggests compensatory mitochondrial biogenesis, with relative reduction in Complex I activity (50%). Functional assay variance; not diagnostic of primary mitochondrial disease.

Mitochondria Function (%)