rss

Recent eLetters

Displaying 1-10 letters out of 208 published

  1. Opportunity for a "one health" approach overlooked?

    To Whom It May Concern

    "Lick of death: Capnocytophaga canimorsus is an important cause of sepsis in the elderly"1 describes an excellent outcome thanks to an elegant diagnostic work up and excellent treatment. However, I believe the headline "Lick of death" is unnecessarily fear-mongering and unwarranted (the patient, after all, did not die). Additionally, while the authors should be congratulated for educating practitioners about C. canimorsus, I feel there is scope for discussion with veterinarians to reduce further risk to this and other patients.

    The authors conclude that the source of the patient's infection was the owner's own dog, via a lick, on the grounds that Capnocytophaga canimorsus was isolated from that patient, that it is a zoonotic organism and that the patient admitted to being licked by the dog. My understanding is that this conclusion is based on findings that C canimorsus colonises the mouths of dogs and cats. This seems reasonable though for the sake of completeness and illuminating our understanding of this condition I feel it would have been helpful to examine and test the dog, and here there is scope for veterinary input2.

    As the authors note, the elderly rely on companion animals. Could C canimorsus be isolated from the oral cavity of the patient's Italian greyhound? Was the dental and periodontal health of the dog assessed? What measures could be taken to reduce the risk of exposure, apart from avoiding being licked by the dog? A recent UK study found that 9.3 per cent of dogs suffered from periodontal disease3. What we don't know is whether regular dental scaling may reduce carriage of C canimorsus.

    Another question, perhaps to be answered by veterinarians, is whether the patient's comorbidities contributed to the licking by the dog? Companion animals may alter behaviour in response to owners, and may engage in licking or biting as an attempt to rouse owners with a reduced state of consciousness4. In fact, licking behaviour was performed by 50 per cent of seizure response dogs when owners suffered seizures5. (It is important to note that while licking may be detrimental, seizure response dogs can save lives - in the previous study, one dog brought the cordless phone, another rolled the owner, who had a history of aspiration pneumonia, onto their side, and yet another turned off the electric wheelchair as several accidents had occurred during seizures).

    Human animal interactions are complex, involving mutual benefit as well as potential risks to both parties. This complexity demands a genuine 'one health' approach. Discussion of the role of the dog in this case with a veterinarian may help illuminate and reduce animal-based risk factors.

    Sincerely,

    Anne Fawcett

    References

    1. Wilson JP, Kafetz K, Fink D. Lick of death: Capnocytophaga canimorsus is an important cause of sepsis in the elderly. BMJ Case Reports 2016;2016. 2. Speare R, Mendez D, Judd J, et al. Willingness to Consult a Veterinarian on Physician's Advice for Zoonotic Diseases: A Formal Role for Veterinarians in Medicine? Plos One 2015;10(8):8. 3. O'Neill DG, Church DB, McGreevy PD, et al. Prevalence of Disorders Recorded in Dogs Attending Primary-Care Veterinary Practices in England. Plos One 2014;9(3):16. 4. Seligman WH, Manuel A. The cat and the nap. Medical Journal of Australia 2014;200(4):229-29. 5. Kirton A, Winter A, Wirrell E, et al. Seizure response dogs: Evaluation of a formal training program. Epilepsy Behav 2008;13(3):499-504.

    Conflict of Interest:

    I am a companion animal veterinarian and co-habit with companion animals.

    Read all letters published for this article

    Submit response
  2. 7q11.23-q21.2 microdeletion: 2 years follow-up

    As reported in the original article, the developmental assessment at 13.5 months (adjusted for prematurity) showed a global developmental delay.

    Bayley III assessment at 24.8 months (adjusted for prematurity) confirmed the global developmental delay affecting cognitive, communication and motor domains (percentile ranks: 0.4, 4, 0.4, respectively). The passive tone of his upper extremities was symmetrical bilaterally, but with mild hypotonia.

    His mother also reported two major episodes of generalised tonic-clonic seizures requiring attendance to hospital and referral to epilepsy clinics.

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  3. Gastrointestinal bleeding secondary to trimethoprim-sulfamethoxol induced vitamin K deficiency

    The combination of trimethoprim and sulafamethoxole has been used for the prophylaxis of malaria for over several decades. While the development of vitamin K deficiency due to this drug combination is theoretically possible, it is not very common. There are many risk factors for vitamin K deficiency, such as diet, interactions with other drugs and basic liver function. To state that this drug combination caused vitamin K deficiency in the patient is presumptive. Other factors may have lead to reduced levels of vitamin K in this patient. Furthermore, to state that the patient developed GI bleeding secondary to vitamin K deficiency is speculative. The use of this drug combination for the prevention of malaria is important for those residing in these endemic areas and for those intending to travel to these areas.

    Conflict of Interest:

    Nil

    Read all letters published for this article

    Submit response
  4. Spleen and gone? An interesting case of fever in a young man

    The spleen can become infected as a result of septicemia, especially in immunodeficient patients. On some occasions, it can also get infected in immunologically competent patients. The spleen is known to undergo infarction in situ and may subsequently become infected. In addition, it could undergo sequestration and get infected under a variety of situations, without producing any significant symptoms and clinical findings. It is therefore not surprising to note that there was no palpable splenic mass before the radiological investigations revealed an abscess in the splenic region. The repeat admission and drainage of the collection of pus occurred because the patient may have been discharged too early and could have been avoided. Most of these patients require treatment with high doses of broad spectrum antibiotics for a sufficient duration. A possibility of accessory spleen also needs to be considered. A primary source of infection needs to be established. The prognosis is good for most immunologically competent patients as long as the usual precautions are taken after splenectomy.

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  5. Biotin-Thiamine-Responsive Basal Ganglia Disease Can mimic Acute Disseminated Encephalomyelitis

    I read this article with interest as we too made a diagnosis of post-streptococcal acute disseminated encephalomyelitis with basal ganglia swelling in a female aged 11, who had presented with altered conscious level and dystonia, with similar distribution of basal ganglia lesions on MR brain imaging. However, a diagnosis of Biotin-Thiamine-Responsive Basal Ganglia Disease was considered, and homozygous SLC19A3 mutation was confirmed. This is a treatable condition requiring lifelong biotin and thiamine, and I urge the authors to consider testing their patient for this condition promptly. Many thanks for the opportunity to share this potentially important piece of clinical information. Your sincerely, Katharine Forrest

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  6. Are EBV- associated acute acalculous cholecystitis and EBV-associated cholestatic hepatitis with reactive gall bladder wall thickening synonymous?

    Dear Editor, We read with interest, the case report written by Dr. Magdalani et al., "Acute Acalculous cholecystitis in a Lebanese girl with primary Epstein- Barr viral infection" in the British Medical Journal Case Reports published on 18 April, 2016.

    The authors describe a case of a previously healthy, 16 year old girl, who presented with history of 10 day fever, sore throat, and upper abdominal pain. She appeared clinically stable, with mild leukocytosis (predominantly lymphocytic), mild transaminitis and a cholestatic pattern of direct hyperbilirubinemia.

    A diagnosis of EBV associated with acute acalculous cholecystitis (AAC) was established with sonographic findings of significant gall bladder wall thickening. Her gall bladder was not dilated, and there was no pericholecystic fluid. She was treated with antibiotics with resolution of her symptoms. The authors noted that the benefit of antibiotics is questionable.

    Her symptomology and laboratory findings can also be described as consistent with EBV hepatitis. GB wall thickening in acute hepatitis is well known and is attributed to reactive/viral pericholecystitis. The mechanism is proposed to be due to impaired hepatic function with reduced secretion of bile, or from immunological/inflammatory damage to hepatic and biliary cells (1-6). We believe, like others, that the associated sonographic findings (1, 2, 5, 6) can be attributed to diffuse reactive gall bladder wall thickening secondary to peritoneal fluid produced as a result of extra biliary inflammatory process. Management is supportive, with review of literature in this paper showing resolution in 28 of 29 patients diagnosed with EBV associated AAC.

    AAC carries with it considerable mortality as evidenced by literature. Epidemiologically, it occurs in a select cohort of patients who are clinically sick, on prolonged parenteral nutrition, or immunosuppressed patients. Without intervention (cholecystectomy or cholecystostomy tube placement, and steroids in autoimmune patients), it progresses rapidly to gangrenous gall bladder and then perforation (7, 8). It is usually associated with more serious morbidity and higher mortality rates than calculous cholecystitis. The pathophysiology of cystic duct obstruction in AAC is attributed to ischemia to cystic duct, leading to endothelial injury, gall bladder stasis, and eventual necrosis.

    We and others believe that sonographic findings should not be the sole diagnostic criteria for AAC (1, 3). Differential diagnoses such as EBV, CMV, malaria, and other viral hepatides should be taken into consideration. A diagnosis of AAC should be suspected in the sicker, hospitalized patient, and mandates an admission to a monitored unit, and early operative intervention. We suggest obtaining a HIDA scan, in cases of uncertain diagnosis, with the understanding that the sensitivity and specificity are slightly decrease, since the obstruction is functional and not mechanical.

    References: 1. Debnath et al. Is it acalculous cholecystitis or reactive/viral pericholecystits in acute hepatitis? Braz J Infect Dis 2010;14(6):647-648 2. Lee et al. Acalcuous diffuse gall bladder wall thickening in children. Pediatr Gastroenterol Hepatol Nutr 2014 June 17(2):98-103 3. Shkalim-Zemer et al. Cholestatic Hepatitis Induced by Epstein - Barr virus in a Pediatric Population. Clinical Pediatrics 2015, Vol. 54(12) 1153-1157 4. Khoo. Acute cholestatic hepatitis induced by Epstein-Barr virus infection in an adult: a case report. Journal of Medical Case Reports (2016) 10:75 5. Debnath et al. Post-prandial paradoxical filling of gall bladder in patients with acute hepatitis: Myth or reality? Medical Journal Armed Forces of India 68 (2012) 346 e349 6. Poddighe, .Acalculous Acute Cholecystitis in Previously Healthy Children: General Overview and Analysis of Pediatric Infectious Cases. Int J Hepatol. 2015; 2015: 459608. 7. Owen et al. Acute Acalculous Cholecystitis. Curr Treat Options Gastroenterol. 2005 Apr;8(2):99-104. 8. Barie et al. Acute acalculous cholecystitis. Gastroenterol Clin North Am. 2010 Jun;39(2):343-57.

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  7. BESS ( benign enlargement of subara chnoid spaces)

    The authors rightly mention in their case report that it is not an uncommon finding in normal infants who are referred to the paediatrician because of large head size or a rapid increase in OFC. My concern is that the patient 1 in the case report may send a wrong message to the trainees or other doctors that CT head is the primary mode of imaging in such cases because of high dose of radiation involved with a CT. Most of them can be confirmed /recognized by a cranial ultrasound which can be easily performed even in a district general hospital setting and followed up by a repeat U/S if necessary, as the anterior fonatenelle is open in a large number of cases at that age. A CT or MRI should be needed rarely unless we have a case like patient 2 in the case report with head injury or suspicion of non accidental injury etc.

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  8. Oscillicoccinum has no benefit for influenza - it's inactive

    The authors make a claim that the patient developed angioedema following ingestion of oscillococcinum, a homeopathic "remedy" used for treating influenza symptoms. The authors claim that evidence of benefit exists to claim that this preparation has proven clinical activity. Unfortunately, they omit to use up-to-date information to base this claim on. The most recent Cochrane review (1), published January 2015 and authored by two well-known homeopaths concluded "There is insufficient good evidence to enable robust conclusions to be made about oscillococcinum in the prevention or treatment of influenza and influenza -like illness. Our findings do not rule out the possibility that oscillococcinum could have a clinically useful treatment effect but, given the low quality of the eligible studies, the evidence is not compelling. There was no evidence of clinically important harms due to oscillococcinum." The second problem with this report is the constituents of the oscillococcinum remedy itself. It is based on a preparation of Barbary duck heart and liver, misinterpreted by French physician Joseph Roy of a preparation of blood samples from victims of Spanish Flu towards the end of World War 1 (2). The preparation is supplied in the form of lactose pills onto which the remedy has been dripped. The solution dripped onto the pills has been diluted to the homeopathic "potency" of 200C. This involves serial centessimal dilutions to a factor of 200. This means that it is not possible to find a single particle or molecule of the original starting material in the final diluted solution. Serial dilution beyond the 12C "potency" exceeds Avogadro's constant. Dilution to 200C means that you could search the entire known universe and still fail to find a single entity from the starting material! (3) Their patient would appear to have had an allergic response to something, but if it is the pills he took, then it could only be the lactose, which is possible but unlikely. This therefore begs the question as to what the patient actually had the allergic reaction to? He should undergo a formal allergy review by a specialist, possibly including formal testing to work out what the allergy really is.

    1. http://www.cochrane.org/CD001957/ARI_homeopathic-oscillococcinumr- for-preventing-and-treating-influenza-and-influenza-like-illness 2. http://www.homeowatch.org/history/oscillo.html 3. https://www.sciencebasedmedicine.org/homeopathy-as-nanoparticles/

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  9. Not all ST - T & QRS complex changes are myocardial injury.

    I completely agree with the authors in saying that all ST-T changes are not myocardial injury.

    In my experience, not all new widened QRS complex changes (LBBB) indicate myocardial infarction or injury.

    I would like to say this on the basis that quite a few times, a patient with new wide QRS complex and bradycardia is referred to cardiology to rule out myocardial infarction and after investigations patient is found to have severe hyperkalemia and with ARF or an undiagnosed and progressive CKD. After immediate correction of hyperkalemia with glucose -insuln infusion, and intravenous Normal saline, and inj. frussemide in non-oliguric patients, the ECG changes revert back to normal.

    It's important to take ST-T changes on ECG seriously, but also have to look at clinical signs and symptoms and investigations to ascertain myocardial injury especially in emergency situations.

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  10. NG tube insertion - to be taken seriously

    Insertion of the nasogastric tube is taken very casually at the medical graduate level.

    In my opinion , insertion of NG tubes should be done very judiciously and gently in an awake patient.

    Points to note --

    1) Insert the tube very gently in the backwards and downward direction in the nostril, to avoid inadvertent damage of the roof of the nasal cavity, and passage of the tube intracranial.

    2) The tube should pass in without any resistance, in case of any undue resistance, please take it out and insert again.

    3) The NG tube be confirmed by auscultation on the epigastrium by inflating air with a 20 cc syringe.

    4) The patient can have cough while insertion, but this has to subside after few minutes, if cough persists, then it is very important to confirm the proper positioning of NG tube with the 4 point test mentioned in the case report.

    5) Its also important to insert the tube gently as it can cause trauma and bleeding especially in patients on antiplatelets/anticoagulants.

    In conclusion, insertion of NG tube is a routine procedure done in the hospitals,but it needs due diligence and good practice.

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response

Register for free content

The full text of all Editor's Choice articles and summaries of every article are free without registration

The full text of Images in ... articles are free to registered users

Only fellows can access the full text of case reports (apart from Editor's Choice) - become a fellow today, or encourage your institution to, so that together we can grow and develop this resource

Don't forget to sign up for content alerts so you keep up to date with all the case reports as they are published, and let us know what you think by commenting on the Editor's blog